Mark T. O'Hollaren, MD

Disclosures

March 21, 2006

Question

Aside from inhaled and other steroid delivery methods to treat nasal polyps, are any additional medications available? We have a patient who has had 2 operations and is dealing with on-off steroids. The patient does not have insurance and is reluctant to have yet another surgery, knowing that polyps can recur.

Mary Efremov, MD

Response From the Expert

Mark T. O'Hollaren, MD 
Director, Allergy Clinic, LLC, Portland, Oregon; Clinical Professor of Medicine, Oregon Health and Science University, Portland, Oregon

 

Patients with recurring nasal polyps are extremely difficult to treat, and their polyps are often accompanied by chronic sinusitis, with or without asthma. The inciting factor leading to the formation of nasal polyps is unknown, but for unclear reasons, this inflammatory process may start after a viral respiratory infection. Patients may state that ever since they had a severe respiratory infection, often described as bronchitis or pneumonia, they admit to having chronic problems with recurring nasal polyposis and sinusitis, and often asthma as well. In some cases, these patients have "triad asthma," previously known as "Samter's triad" (named after the physician who described the association of asthma, nasal polyposis/sinusitis, and aspirin allergy). This syndrome has also been recently referred to as "AERD" or "aspirin-exacerbated respiratory disease." Patients with this syndrome have frequent problems with recurring inflammatory tissue in the nasal and sinus cavities, and often have lower respiratory symptoms (ie, asthma) as well as significant upper airway disease. Examination of the nose may reveal nasal polyposis, and computerized tomographic examination of the sinuses often shows significant mucosal thickening and polypoid tissue within the sinuses.

Unfortunately, one of the hallmarks of this syndrome is its recurring nature. Nasal polyps may be reduced in size with oral corticosteroids, and topical nasal corticosteroid sprays may help delay their recurrence. Any concomitant infection may be treated with an antibiotic, sometimes given simultaneously with an oral corticosteroid burst and topical nasal corticosteroid sprays. In my experience, some patients, especially those with AERD, may also benefit from the addition of a leukotriene receptor antagonist such as montelukast. Although this indication (ie, treatment for nasal polyps) has not been approved by the US Food and Drug Administration, use of montelukast for the treatment of asthma is consistent with the package insert. It appears that some of these patients have abnormalities of leukotriene metabolism, which helps to explain their violent response when they are given a cyclooxygenase inhibitor such as aspirin or nonsteroidal anti-inflammatory drugs; violent reactions may include wheezing, chest tightness, angioedema, or even anaphylaxis in some patients.

I try to minimize potential causes of inflammation in these patients. Although it was originally thought that those with nasal polyposis, chronic sinusitis, asthma, and aspirin allergy frequently did not have any atopic triggers (ie, nonallergic or intrinsic asthma), it is now known that a number of these patients do have allergic triggers likely contributing to their symptom complex. If your patient has not had an allergy evaluation, then it may be prudent to perform one. If the patient does have significant allergen triggers, then consideration for strict allergen avoidance and possible immunotherapy could be considered. As you allude to, sometimes patients need repeat sinus and/or nasal surgery for symptom control.

Finally, if other avenues fail, then aspirin desensitization could be considered. The allergy group at the Scripps Institute in La Jolla, California, is among the most knowledgeable in this procedure. It may be worth calling or writing to them to investigate this further, as some patients with recurring nasal polyposis (that are aspirin allergic) have responded to this type of treatment protocol. It should be noted that once a patient is desensitized, he or she must continue to take aspirin to maintain the desensitized state.

In summary, a comprehensive approach aimed at reducing inflammation from all possible sources is recommended. This includes managing sinus infections and decreasing polyp size using medications such as oral and topical corticosteroids, as well as leukotriene modifiers in some patients. Allergy triggers should be sought and aggressively treated if they exist, and if the patient is aspirin allergic, then aspirin desensitization could be considered.

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