Samter's triad
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Synonyms and keywords: AERD (aspirin-exacerbated respiratory disease); AIAR (aspirin-induced asthma and rhinitis); Widal's triad; Francis' triad; aspirin triad; aspirin allergy (a misnomer); aspirin intolerance
Overview
Samter's triad is a medical condition consisting of asthma, aspirin sensitivity, and nasal polyposis. It occurs in mid-life (twenties and thirties are the most common onset times) and may not include any allergies. It is also known as aspirin-sensitive asthma, aspirin triad, Widal's triad, and aspirin induced asthma and rhinitis (AIAR).
History and Symptoms
Most commonly, the first symptom is rhinitis (inflammation of the nose), which might be described as sneezing, a runny nose, or congestion. The disorder typically progresses to asthma, then polyposis, with aspirin sensitivity coming last. The aspirin reaction can be severe, including an asthma attack, anaphylaxis, and urticaria in some cases. Patients typically react to other NSAIDS such as ibuprofen, although Tylenol (acetaminophen or paracetamol) is generally considered safe.
Anosmia (lack of smell) is also typical, as the inflammation reaches the olfactory receptors in the nose.
Treatment
The preferred treatment now is desensitization to aspirin, undertaken at a clinic specilizing in such treatment, as the Allergy Dept. at Scripps Clinic in San Diego, CA. Patients who are desensitized then take a maintenance dose of aspirin daily; they have reduced need for supporting medications and fewer asthma and sinusitis symptoms than previously; many have an improved sense of smell. Treatment formerly focused on relieving the symptoms. Even desensitized people may continue to use nasal steroids, inhaled steroids, and leukotriene antagonists. Occasionally surgery may be required to remove polyps, although they typically recur, particularly if desensitization is not undertaken. Some patients require oral steroids to alleviate asthma and congestion, and most patients will have recurring or chronic sinusitis due to the nasal inflammation. Desensitization reduces the chance of recurrence.
The cause of Samter's triad is unknown, but it is widely believed that the disorder is caused by an anomaly in the arachidonic acid cascade, which causes undue production of leukotrienes, a series of chemicals involved in the body's inflammatory response. When prostaglandin production is blocked by NSAIDS like aspirin, the cascade shunts entirely to leukotrienes, producing the severe allergy-like effects.
Leukotriene antagonists and inhibitors such as Singulair, Accolate, and Zyflo are helpful in treating Samter's. A diet low in omega-6 oils (precursors of arachidonic acid), and high in omega-3 oils, may also help. Ongoing study at the Scripps clinic suggests that aspirin desensitization may be beneficial, but the procedure is dangerous due to the risk of asthma events or urticaria, if not done under medical supervision.
Some people gain relief through use of the Feingold diet (Stage One) which eliminates not only aspirin-containing products, but dietary salicylates (which are different from aspirin). Although this diet is commonly thought of as a treatment for ADHD, it was originally developed for asthma, urticaria, and nonspecific allergies. The Feingold Association of the United States provides a comprehensive Foodlist & Shopping Guide with monthly updates - The entire "Stage One" section eliminates salicylates as well as the synthetic food dyes which have been shown to produce cross-sensitization. More information on identification of salicylates can be found at the Feingold Association's page.
A sufferer who has not yet experienced asthma or aspirin sensitivity might be diagnosed as having:
- Non-allergic rhinitis
- Nonallergic rhinitis with eosinophilia syndrome (NARES)