RESUMEN
INTRODUCTION: Live attenuated zoster vaccine (Zostavax) was used to test the hypothesis that constitutive level of interleukin 10 (IL-10), which may be high in elderly subjects, impairs vaccine efficacy. If constitutive IL-10 impairs vaccine efficacy, the effectiveness of viral vaccines might be improved by transient inhibition of IL-10 before vaccination. METHODS: Zostavax was given to 26 patients (age, 60-80 years). IL-10 and immunity to varicella zoster virus (VZV) were measured at baseline and after vaccination. Fluorescent antibody to membrane antigen (FAMA) assays and glycoprotein enzyme-linked immunosorbent assays (gpELISAs) were used to assess humoral immunity; anti-varicella virus T-cell responses were studied in a subset of subjects. In a prospective animal model, T-cell responses to chimeric vaccines against lymphocytic choriomeningitis virus (LCMV) were assessed in mice that express or lack IL-10. RESULTS: FAMA assays revealed significant boosting (by 4-fold) of humoral immunity, which occurred only in subjects (10 of 26) with a low constitutive IL-10 level (ie, <20 pg/mL); moreover, the Zostavax-induced FAMA and gpELISA responses were inversely related to the constitutive IL-10 level. Significant VZV-specific T-cell responses followed vaccination only in subjects with a low constitutive IL-10 level. Vaccine-induced LCMV-specific T-cell responses in mice lacking IL-10 were greater than in wild-type animals. CONCLUSIONS: A high constitutive IL-10 level adversely affects vaccine efficacy.
Asunto(s)
Vacuna contra el Herpes Zóster/inmunología , Herpesvirus Humano 3/inmunología , Interleucina-10/sangre , Anciano , Anciano de 80 o más Años , Animales , Ensayo de Inmunoadsorción Enzimática , Femenino , Técnica del Anticuerpo Fluorescente , Humanos , Inmunidad Humoral/inmunología , Masculino , Ratones , Ratones Noqueados , Persona de Mediana EdadAsunto(s)
Antiinflamatorios no Esteroideos/efectos adversos , Aspirina/efectos adversos , Asma Inducida por Aspirina , Inhibidores de la Ciclooxigenasa/efectos adversos , Aspirina/inmunología , Asma Inducida por Aspirina/diagnóstico , Asma Inducida por Aspirina/tratamiento farmacológico , Ciclooxigenasa 1 , Desensibilización Inmunológica , Glucocorticoides/uso terapéutico , Humanos , Pólipos Nasales/inducido químicamente , Pólipos Nasales/cirugíaRESUMEN
BACKGROUND: Aspirin-exacerbated respiratory disease (AERD) is manifested by adult-onset asthma, nasal polyposis, chronic rhinosinusitis, and aspirin sensitivity. Previously reported prevalence rates have been widely variable based on the population studied, method of diagnosis, and definition of aspirin sensitivity. OBJECTIVE: We sought to determine the prevalence of AERD among asthmatic adults. METHODS: A systematic review of databases was performed to identify all clinical trials published on or before June 16, 2013, that evaluated the prevalence of AERD. The studies were clustered into 7 different groups based on underlying disease (asthma, nasal polyps or chronic rhinosinusitis, or both), as well as on the methodology of prevalence determination. RESULTS: A total of 1770 articles were identified, with 27 considered appropriate for inclusion. Prevalence rates of AERD ranged from 5.5% to 12.4% based on study type. Among all studies in asthmatic patients, regardless of method, the prevalence of AERD was 7.15% (95% CI, 5.26% to 9.03%). The prevalence of AERD was highest among patients with severe asthma (14.89% [95% CI, 6.48% to 23.29%]). Among patients with nasal polyps and chronic rhinosinusitis, the prevalence was 9.69% (95% CI, 2.16% to 17.22%) and 8.7% (95% CI, -1.02% to 18.34%), respectively. CONCLUSION: AERD is a distinct and important subtype of asthma and polypoid sinus disease. The prevalence of AERD is 7% in typical adult asthmatic patients and twice that number in patients with severe asthma, which underscores the importance of recognizing this disorder. Early identification of this syndrome is critical in view of the increased morbidity and costs associated with asthma exacerbations and the option to treat patients with AERD with long-term aspirin treatment after desensitization.
Asunto(s)
Asma Inducida por Aspirina/epidemiología , Pólipos Nasales/epidemiología , Rinitis/epidemiología , Adulto , Asma Inducida por Aspirina/complicaciones , Asma Inducida por Aspirina/inmunología , Asma Inducida por Aspirina/terapia , Enfermedad Crónica , Desensibilización Inmunológica , Humanos , Pólipos Nasales/complicaciones , Pólipos Nasales/inmunología , Pólipos Nasales/terapia , Prevalencia , Rinitis/complicaciones , Rinitis/inmunología , Rinitis/terapia , Índice de Severidad de la Enfermedad , SinusitisRESUMEN
BACKGROUND: Aspirin prevents coronary thrombosis and is used extensively in cardiovascular prophylaxis. However, patients with a prior history of an aspirin "reaction" are routinely denied this medication. OBJECTIVE: To characterize the clinical presentation of a cohort of patients with coronary artery disease (CAD) and aspirin reactions. METHODS: Between 2009 and 2012, using a retrospective computer analysis, information was collected on all patients within a county-wide health care system presenting with CAD and a prior history of aspirin reactions. RESULTS: Of 9,565 patients with CAD, a prior history of aspirin reactions was recorded in 142 patients. Of these 142 patients, 30 (21%) had histories compatible with cutaneous and/or respiratory reactions. The other patients described adverse effects to aspirin, mostly gastrointestinal intolerance and bleeding. Aspirin-induced anaphylaxis was recorded in patients but may have been misdiagnosed, describing instead respiratory hypersensitivity reactions. Of the 142 patients, only 34 (24%) were receiving daily cardiovascular prophylaxis with aspirin. Of 108 patients not receiving aspirin, 25 (17.6%) were prescribed clopidogrel. CONCLUSION: Histories of aspirin reactions in patients with CAD are uncommon, occurring in only 1.5% of our study population. The 21% of patients with histories compatible with aspirin hypersensitivities can be challenged and, if the results are positive, successfully desensitized. Moreover, almost all patients with gastric intolerance to aspirin can be treated with aspirin and a proton pump inhibitor. However, both approaches, which result in restoration of cardiovascular prophylaxis, were seriously underused in our study population.
Asunto(s)
Aspirina/efectos adversos , Enfermedad de la Arteria Coronaria/inmunología , Hipersensibilidad a las Drogas/inmunología , Anciano , Anciano de 80 o más Años , Aspirina/inmunología , Aspirina/uso terapéutico , California/epidemiología , Enfermedades Cardiovasculares/tratamiento farmacológico , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/prevención & control , Clopidogrel , Enfermedad de la Arteria Coronaria/epidemiología , Hipersensibilidad a las Drogas/epidemiología , Femenino , Humanos , Masculino , Estudios Retrospectivos , Ticlopidina/análogos & derivados , Ticlopidina/uso terapéuticoRESUMEN
Aspirin desensitization is a treatment option for patients with aspirin-exacerbated respiratory disease (AERD). Some patients with an excellent history of aspirin or nonsteroidal anti-inflammatory drug (NSAID) reactions have negative aspirin challenges/desensitization. This study discusses the clinical entity of silent desensitization in AERD and the dilemma that this presents to the practicing allergist/immunologist. We discuss a series of patients with a strong history of NSAID reactions who initially underwent a negative challenge/silent desensitization. These patients were subsequently proven to have AERD after a second positive aspirin challenge. Silent desensitization is an uncommon but important outcome to recognize in AERD. Clinicians performing aspirin desensitization should understand that this can occur and consider a second confirmatory aspirin challenge in some patients.
Asunto(s)
Antiinflamatorios no Esteroideos , Aspirina , Desensibilización Inmunológica/métodos , Hipersensibilidad a las Drogas/tratamiento farmacológico , Adulto , Antiinflamatorios no Esteroideos/efectos adversos , Antiinflamatorios no Esteroideos/uso terapéutico , Aspirina/efectos adversos , Aspirina/uso terapéutico , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedades Respiratorias/inducido químicamente , Enfermedades Respiratorias/tratamiento farmacológico , Adulto JovenRESUMEN
The occurrence of an emergent need for aspirin therapy in an aspirin or nonsteroidal anti-inflammatory drug (NSAID)-"allergic" individual presents one of the more challenging situations the allergist may face. A common request is for the allergist to evaluate an acutely ill patient in a monitored hospitalized setting with a vague and remote history of a "reaction to aspirin." Because of significant diagnostic limitations, introducing aspirin can be very difficult. The concern about the potential for causing anaphylaxis in an acutely ill patient can lead to fear about performing any challenge or desensitization in these patients. The objective of this article was to review the literature regarding aspirin challenges and desensitization in the emergency setting and present a rational approach to administering aspirin to patients that require this drug.
Asunto(s)
Antiinflamatorios no Esteroideos/efectos adversos , Aspirina/efectos adversos , Desensibilización Inmunológica , Hipersensibilidad a las Drogas/terapia , Isquemia Miocárdica/tratamiento farmacológico , Anafilaxia/inducido químicamente , Anafilaxia/terapia , Contraindicaciones , Desensibilización Inmunológica/efectos adversos , Hipersensibilidad a las Drogas/diagnóstico , Urgencias Médicas , Humanos , Isquemia Miocárdica/inmunología , Accidente Cerebrovascular/inmunología , Accidente Cerebrovascular/terapia , Urticaria/inducido químicamente , Urticaria/terapiaRESUMEN
BACKGROUND: Tobacco smoke is a widely recognized environmental pollutant and is a major public health hazard worldwide. Although environmental tobacco smoke (ETS) has a clear link with many conditions, including asthma, ear infections, and sinus cancer, evidence related to aspirin-exacerbated respiratory disease (AERD) requires further investigation. OBJECTIVE: To investigate whether active smoke or ETS exposures are associated with an increased risk of developing AERD. METHODS: A total of 260 patients with AERD were enrolled in a case-control study with their respective asymptomatic spouses serving as matched controls. Multiple logistic regression analysis was used to examine the association of AERD with active smoking and ETS, adjusted for age, sex, and location of childhood residence. RESULTS: The AERD case patients were more likely to have ever smoked actively when compared with controls (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.04-2.28). A significant association (OR, 3.46; 95% CI, 2.22-5.39) was found between childhood ETS exposure and AERD. If a patient was exposed to ETS during both childhood and adulthood, results showed an OR of 5.09 for developing AERD (95% CI, 2.75-9.43). However, no statistically significant association between AERD and ETS only during adulthood was found (OR, 1.60; 95% CI, 0.75-3.40), suggesting that the combined effect of childhood and adulthood ETS may be augmented by the prior childhood exposure. CONCLUSIONS: Active smoking and childhood ETS exposure are associated with increased odds of developing AERD. In particular, combined childhood and adulthood exposure had major effects. This study suggests that ETS is at least one contributor to the syndrome of AERD.
Asunto(s)
Asma Inducida por Aspirina/etiología , Fumar/efectos adversos , Contaminación por Humo de Tabaco/efectos adversos , Adolescente , Adulto , Anciano , Aspirina/efectos adversos , Estudios de Casos y Controles , Exposición a Riesgos Ambientales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedades Respiratorias/inducido químicamente , Enfermedades Respiratorias/etiología , Factores de Riesgo , Adulto JovenRESUMEN
Aspirin-exacerbated respiratory disease (AERD) is a unique syndrome of airway inflammation that frequently occurs in patients with nasal polyposis, chronic sinusitis, and asthma. These patients tend to have progressive and recalcitrant sinus disease requiring frequent surgical intervention and in many cases systemic corticosteroids. Much about the pathogenesis of AERD remains unclear, but environmental factors likely play a prominent role in its development. Avoidance of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) is imperative in the initial counseling of these patients. Because most of the exposure to these medications is available over the counter, most patients will experience a significant respiratory reaction to full therapeutic doses of seemingly innocent NSAIDs. Although the history of a reaction to aspirin or another NSAID is a very important part of making the diagnosis, the gold standard remains an observed aspirin challenge. Given the prevalence and usefulness of aspirin and NSAID therapy in primary care clinics, an accurate diagnosis should be made in all patients. Desensitization is an effective treatment option for many patients. Recent advances have made this procedure considerably safer and outpatient aspirin desensitization is now the standard of care.
Asunto(s)
Aspirina/efectos adversos , Asma Inducida por Aspirina/fisiopatología , Desensibilización Inmunológica/métodos , Antiinflamatorios no Esteroideos/administración & dosificación , Antiinflamatorios no Esteroideos/efectos adversos , Aspirina/administración & dosificación , Asma Inducida por Aspirina/diagnóstico , Asma Inducida por Aspirina/terapia , Progresión de la Enfermedad , Glucocorticoides/uso terapéutico , Humanos , Pólipos Nasales/epidemiología , Medicamentos sin Prescripción/efectos adversos , Educación del Paciente como Asunto/métodos , Sinusitis/epidemiologíaRESUMEN
Aspirin-exacerbated respiratory disease (AERD) is characterized by adult onset of asthma, chronic rhinosinusitis (CRS), nasal polyposis, and aspirin sensitivity. In this syndrome, each disease component has deleterious effects on the patient's health and quality of life. Latest figures from the Centers for Disease Control indicate 8.2% of the U.S. population has asthma and among adult asthmatic patients, up to 9% have AERD. Approximately 13% of the population suffers from CRS and 15% of patients with CRS with nasal polyposis have AERD. A review of the impact that each component of AERD has on patients will delineate the considerable burden of AERD, especially when considering the cumulative effects of the tetrad.
Asunto(s)
Antiinflamatorios no Esteroideos/efectos adversos , Aspirina/efectos adversos , Asma Inducida por Aspirina/economía , Costo de Enfermedad , Enfermedades Respiratorias/economía , Enfermedades Respiratorias/etiología , Asma Inducida por Aspirina/clasificación , Asma Inducida por Aspirina/fisiopatología , Enfermedad Crónica , Inhibidores de la Ciclooxigenasa/economía , Inhibidores de la Ciclooxigenasa/uso terapéutico , Humanos , Pólipos Nasales/etiología , Pólipos Nasales/fisiopatología , Trastornos del Olfato/economía , Trastornos del Olfato/etiología , Trastornos del Olfato/fisiopatología , Calidad de Vida , Enfermedades Respiratorias/fisiopatología , Rinitis/economía , Rinitis/etiología , Rinitis/fisiopatología , Sinusitis/economía , Sinusitis/etiología , Sinusitis/fisiopatología , Estados Unidos/epidemiologíaRESUMEN
Pelvic abscesses occurring after gynecologic pelvic surgery are uncommon. We describe the case of a woman who, after undergoing such a procedure, was found to have pelvic abscesses infected with methicillin-resistant Staphyloccocus aureus. The purpose of this report is to raise awareness of a life-threatening complication of gynecologic pelvic surgery.
Asunto(s)
Absceso/diagnóstico , Enfermedades de los Genitales Femeninos/diagnóstico , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Prolapso de Órgano Pélvico/cirugía , Infecciones Estafilocócicas/diagnóstico , Absceso/tratamiento farmacológico , Absceso/etiología , Antibacterianos/uso terapéutico , Femenino , Enfermedades de los Genitales Femeninos/tratamiento farmacológico , Enfermedades de los Genitales Femeninos/etiología , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Humanos , Persona de Mediana Edad , Rifampin/uso terapéutico , Infecciones Estafilocócicas/tratamiento farmacológico , Infecciones Estafilocócicas/transmisión , Resultado del Tratamiento , Vancomicina/uso terapéuticoRESUMEN
BACKGROUND: Aspirin desensitization improves clinical outcomes in most patients with aspirin-exacerbated respiratory disease. Most protocols for desensitization are time-consuming. OBJECTIVE: Our objective was to use historical information about the course of aspirin desensitization to enhance the efficiency of the desensitization protocol. METHODS: Four hundred twenty subjects with suspected aspirin-exacerbated respiratory disease underwent oral aspirin challenges. Their clinical characteristics were analyzed in relation to features of reactions during aspirin challenges. RESULTS: Large (FEV(1) decrease >30%) and moderate (FEV(1) decrease 21% to 30%) bronchial reactions occurred in 9% and 20% of subjects, respectively. Multivariate analysis identified risk factors associated with these larger reactions, including lack of leukotriene modifier use, baseline FEV(1) of less than 80% of predicted value, and previous asthma-related emergency department visits. Seventy-five percent of patients reacted to a provoking dose of either 45 or 60 mg. Only 3% of initial reactions occurred after 150- or 325-mg provoking doses, and none occurred after the 650-mg dose. CONCLUSIONS: Most bronchial and naso-ocular reactions during oral aspirin challenges occurred within a narrow dosing range (45-100 mg). Only 1 of 26 patients without risk factors had a moderate reaction.
Asunto(s)
Aspirina/administración & dosificación , Asma/terapia , Desensibilización Inmunológica/métodos , Hipersensibilidad a las Drogas/complicaciones , Administración Oral , Adulto , Aspirina/efectos adversos , Aspirina/inmunología , Asma/inducido químicamente , Asma/inmunología , Asma/fisiopatología , Bronquios/efectos de los fármacos , Bronquios/fisiopatología , Pruebas de Provocación Bronquial , Hipersensibilidad a las Drogas/inmunología , Hipersensibilidad a las Drogas/fisiopatología , Humanos , Persona de Mediana Edad , Factores de RiesgoRESUMEN
NSAIDs-including aspirin (ASA)-that inhibit cyclooxygenase (COX)-1 induce nonallergic hypersensitivity reactions consisting of attacks of rhinitis and asthma. Such reactions occur exclusively in a subset of asthmatic patients who also have underlying nasal polyps and chronic hyperplastic eosinophilic sinusitis. We now refer to their underlying inflammatory disease of the entire respiratory tract as aspirin-exacerbated respiratory disease. This review focuses on descriptions of these patients; methods available to diagnose ASA-exacerbated respiratory disease; the unique ability of all NSAIDs that inhibit COX-1 to cross-react with ASA; lack of cross-reactivity with selective COX-2 inhibitors; an update on pathogenesis; and current thoughts about treatment, including ASA desensitization and daily ingestion of ASA itself.
Asunto(s)
Antiinflamatorios no Esteroideos/efectos adversos , Aspirina/efectos adversos , Asma/diagnóstico , Asma/terapia , Inhibidores de la Ciclooxigenasa/efectos adversos , Hipersensibilidad a las Drogas/diagnóstico , Hipersensibilidad a las Drogas/terapia , Sinusitis/diagnóstico , Sinusitis/terapia , Antiinflamatorios no Esteroideos/uso terapéutico , Aspirina/administración & dosificación , Asma/inducido químicamente , Inhibidores de la Ciclooxigenasa/administración & dosificación , Hipersensibilidad a las Drogas/etiología , Humanos , Sinusitis/inducido químicamenteRESUMEN
Opioid addiction is a world-wide tragedy, with severe consequences for both the victims and the society that must care for them. The pathways to addiction are multiple but postoperative opioid prescriptions for pain management are a major contributor to this crisis. This case report describes the differences in pain management during 2 different arthroplasties of the knees in the same person. After the first arthroplasty of the right knee 10 years ago, postoperative opioids were used, but after the second arthroplasty of the left knee in 2007, anti-inflammatory drugs took the place of opioids. The first postoperative treatment with opioids was marked by addiction and a nasty withdrawal. The recovery of knee function, driving, and return to work were prolonged. After the second arthroplasty in 2007, a combination of meloxicam (COX-2 inhibitor), high-dose acetaminophen (COX-1 inhibitor at higher doses), and diclofenac topical gel (COX-1 inhibitor with local effects) produced excellent pain control and significant reduction in swelling of the operated knee. The clinical course was smooth and recovery was rapid. The patient was walking normally and driving a car at 2 weeks and took an airplane trip at 4 weeks. After arthroplasty, postoperative opioids may not be necessary for most people.
Asunto(s)
Aspirina/efectos adversos , Hipersensibilidad a las Drogas/genética , Enfermedades Respiratorias/inducido químicamente , Enfermedades Respiratorias/genética , Hipersensibilidad a las Drogas/etiología , Hipersensibilidad a las Drogas/inmunología , Predisposición Genética a la Enfermedad , Humanos , Polimorfismo de Nucleótido Simple , Receptores Acoplados a Proteínas G/genética , Receptores Acoplados a Proteínas G/inmunología , Enfermedades Respiratorias/inmunologíaAsunto(s)
Antiinflamatorios no Esteroideos/administración & dosificación , Aspirina/administración & dosificación , Desensibilización Inmunológica/métodos , Hipersensibilidad a las Drogas/terapia , Interleucina-4/antagonistas & inhibidores , Trastornos Respiratorios/terapia , Antiinflamatorios no Esteroideos/farmacología , Aspirina/farmacología , Hipersensibilidad a las Drogas/etiología , Humanos , Trastornos Respiratorios/inducido químicamente , Resultado del TratamientoRESUMEN
INTRODUCTION: Aspirin-exacerbated respiratory disease is defined by the clinical tetrad of aspirin sensitivity, nasal polyps, asthma, and chronic rhinosinusitis. Patients experience acute upper and lower airway reactions with exposure to aspirin and other cyclooxygenase-1 inhibiting medications. However, airway inflammation and disease progression occur even in the absence of exposure to these medications, often leading to aggressive polyp formation and need for systemic corticosteroids to treat exacerbations in asthma and rhinosinusitis. Areas covered: This review focuses on the direct and indirect complications of aspirin-exacerbated respiratory disease. Current and potential management strategies are discussed with emphasis on aspirin desensitization. Expert commentary: Aspirin desensitization remains the gold standard of treatment. Demonstrated benefits of desensitization include improved symptom scores, reduction in use of systemic corticosteroids, slowing of polyp regrowth, and tolerance of aspirin and other NSAIDs for various therapeutic purposes. Continued investigation into the pathogenic mechanisms of AERD is likely to yield new diagnostic and therapeutic approaches.