Intranasal ketorolac challenge for the diagnosis of aspirin-exacerbated respiratory disease.
BACKGROUND
Intranasal administration of aspirin-lysine has been used in Europe for the diagnosis of aspirin-exacerbated respiratory disease. It has a low adverse effect profile and is believed to be safer for asthmatic patients, particularly those with a low baseline forced expiratory volume in 1 second, in whom oral aspirin challenge would be contraindicated. Ketorolac, a nonsteroidal anti-inflammatory drug useful for severe pain, is available in the United States in parenteral form.


OBJECTIVE
To determine whether ketorolac nasal challenge has acceptable specificity and sensitivity for diagnosing aspirin-exacerbated respiratory disease.


METHODS
Twenty-nine patients with suspected aspirin-exacerbated respiratory disease were challenged with nasal ketorolac before oral challenge and desensitization with aspirin. Symptoms, objective changes in nasal examination findings, and peak nasal inspiratory flow values were recorded. Nasal lavage fluid for cysteinyl leukotriene analysis was collected. Ketorolac doses of 2.1, 5.2, or 7.8 mg were administered and compared with the results of oral aspirin challenge.


RESULTS
Eighteen patients had a positive challenge reaction to oral aspirin. Ketorolac nasal inhalation had a sensitivity of 78% and a specificity of 64%. Patients in the reactor group had significantly higher levels of cysteinyl leukotrienes after ketorolac challenge than in the nonreactor group. Mild bronchospasm occurred in 3 patients, and 2 of these occurred at higher starting doses of ketorolac.


CONCLUSIONS
Nasal ketorolac administration is a reasonably accurate and safe method for diagnosing aspirin-exacerbated respiratory disease.
White
Andrew
A
Department of Allergy, Asthma, and Immunology, Scripps Clinic, La Jolla, California, USA. drew_white@hotmail.com
Bigby
Timothy
T
Stevenson
Donald
D
D000281:Administration, Intranasal; D001241:Aspirin / Q000009:adverse effects*; D016861:Cyclooxygenase Inhibitors / Q000008:administration & dosage*; D004305:Dose-Response Relationship, Drug; D004342:Drug Hypersensitivity / Q000175:diagnosis*; D004797:Enzyme-Linked Immunosorbent Assay; D006801:Humans; D020910:Ketorolac / Q000008:administration & dosage*; D015289:Leukotrienes / Q000032:analysis; D017817:Nasal Lavage Fluid / Q000737:chemistry; D009299:Nasal Provocation Tests / Q000379:methods; D010865:Pilot Projects; D011453:Prostaglandins / Q000032:analysis; D012140:Respiratory Tract Diseases / Q000139:chemically induced / Q000175:diagnosis*; D012680:Sensitivity and Specificity
D016861:Cyclooxygenase Inhibitors; D015289:Leukotrienes; D011453:Prostaglandins; D001241:Aspirin; D020910:Ketorolac