Aspirin-Exacerbated Respiratory Disease: Diagnosis and Desensitization Guide

Imagine waking up every morning with your nose completely blocked, struggling to breathe through your mouth, and losing the ability to smell coffee, rain, or even your own food. For people with Aspirin-Exacerbated Respiratory Disease (AERD), this isn’t rare-it’s daily life. AERD, also known as Samter’s Triad, isn’t just allergies or asthma. It’s a chronic, complex condition that hits the nose, sinuses, and lungs all at once. And unlike typical allergies, it’s triggered not by pollen or pet dander, but by common painkillers like aspirin and ibuprofen. If you’ve been told you have "bad asthma" that doesn’t respond to standard treatments, or if you’ve had nasal polyps come back again and again after surgery, you might be dealing with AERD.

What Exactly Is AERD?

AERD is defined by three things happening together: chronic sinusitis with nasal polyps, asthma, and sudden breathing problems after taking aspirin or other NSAIDs. It doesn’t show up in childhood. Most people first notice symptoms between ages 20 and 50, and women are slightly more likely to develop it than men. The condition affects about 7% of all adults with asthma-and up to 14% of those who also have nasal polyps.

It’s not an allergy in the classic sense. There’s no IgE antibody involved. Instead, AERD is a metabolic disorder. When you take aspirin or NSAIDs, your body overproduces inflammatory chemicals called cysteinyl leukotrienes. These cause swelling, mucus overproduction, and tightening of the airways. That’s why a simple pain reliever can trigger wheezing, congestion, or even an asthma attack within minutes.

It’s named after Dr. Max Samter, who first described the full triad in 1968. But the pattern was noticed as early as 1922. Today, we know it’s not just about the drugs-it’s about the body’s broken response to them.

How Is AERD Diagnosed?

There’s no single blood test or scan that confirms AERD. Diagnosis relies on your medical history and symptoms. If you have asthma, nasal polyps, and a history of breathing trouble after taking aspirin or ibuprofen, the chances are very high you have AERD.

But what if you’ve never taken aspirin? Or you avoid NSAIDs and don’t know if they trigger you? That’s where the aspirin challenge comes in. This is the gold standard for diagnosis. It’s done in a controlled hospital or allergy clinic setting, where doctors slowly give you increasing doses of aspirin-starting at 20-30mg-and watch closely for any reaction. Doses are doubled every 90 to 120 minutes until you reach 325mg or symptoms appear. The whole process takes about 5 to 6 hours.

Reactions can include nasal congestion, wheezing, coughing, or a drop in lung function. If you react, it’s confirmed: you have AERD. About 98% of people with suspected AERD react during this test.

Doctors also look for supporting clues: high levels of eosinophils (a type of white blood cell) in your blood-over 500 cells/μL in 76% of cases-and elevated urinary leukotriene E4, which is found in 89% of active AERD patients. These aren’t diagnostic on their own, but they help paint the full picture.

What Happens If You Don’t Get Diagnosed?

Many people with AERD go years without a proper diagnosis. They’re treated for "severe asthma" or "recurrent sinus infections," but nothing sticks. They get repeated surgeries for nasal polyps-only to have them grow back within a year or two. They avoid NSAIDs, thinking that’s enough. But here’s the problem: AERD keeps progressing even if you avoid aspirin.

Without treatment, nasal polyps keep growing, smell fades (anosmia affects up to 80% of patients), asthma worsens, and you end up relying on oral steroids more often. One study found that 78% of AERD patients say their daily activities are severely limited by nasal congestion. Forty-five percent have had at least one sinus surgery within two years of diagnosis.

And it’s not just physical. Losing your sense of smell affects your appetite, your safety (you can’t smell smoke or gas), and even your emotional well-being. On patient forums, people describe crying because they can’t smell their child’s hair or their favorite meal cooking. That’s the hidden cost of undiagnosed AERD.

Medical Management: Beyond Avoidance

Avoiding NSAIDs is important, but it’s not enough. AERD is a systemic disease. You need aggressive, targeted treatment.

Sinus rinses are the first line of defense. High-dose steroid rinses with budesonide (50-100mg) used twice daily can shrink polyps by 30-40% in just eight weeks. Regular saline rinses help too-many patients add a drop of tea tree oil to reduce fungal buildup.

Intranasal sprays like fluticasone (two sprays per nostril twice daily) improve nasal symptoms by 35% on the SNOT-22 quality-of-life scale after 12 weeks.

For asthma, the standard is a combination inhaler: medium-dose inhaled corticosteroid plus a long-acting beta agonist (like fluticasone/salmeterol). This improves lung function by 15-20% in most patients.

Then there are the leukotriene modifiers. Zileuton, which blocks leukotriene production, works well-75% reduction in urinary leukotriene E4 within two weeks. But it requires taking it four times a day, and only 28% of patients call it "extremely effective." Montelukast is easier (once daily), but only 15% report strong results.

For those who don’t respond, biologics are changing the game. Dupilumab (injected every two weeks) reduces polyp size by 55% and improves SNOT-22 scores by 40% in 16 weeks. Mepolizumab (monthly injection) cuts eosinophil counts by 85% and reduces the need for repeat sinus surgery by 57% over a year.

Aspirin Desensitization: The Game-Changer

Here’s where things get powerful. Once you’re diagnosed, and especially if you’ve had sinus surgery, aspirin desensitization is the most effective long-term treatment.

The process starts with the same challenge used for diagnosis-but instead of stopping when you react, doctors keep going. They give you daily aspirin doses, gradually increasing until you reach 650mg twice a day. You’re monitored closely, and once you can tolerate that dose without a reaction, you’re considered desensitized.

Then you take 650mg twice daily, for life. It sounds scary, but the results are dramatic. Patients who do this see:

• Reduction in oral steroid bursts-from 4.2 per year to just 1.1
• Polyp recurrence drops from 85% to 35% within two years after surgery
• Smell function improves dramatically: scores on smell tests jump from 12.4 to 23.7 out of 40
• 82% report "major improvement" in overall quality of life

One study showed that combining sinus surgery with aspirin desensitization cuts polyp recurrence by 65% compared to surgery alone. That’s not a small win-it’s life-changing.

And it’s cost-effective. The procedure costs about $12,500 per quality-adjusted life year gained-far less than the $18,500 price tag of a single revision sinus surgery.

Who Can’t Have Desensitization?

It’s not for everyone. If you have severe heart disease, active peptic ulcers, or a history of bleeding disorders, aspirin is too risky. If you can’t commit to taking it twice daily, every day, without missing doses, you’re not a good candidate.

Missing just two or three days of aspirin means you lose your desensitization. You’ll need to go through the whole process again. About 68% of patients who miss doses have to restart desensitization.

And yes, side effects happen. About 22% of long-term users get stomach upset or ulcers. That’s why many take it with food, or add a proton-pump inhibitor like omeprazole. It’s not perfect-but for most, the trade-off is worth it.

The Bigger Picture: Access and the Future

Here’s the hard truth: there are only 35 dedicated AERD centers in the entire United States. Most allergists aren’t trained to do aspirin challenges or manage desensitization. A 2022 survey found only 18% of U.S. allergists feel comfortable treating AERD.

That means many patients wait years-or never get diagnosed at all. Telemedicine has helped, increasing access by 35% since 2020. But rural patients still face huge barriers. Only 22% can reach a specialist within 100 miles.

On the horizon, new drugs are being tested. MN-001 (tipelukast), a dual inhibitor of leukotriene and PDE4, showed a 60% drop in inflammatory markers in early trials. And combining dupilumab with aspirin therapy is producing even better results than either alone.

Regulations are catching up too. The FDA issued draft guidance in 2023 to standardize safety protocols for aspirin desensitization across centers. That’s a step toward making this life-saving treatment more widely available.

What Should You Do If You Suspect AERD?

If you have asthma and nasal polyps, and you’ve ever had a bad reaction to aspirin, ibuprofen, or naproxen-don’t ignore it. Talk to an allergist or ENT who specializes in airway inflammation. Ask specifically about AERD and whether an aspirin challenge is right for you.

If you’ve had polyps come back after surgery, you’re not just unlucky. You might have an underlying condition that’s being missed. Ask if aspirin desensitization could help you avoid more surgeries.

And if you’re already diagnosed: stick with your treatment. Use your steroid rinses. Take your aspirin. Don’t stop because it’s inconvenient. The difference between taking it and not taking it is the difference between living with constant congestion and breathing normally again.

This isn’t a condition you cure. It’s one you manage. But with the right approach, you can take back your sense of smell, your breathing, and your life.