Aspirin-induced asthma

Samter's triad is a medical condition consisting of asthma, aspirin sensitivity, and nasal/ethmoidal polyposis. It occurs in middle age (twenties and thirties are the most common onset times) and may not include any allergies.

Signs and symptoms
Most commonly, the first symptom is rhinitis (inflammation or irritation of the nasal mucosa), which can manifest with symptoms of sneezing, 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 paracetamol (known as acetaminophen in the United States) is generally considered safe.

Anosmia (lack of smell) is also typical, as the inflammation reaches the olfactory receptors in the nose.

Cause
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, causing overproduction of LT-4 and producing the severe allergy-like effects.

There may be a relationship between aspirin-induced asthma and TBX21, PTGER2, and LTC4S.

In addition to aspirin, other vaso-dilators may induce the same reaction, such as alcohol.

Medication
The preferred treatment now is desensitization to aspirin, undertaken at a clinic specializing in such treatment. 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.

Leukotriene antagonists and inhibitors (montelukast, zafirlukast, and zileuton) are helpful in treating Samter's.

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.

Surgery
Occasionally surgery may be required to remove polyps, although they typically recur, particularly if desensitization is not undertaken.

Diet
A diet low in omega-6 oils (precursors of arachidonic acid), and high in omega-3 oils, may also help.

Some people find relief of symptoms by following a low-salicylate diet such as the Feingold diet. They may need to eliminate the other salicylate-containing foods identified by Swain in 1985 as well. For those who need them, these salicylates are listed in charts in the Feingold Handbook based on level of salicylate measured in the item. Unfortunately, any such list is only a rough guideline since amounts will vary depending on fruit/vegetable variety and where grown; in fact, organic foods have been shown to contain more salicylate than conventional produce because the plant is more likely to be under attack from pests, and salicylate is produced by the plant as protection.

Alternate and related names
Samter's triad goes by several other names:
 * Acetylsalicylic acid triad
 * Widal's triad
 * Francis' triad
 * Aspirin triad

"AERD" ("aspirin-exacerbated respiratory disease") adds chronic rhinosinusitis to the triad. Similarly, "AIAR" ("aspirin-induced asthma and rhinitis") by definition includes rhinitis.

A sufferer who has not yet experienced asthma or aspirin sensitivity might be diagnosed as having:
 * Non-allergic rhinitis
 * Non-allergic rhinitis with eosinophilia syndrome (NARES)

History
It is named for Max Samter.

Initial reports on the link between asthma, aspirin and nasal polyposis were made by Widal in 1922. Further studies were done by Samter & Beers in reports published in 1968.