Case Presentation: A 64-year old female with aspirin-exacerbated respiratory disease (AERD) with severe persistent asthma who had previously undergone aspirin desensitization now taking aspirin 650mg in the morning and 325mg at bedtime presented for total knee arthroplasty (TKA).
The surgeon preferred cessation of aspirin 1 week preoperatively and a maximum dose of 325mg daily postoperatively for 2 weeks due to bleeding risks. Her allergist recommended perioperative management as shown in Table 1.

The patient followed her allergist’s instructions and underwent uncomplicated TKA. On POD 0, she was wheezing with sustained hypoxia. The consulting hospitalist recommended continuing bronchodilators, resuming aspirin as recommended by her allergist, and steroids if clinically worsening. Scheduled celecoxib was discontinued and acetaminophen was dose reduced.

On POD 1, the hospitalist was concerned about an AERD exacerbation given persistent hypoxia, congestion and cough. Infectious workup was negative. The hospitalist coordinated a discussion with the allergist and orthopedist. The maintenance aspirin regimen was resumed on POD 2. The patient was weaned off oxygen by POD 3 and her hemoglobin nadired at 8.5g/dL attributed to expected blood loss. She was discharged home on POD 4.

Discussion: AERD (or Samter’s triad) is the triad of asthma, chronic rhinosinusitis (CRS) with nasal polyps, and acute respiratory tract reactions to aspirin and NSAIDs affecting cyclooxygenase-1 (COX-1) production resulting in bronchospasm, laryngospasm, rhinitis and conjunctivitis. AERD is present in 5-7% of asthmatics and 15% of severe asthmatics. Patients with AERD avoid aspirin and NSAIDs, or undergo aspirin desensitization which improves asthma, CRS and nasal polyposis. Desensitized patients are treated with maintenance doses of aspirin 325-650mg twice daily.

Missed aspirin doses during maintenance are managed as shown in Table 2.

Many patients with AERD tolerate selective NSAIDS including COX-2 inhibitors. However, patients with severe respiratory disease who are not desensitized may react to COX-2 inhibitors and high-dose acetaminophen (≥1000mg doses).

There are no management guidelines for desensitized patients with AERD at high-risk of perioperative bleeding. Surgery in this case required perioperative aspirin dose reduction, but cessation was less than 48 hours obviating the need for desensitization.

Conclusions: No guidelines exist for the management of patients with AERD who are stable on high-dose aspirin after desensitization and at risk for perioperative bleeding. Hospitalists should be familiar with the importance of aspirin maintenance in patients with AERD, including the 2-3 day refractory period when aspirin can be safely held perioperatively, and the need for full desensitization after 5 days. NSAIDs, or high-doses of COX-2 inhibitors or acetaminophen may trigger respiratory symptoms when a patient is not desensitized. This case illustrates the successful multidisciplinary perioperative management of aspirin-desensitized AERD.

IMAGE 1: Table 1: Allergist recommendation for perioperative aspirin management

IMAGE 2: Table 2: Management of aspirin interruption during maintenance phase in desensitized patients