HOUSTON – About 63% of allergists and fellows in training perform aspirin desensitization for aspirin-exacerbated respiratory disease, according to a national survey.
That figure is lower than it should be, given the wealth of published evidence that aspirin desensitization is a safe and effective component of the treatment of aspirin-exacerbated respiratory disease (AERD), Dr. Jeremy D. Waldram asserted in presenting the survey findings at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
Moreover, the figure likely overcalls the true rate, since participation in the survey was voluntary and fans of aspirin desensitization were probably more inclined to complete the 16-item questionnaire, added Dr. Waldram, a fellow in allergy and immunology at the Scripps Clinic in San Diego.
Bruce Jancin/Frontline Medical News
Dr. Jeremy D. Waldram
Was he surprised to find that aspirin desensitization isn’t more widely utilized?
“I think the number that surprised me more was that among the 37.5% of allergists who don’t do aspirin desensitization, almost 30% of them don’t even refer their patients to others who do the procedure. We don’t know why they don’t refer out; it wasn’t a question included in the survey. Perhaps they see patients who are of a less severe phenotype,” he said in an interview.
The 684 survey responses represented a 15% response rate. While 37.5% of respondents indicated they don’t perform aspirin desensitization, 73% of those who reported doing the procedure said they do an average of 1-5 cases annually.
Among allergists who don’t perform aspirin desensitization, safety concerns were the leading reason cited. Indeed, 70% of those who don’t do aspirin desensitization indicated safety risks were the main reason. More than one reason could be given, however, and 30% of allergists cited poor compensation for the procedure as a deterrent, nearly 60% said the logistics of monitoring care were too onerous, and one-third said they didn’t perform aspirin desensitization because they hadn’t been trained to do it.
Of allergists who reported doing aspirin desensitization, 52% perform the procedure in an outpatient setting unattached to a hospital. Another 21% do so in an outpatient clinic that’s physically attached to a hospital.
Within the past 5 years, 9% of respondents said that they’ve had a patient react severely to aspirin desensitization, requiring an unanticipated transfer to a higher level of care. That’s contrary to the experience among allergists at the Scripps Clinic, which is widely credited with pioneering the outpatient approach.
“We essentially do all our aspirin desensitizations for AERD in the outpatient setting. In 1,500 treated patients we’ve never had one that we had to transfer to a higher level of care. We don’t have any special setup. It’s a typical outpatient clinic. We usually don’t start IVs or do anything above and beyond,” Dr. Waldram said.
While 26% of respondents reported they generally recommend aspirin desensitization immediately upon identifying a patient history that supports the diagnosis of AERD, another 54% said they usually recommend the procedure to patients only after they’ve failed to improve on typical medical therapy.
Twenty percent of physicians rated aspirin desensitization as “extremely helpful for the majority of patients,” another 49% said they find it most beneficial as an adjuvant to ongoing medical therapy.
Forty-four percent of allergists who perform aspirin desensitization reported that they learned to do the procedure during fellowship training. Fourteen percent said they learned to the procedure at an annual meeting, and 36% picked it up by reviewing the relevant literature.
Several allergists commented that had Dr. Waldram’s survey been conducted even a couple of years ago the rate of utilization of aspirin desensitization would have been far lower. They interpreted his reported 62.5% rate as a sign of progress. Dr. Waldram said he believes the key to further boosting utilization of aspirin desensitization lies in increasing exposure to the procedure during fellowship training. He noted that internal medicine-trained fellows who responded to the survey had a significantly higher aspirin desensitization utilization rate than those who came to their allergy fellowship with a background in pediatrics.
The hallmarks of AERD are difficult-to-treat nasal polyps, chronic eosinophilic sinusitis, and asthma in a patient with sensitivity to aspirin and other COX-1 inhibitors.
Dr. Waldram reported having no financial conflicts with regard to his study, which was conducted free of commercial support.