Biologic Therapy and Aspirin Reactivity in Aspirin-Exacerbated Respiratory Disease: A Scoping Review

Aspirin-exacerbated respiratory disease (AERD) is defined by respiratory reactivity after COX-1 inhibition. This reactivity largely persists despite adequate control of the respiratory inflammation. More recently, monoclonal biologic agents targeting type 2 inflammation have been increasingly used in managing AERD and may significantly alter COX-1 reactivity.

To evaluate the effects of biologic therapies systematically on aspirin/COX-1 reactivity in patients with AERD.

A thorough literature review identified all studies evaluating the effects of omalizumab, dupilumab, mepolizumab, benralizumab, reslizumab, and tezepelumab on aspirin reactivity in AERD.

We preliminarily reviewed 652 articles and identified 23 for further evaluation and potential inclusion. Omalizumab and dupilumab were the most frequently studied biologics associated with complete or partial improvements in aspirin challenge thresholds. However, these studies are limited by small numbers and in many cases are not controlled. Evidence was minimal to nonexistent for the other biologics.

There are limited studies in the literature about biologic use specifically on COX-1 reactivity in AERD. Studies that have been completed are relatively small and predominantly nonrandomized. Larger studies are needed to provide a more precise measurement of the effect of the various therapies on aspirin reactivity in AERD. Methods to predict resolution of aspirin reactivity in AERD are needed to counsel patients appropriately. Given the widespread use of biologic therapies in AERD, the lack of understanding regarding residual COX-1 reactivity even when AERD is otherwise controlled presents an urgent future research need.