Diagnóstico e tratamento da DREA: realidades da prática clínica
Diagnosis and treatment of AERD: clinical practice reality
Resumo
Introdução: A doença respiratória exacerbada por aspirina (DREA), caracterizada por asma, rinossinusite, polipose nasal e hipersensibilidade à aspirina, pode ser sugerida pela história, porém, o teste de provocação oral com a aspirina é o padrão ouro para o diagnóstico, e a dessensibilização com aspirina, uma boa opção terapêutica. O objetivo do trabalho foi avaliar as características clínicas e os resultados dos procedimentos de provocação e/ou de dessensibilização com aspirina nos pacientes com suspeita de DREA, bem como observar se houve correlação com a literatura. Métodos: Neste estudo retrospectivo, foram avaliados prontuários de pacientes adultos com suspeita de DREA, em acompanhamento em um hospital terciário e que foram submetidos à provocação e/ ou dessensibilização com aspirina. Dois protocolos foram utilizados para o teste de provocação: (a) cetorolaco nasal/aspirina oral, e (b) apenas aspirina oral. Foram avaliados: características clínicas, a positividade do teste e da dessensibilização e a comparação deste resultado com a história prévia. Resultados: Participaram do estudo 24 pacientes, com média de idade de 50,8 anos, sendo 54,2% do sexo feminino. Treze pacientes (54,2%) tinham asma grave, e seis (25%), asma alérgica. Média do volume expiratório forçado no primeiro segundo (VEF1) foi de 81,5% do valor predito. Dezenove pacientes (79,2%) referiam broncoespasmo e/ou urticária com anti-inflamatórios não esteroidais. Cinco pacientes não faziam associação com essas medicações. Independente do protocolo usado, onze pacientes (45,8%) apresentaram teste positivo, confirmando a DREA, sendo que seis pacientes (25%) foram submetidos à dessensibilização com aspirina. Oito pacientes (33,3%) apresentaram provocação negativa, e cinco (20,8%) não conseguiram completar a investigação devido à presença de urticária. Conclusões: Pacientes com suspeita de DREA deveriam ser submetidos à provocação com aspirina para confirmar o diagnóstico. Um quarto dos pacientes foi submetido à dessensibilização, entretanto, para a maioria dos pacientes não foi possível confirmar o diagnóstico ou o teste foi negativo.
Palavras-chave
Abstract
Introduction: Aspirin-exacerbated respiratory disease (AERD) is characterized by asthma, rhinosinusitis, nasal polyps, and aspirin hypersensitivity. The condition may be suggested by the patient’s medical history; however, oral provocation test with aspirin is the gold standard for diagnosis, and desensitization with aspirin, a good therapeutic option. The aim of this study was to evaluate the clinical characteristics and results obtained with aspirin provocation tests and/or desensitization in patients with suspected AERD, as well as to correlate these data with the literature available. Methods: In this retrospective study, the medical records of adult patients with suspected AERD followed at a tertiary hospital who underwent aspirin challenge and/or desensitization were evaluated. Two protocols were used for the challenge test: (a) nasal ketorolac/ oral aspirin; and (b) oral aspirin alone. Clinical characteristics and both test and desensitization positivity were evaluated, and the results were compared with data from the patient’s history. Results: Twenty-four patients participated in the study, with a mean age of 50.8 years; 54.2% were female. Thirteen patients (54.2%) had severe asthma, and six (25%) had allergic asthma. Mean forced expiratory volume in 1 second (FEV1) was 81.5% of the predicted value. Nineteen patients (79.2%) reported bronchospasm and/or urticaria with nonsteroidal anti-inflammatory drugs. Five patients had no association with these medications. Regardless of the protocol used, eleven patients (45.8%) presented positive tests, confirming the diagnosis of AERD, and six patients (25%) underwent aspirin desensitization. Eight patients (33.3%) had negative results in the provocation test, and five (20.8%) failed to complete the investigation due to the presence of urticaria. Conclusions: Patients with suspected AERD should undergo aspirin challenge to confirm the diagnosis. One-fourth of our patients underwent desensitization, but for most patients, either it was not possible to confirm the diagnosis or the test resulted negative.
Keywords
Referências
1. Samter M, Beers RF Jr. Intolerance to aspirin: clinical studies and consideration of its pathogenesis. Ann Intern Med. 1968;68:975‑83.
2. Kennedy JL, Stoner AN, Borish L. Aspirin-exacerbated respiratory disease: prevalence, diagnosis, treatment, and considerations for the future. Am J Rhinol Allergy. 2016;30:407-13.
3. Rajan JP, Wineinger NE, Stevenson DD, White AA. Prevalence of aspirin-exacerbated respiratory disease among asthmatic patients: A meta-analysis of the literature. J Allergy Clin Immunol. 2015;135:676-81.
4. Stevenson DD, Szczeklik A. Clinical and pathologic perspectives on aspirin sensitivity and asthma. J Allergy Clin Immunol 2006; 118:773-86;quiz 787-8.
5. Mascia K, Borish L, Patrie J, Hunt J, Phillips CD, Steinke JW. Chronic hyperplastic eosinophilic sinusitis as a predictor of aspirinexacerbated respiratory disease. Ann Allergy Asthma Immunol. 2005;94:652-7.
6. Chaaban MR, Walsh EM, Woodworth BA. Epidemiology and differential diagnosis of nasal polyps. Am J Rhinol Allergy. 2013;27:473-8.
7. Scott DR, White AA. Approach to desensitization in aspirinexacerbated respiratory disease. Ann Allergy Asthma Immunol. 2014;112:13-7.
8. Laidlaw TM, Boyce JA. Aspirin-Exacerbated Respiratory Disease - New Prime Suspects. N Engl J Med. 2016;374:484-8.
9. Szczeklik A, Sladeck K, Dworski R, Nizankowska E, Soja J, Sheller J, Oates J. Bronchial aspirin challenge causes specific eicosanoid response in aspirin-sensitive asthmatics. Am J Respir Crit Care Med. 1996;154(6 Pt 1):1608-14.
10. Woessner, KM. Update on Aspirin-Exacerbated Respiratory Disease. Curr Allergy Asthma Rep. 2017;17:2.
11. Dursun AB, Woessner KA, Simon RA, Karasoy D, Stevenson DD. Predicting outcomes of oral aspirin challenges in patients with asthma, nasal polyps, and chronic sinusitis. Ann Allergy Asthma Immunol. 2008;100(5):420-5.
12. Bochenek G, Nizankowska-Mogilnicka E. Aspirin-exacerbated respiratory disease: clinical disease and diagnosis. Immunol Allergy Clin N Am. 2013;33(2):147-61.
13. Stevenson DD. Aspirin sensitivity and desensitization for asthma and sinusitis. Curr Allergy Asthma Rep. 2009;9(2):155-63.
14. Macy E, Bernstein JA, Castells MC, Gawchik SM, Lee TH, Settipane RA, et al. Aspirin challenge and desensitization for aspirin-exacerbated respiratory disease: a practice paper. Ann Allergy Asthma Immunol. 2007;98(2):172-4.
15. Cahill KN, Bensko JC, Boyce JA, Laidlaw TM. Prostaglandin D(2): A dominant mediator of aspirin-exacerbated respiratory disease. J Allergy Clin Immunol. 2015;135:245-52.
16. Lee RU, Stevenson DD. Aspirin-exacerbated respiratory disease: evaluation and management. Allergy Asthma Immunol Res. 2011;3:3-10.
17. Cook KA, Stevenson DD. Current complications and treatment of aspirin-exacerbated respiratory disease. Expert Rev Respir Med. 2016;10:1305-16.
18. Global Initiative for Asthma (GINA) Global Strategy for Asthma management and Prevent 2017. Disponível no site www.ginasthma. org. Acessado em: 30/06/2017.
19. Walters K, Woessner KM. An overview of nonsteroidal antiinflammatory drug reactions. Immunol Allergy Clin N Am. 2016;36:625-41.
20. Takejima P, Agondi RC, Rodrigues H, Aun MV, Kalil J, GiavinaBianchi P. Allergic and nonallergic asthma have distinct phenotypic and genotypic features. Int Arch Allergy Immunol. 2017;172(3):150‑60.
21. Andrade MC, Almeida M, Aun MV, Takejima PM, Kalil J, GiavinaBianchi P, Agondi RC. Frequência de pacientes com DREA e quadro cutâneo associado. Braz J Allergy Immunol. 2015;3(4):123.
22. White AA, Stevenson DD. Aspirin desensitization in aspirinexacerbated respiratory disease. Immunol Allergy Clin North Am. 2013; 33:211‑22.
23. Swierczynska-Krepa M, Sanak M, Bochenek G, Strek P, Cmiel A, Gielicz A, et al. Aspirin desensitization in patients with aspirininduced and aspirin-tolerant asthma: a double-blind study. J Allergy Clin Immunol. 2014;134(4):883‑90.
24. Berges-Gimeno MP, Simon RA, Stevenson DD. Long-term treatment with aspirin desensitization in asthmatic patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol. 2003;111(1):180-6.
25. Havel M, Ertl L, Braunschweig F, Markmann S, Leunig A, Gamarra F, et al. Sinonasal outcome under aspirin desensitization following functional endoscopic sinus surgery in patients with aspirin triad. Eur Arch Otorhinolaryngol. 2013;270(2):571-8.
26. Cho KS, Soudry E, Psaltis AJ, Nadeau KC, McGhee SA, Nayak JV, et al. Long-term sinonasal outcomes of aspirin desensitization in aspirin exacerbated respiratory disease. Otolaryngol Head Neck Surg. 2014;151(4):575‑81.
27. Hope AP, Woessner KA, Simon RA, Stevenson DD. Rational approach to aspirin dosing during oral challenges and desensitization of patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol. 2009;123(2):406‑10.
28. Ta V, White AA. Survey-defined patient experiences with aspirinexacerbated respiratory disease. J Allergy Clin Immunol Pract. 2015;3(5):711‑8.
Submetido em:
14/08/2017
Aceito em:
29/09/2017
Facebook
LinkedIn
Mendeley
StumbleUpon
Reddit
Email