Refining intranasal aspirin challenge for safer AERD diagnosis

Published online April 3, 2025

Aspirin-exacerbated respiratory disease (AERD) is a chronic eosinophilic inflammatory disorder characterized by asthma, chronic rhinosinusitis with nasal polyps (CRSwNP), and intolerance to cyclooxygenase-1 inhibitors. Patients with AERD commonly suffer from persistent symptoms and recurrent disease flares, leading to significantly impaired quality of life and considerable healthcare costs. Successful diagnosis and management of AERD thus have significant societal benefits in addition to improving a patient’s quality of life. Aspirin challenge tests are reliable methods for diagnosing AERD, with intranasal aspirin challenge (IAC) increasingly used for its practicality and safety. However, the lack of standardized symptom score criteria and optimal dosage complicates its diagnostic utility.

This study, published in The Journal of Allergy and Clinical Immunology: In Practice by lead author Prof. Juan Meng, enrolled 116 adult patients with CRSwNP, with or without asthma, from the Allergy Center of West China Hospital, Sichuan University. Among them, 58 were diagnosed with AERD either through a reliable clinical history or a positive oral aspirin challenge (OAC), while the remaining 58 were confirmed to be non-AERD based on negative OAC. The cohort was stratified into two groups: Group A (n=70, 35 AERD, 35 non-AERD), enrolled between April 2021 and October 2023, was utilized to establish the symptom scoring criteria. Group B (n=46, 23 AERD, 23 non-AERD), enrolled between November 2023 and October 2024, was used for validation. Additionally, 20 healthy controls were included in the study. 

All participants underwent IAC using lysine aspirin, administered in incremental doses up to a total cumulative of 150 mg aspirin. Symptom severity was recorded using a 0-10 visual analog scale (VAS), including rhinorrhea, nasal congestion, sneezing, and itchy nose. Diagnostic accuracy was assessed using receiver operating characteristic (ROC) curve analysis. The safety and optimal dosage of IAC were also investigated.

This study establishes a total VAS increase of 7.5 points (with 80.0% sensitivity and 97.1% specificity) and a maximal cumulative aspirin dosage of 70 mg as optimal criteria for diagnosing AERD via IAC, yielding a diagnostic accuracy of 91.3% and a sensitivity of 87.0%. Among them, 4.3% of participants experienced acute worsening of asthma during the challenge. These findings provide evidence-based recommendations for standardizing IAC protocols, supporting its use as a reliable, safe, and practical diagnostic approach that may significantly improve the overall management of AERD.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

Full Article