Samter’s Syndrome and Aspirin De-sensitization

Samter’s syndrome (also called Samters Triad or aspirin induced asthma) is an inflammatory disease characterized by chronic rhinosinusitis, nasal polyps, asthma and airway reactivity to aspirin (ASA) and other non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen (Motrin) and Naproxen (Aleve).

These patients frequent allergists, ENT’s (otolaryngologists)  and pulmonologists offices. Their nasal symptoms include chronic nasal congestion and the inability to appreciate smells (anosmia). They require many nasal treatments including topical nasal corticosteroids, decongestants, frequent antibiotics and systemic corticosteroids (Medrol dosepak/Prednisone). Many of these patients have undergone sinus and nasal polyp surgeries.  Unfortunately, their polyps typically grow back.

Their asthma maybe classified as mild intermittent to severe persistent. They often require multiple inhalers. This adds to their poor quality of life. Steroid bursts may also be necessary to control their asthma.

With Samter’s syndrome, ASA (aspirin) as well as NSAIDS (ibuprofen or naproxen) result in anaphylaxis. This may include: swelling of the lips and/or tongue, difficult swallowing, coughing, wheezing, shortness of breath, chest tightness, and hives or in some cases loss of consciousness and respiratory arrest shortly after ingesting these medications.

Recent studies involving ASA desensitization via a standardized protocol has shown significant improvement in patient’s symptoms. Once patients are desensitized, they are then required to take a daily dose of aspirin. This results in a decrease in their nasal/sinus/polyp and lung symptoms. A significant improvement in their quality of life follows successful desensitization.

Patients undergoing aspirin desensitization are scheduled in our office for pulmonary function tests several weeks prior to desensitization. They are also started on Singulair 10 mg a day, unless they are already on it or describe adverse reactions to it in the past. No antihistamines should be used for > 48 hrs prior to admission. Patients cannot be on a beta-blocker (i.e. Coreg, Inderal, Lopressor, Tenormin or Toprol) for this procedure.

All patients should confirm with their insurance company approval for this 2 day hospital stay at DEGRAFF MEMORIAL ICU. Admitting diagnosis is ASPIRIN DENSENSITIZATION (CPT CODE # 95076). Patients should arrive at 6 AM to Degraff admissions on day 1. All patients should bring all their maintenance medications from home. Patients will be admitted to the ICU by 6:30 AM. An intravenous line is established and patients are connected to a heart monitor.

Patients are given incremental dosages of aspirin until a provoking dose is reached. This usually results in nasal congestion, itchy eyes or nose, sneezing, coughing, wheezing or an itchy rash (hives). Patients are then treated for their symptoms. Most patients react between 20-100mg. The provoking dose is repeated several hours later or the following day (#2). Dosages are then increased incrementally to either 325, 650, 975, or 1300mg. The lowest dose which provides the most clinical benefit is chosen. Patients are discharged by 5-6pm on day # 2. Patients will need to take their aspirin daily thereafter. A scheduled follow-up (with pulmonary function test) in our office should be made ~ 4-6 weeks after their aspirin challenge.