Nonsteroidal anti-inflammatory drug (NSAID) tolerance after biological therapy in patients with NSAID-exacerbated respiratory disease: a randomized comparative trial

Journal article

Background
There are no prospective studies comparing how biological therapies affect nonsteroidal anti-inflammatory drug (NSAID) tolerance in NSAID-exacerbated respiratory disease.

Objective
To study the induction of NSAID tolerance after biological therapy in patients with NSAID-exacerbated respiratory disease.

Methods
A prospective pilot study in a real-world clinic setting was conducted among subjects with severe asthma and type 2 inflammation. A random allocation of therapy was carried out: benralizumab, dupilumab, mepolizumab, or omalizumab. NSAID intolerance was confirmed by an oral challenge test (OCT) using acetyl-salicylic acid (ASA-OCT). The principal outcome was NSAID tolerance according to OCT before and after 6 months of each biological therapy (intragroup comparisons). As exploratory outcomes, we compared NSAID tolerance between biological therapies (intergroup comparisons).

Results
A total of 38 subjects were included; 9 received benralizumab, 10 dupilumab, 9 mepolizumab, and 10 omalizumab. There was an increase in the concentration needed to produce a reaction during ASA-OCT with omalizumab (P < .001) and dupilumab (P = .004) but not with mepolizumab and benralizumab. Omalizumab and dupilumab achieved the highest frequency of NSAID tolerance (omalizumab 60%, dupilumab 40%, mepolizumab 22%, and benralizumab 22%).

Conclusions
Biological therapies for asthma are useful for inducing NSAID tolerance; however, in patients with type 2 inflammation and high levels of total IgE, atopy, and eosinophils, anti-IgE or anti-IL4/13 seem to be more effective than antieosinophilic therapies. Omalizumab and dupilumab increased ASA tolerance, whereas mepolizumab and benralizumab did not. Future trials will be able to clarify this finding.

Authors: Sánchez, J; García, E; Lopez, J-F; Calle, A; Buendia, J-A

• Publication status: Published
• Peer review status: Peer reviewed
• Publisher: Elsevier
• Journal: Journal of Allergy and Clinical Immunology: In Practice
• Volume: 11
• Issue: 7
• Pages: 2172-2179
• Publication date: 2023-05-03
• Acceptance date: 2023-04-13
• DOI: 10.1016/j.jaip.2023.04.033
• EISSN: 2213-2198
• Language: English
• Keywords: dupilumab; mepolizumab; benralizumab; omalizumab; rhinosinusitis; acetylsalicylic acid; aspirin; nonsteroidal anti-inflammatory drug–exacerbated respiratory disease; Samter’s triad