COX-2 Inhibitors Are Safe in Patients with Aspirin-Exacerbated Respiratory Disease

Summary and Comment |
July 24, 2014

COX-2 Inhibitors Are Safe in Patients with Aspirin-Exacerbated Respiratory Disease

  1. David J. Amrol, MD

A meta-analysis shows that AERD patients usually will tolerate celecoxib better than meloxicam.

  1. David J. Amrol, MD

The triad of asthma, aspirin sensitivity, and nasal polyposis is known as aspirin-exacerbated respiratory disease (AERD). AERD is caused by inhibition of the cyclooxygenase (COX)-1 enzyme, which, in susceptible patients, causes high cysteinyl leukotriene levels and resulting asthma and rhinitis symptoms. All nonsteroidal anti-inflammatory drugs (NSAIDs) carry an FDA contraindication for patients with AERD, but such patients usually tolerate COX-2 inhibitors.

To examine the safety of COX-2 inhibitors (i.e., celecoxib and rofecoxib) or traditional NSAIDs with relatively high COX-2 selectivity (e.g., meloxicam) in AERD patients, researchers analyzed 14 blinded, placebo-controlled trials (426 patients). No patient who received COX-2 inhibitors reported AERD symptoms; such symptoms were reported by about 8% of those who received relatively selective drugs such as meloxicam.


Traditional NSAIDs with relatively high COX-2 selectivity are 10 times more selective for COX-2 than for COX-1, whereas COX-2 inhibitors are >100 times more selective for COX-2. In AERD patients who require anti-inflammatory or analgesic agents other than low-dose acetaminophen, celecoxib is a safe option. If price is a barrier, most patients will tolerate meloxicam, but, because life-threatening reactions can occur, meloxicam should be given to AERD patients only in facilities that are prepared to treat severe respiratory reactions.

Editor Disclosures at Time of Publication

  • Disclosures for David J. Amrol, MD at time of publication Equity Abbott; AbbieVie; Express Scripts; Johnson and Johnson; Novartis; Pfizer; United Health Leadership positions in professional societies Allergy Society of South Carolina (Past President)


Reader Comments (4)


Yes, an IgE mediated reaction is different than AERD but IgE mediated reactions are much less common in NSAIDS and almost unheard of to aspirin. If you have an immediate IgE mediated reaction to an NSAID it can be NSAID specific and not a class effect.
Typically an ant- leukotriene medication is used with a ICS/LABA for aspirin desensitization in a AERD patient

alan garcia gtz Medical Student, GDL

the best article of asthma

Marc Baskin Physician, Allergy/Immunology

As I understand, anaphylaxis is a different animal than an acute respiratory reaction in AERD syndrome and it may not be safe to use a cox 2 inhibitor.
It is correct that a LTA preferably enzyme inhibitor (ie. Zyflo) provides added safety to a ASA challenge in AERD

DARRELL MCINDOE Physician, Internal Medicine, retired

This is signifigant information. As a person who had anaphylaxis to aspergum as a teenager and subsequent angioneurotic edema and giant urticaria to codeine, this solves my dilemma. I recently developed a fixed drug reaction to Tylenol and Darvon which I have used for years is no longer available. I will plan on using celecoxib the next time I need an analgesic, but have epinephrine handy. Would it also be wise to consider using montelukast on a chronic basis?

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