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Published: March 1999

NSAID-induced Bronchospasm: A Common and Serious Problem

Prescriber Update 18: 22-24
March 1999

Ms Joanna Sturtevant, Clinical Pharmacist, Health Waikato, Hamilton

Between 8 - 20% of adult asthmatics experience bronchospasm following ingestion of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs). Termed aspirin-induced asthma, this reaction is potentially fatal. Asthmatics with chronic rhinitis or a history of nasal polyps are at greater risk. The reaction rarely occurs in children.
Patients initially present with an acute episode of vague malaise, sneezing, nasal obstruction, rhinorrhoea and often a productive cough. Persistent rhinitis and nasal polyps may then develop. Asthma and aspirin sensitivity may appear in the following months. Within 20 minutes to 3 hours of taking a NSAID, aspirin-sensitive asthmatics can develop respiratory symptoms (e.g. bronchospasm, rhinorrhoea, respiratory arrest), urticaria/angiodema or, rarely, a combination of the two.
NSAIDs (systemic or topical) should be used with caution in asthmatics and avoided in asthmatics with nasal polyps. Tell asthmatics to seek medical help if symptoms worsen on initiation of a NSAID.

To October 1998, the Centre for Adverse Reactions Monitoring had 81 reports of bronchospasm following the ingestion of non-steroidal anti-inflammatory drugs (NSAIDs) and 6 reports of exacerbation of asthma symptoms. This includes one fatality following aspirin administration.

NSAID-induced bronchospasm common

Aspirin and other NSAIDs can induce bronchospasm and, in rare cases, this reaction can lead to death in aspirin-sensitive asthmatics.1-4 This reaction is generally referred to as aspirin-induced asthma. The reported incidence varies widely affecting between 8% and 20% of adult asthmatics.5,6 The incidence is increased in asthmatics who also have chronic rhinitis or a history of nasal polyps.4 Aspirin-induced asthma is most likely to be encountered in the third or fourth decade of life although it may occur in childhood, albeit rarely.5,6

There is marked cross-sensitivity between most NSAIDs, even where they are structurally dissimilar.2,5

A report of worsening asthma, necessitating hospital admission, following the use of NSAID ophthalmic drops serves to warn that all routes of administration can precipitate bronchospasm in sensitive asthmatics.7

Symptoms usually respiratory or involve urticaria/angiodema

Patients initially present with an acute episode of vague malaise, sneezing, nasal obstruction, rhinorrhoea and often a productive cough. These symptoms resolve in a few weeks and may be followed by persistent rhinitis and the development of nasal polyps. Asthma and aspirin sensitivity may appear in the following months.6 Within 20 minutes to 3 hours of ingestion of a NSAID, aspirin-sensitive asthmatics can develop:

  1. respiratory symptoms such as acute bronchospasm, rhinorrhoea, conjunctival irritation and/or cutaneous flushing of the head and neck, and even circulatory collapse and respiratory arrest5,6
  2. urticaria/angiodema or
  3. rarely, a combination of these responses.

Identification of aspirin-sensitive individuals is not merely a matter of asking whether they have experienced symptoms with a previous ingestion of NSAIDs. This does not exclude the possibility of a reaction as many patients may have had NSAIDs in the past with no ill-effect. Prescribers should determine whether their patient is an asthmatic or has nasal polyps.

Asthmatics with nasal polyps should avoid NSAIDs; others use with caution

NSAID-induced bronchospasm should be suspected in any patient whose asthma control worsens on initiation of a NSAID. Patients with a history of asthma should be warned of this reaction and to seek medical help if symptoms worsen on initiation of a NSAID.

NSAIDs should be used with caution in the presence of asthma and avoided in asthmatics with nasal polyps. As it is difficult to identify ‘at risk’ asthmatics, it would seem prudent to prescribe paracetamol instead of aspirin unless there are any specific contra-indications.

Patients should be reminded to read labels of over-the-counter medicines as some, such as cough/cold preparations, may contain aspirin. Ibuprofen, diclofenac and other NSAIDs are also available over-the-counter.

Correspondence to Ms Joanna Sturtevant, Clinical Pharmacist, Health Waikato, Private Bag 3200, Hamilton. phone 07 839 8899 pager 0565, fax 07 839 8769, e-mail sturtevj@hwl.co.nz

References
  1. Ayres JG, Fleming DM, Whittington RM. Asthma death due to ibuprofen. Lancet 1987;1:1082.
  2. Bosso JV, Creighton D, Stevenson DD. Flurbiprofen cross-sensitivity in an aspirin-sensitive asthmatic patient. Chest 1992;101(3):856-858.
  3. Chen AH, Bennett CR. Ketorolac-induced bronchospasm in an aspirin-intolerant patient. Anesth Prog 1994;41:102-107.
  4. Zikowski D, Hord AH, Haddox JD, Glascock J. Ketorolac-induced bronchospasm. Anesth Analg 1993;76:417-419.
  5. Slepian IK, Mathews KP, McLean JA. Aspirin-sensitive asthma. Chest 1985;87(3):386-391.
  6. Power I. Aspirin-induced asthma (Editorial) Brit J Anaes 1993;71(5):619-620.
  7. Sitenga GL, Ing EB, Van Dellen RG, et al. Asthma caused by topical application of ketorolac. Ophthalmology 1996;103:890-892.