Alcohol Triggers Symptoms in Some Aspirin-Associated Asthma

SAN ANTONIO, Texas — Alcohol-induced respiratory symptoms, primarily in the upper airway, are reported by the majority of patients with aspirin-exacerbated respiratory disease, according to the preliminary findings of a new survey.

This is the first report of this association, Tanya Laidlaw, MD, told Medscape Medical News. "It's really never been talked about in the literature, and those of us who see it all the time have never learned about it at all," said Dr. Laidlaw, from Brigham and Women's Hospital in Boston, Massachusetts, adding that this information is now included in advice to patients.

"We not only warn them that it can happen, but we're also starting to think it might help us in some diagnoses, because there are many more [people] who have tried alcohol than who have tried aspirin."

The study was shown at a news conference in advance of its presentation here at the American Academy of Allergy, Asthma & Immunology (AAAAI) 2013 Annual Meeting.

The work is ongoing; investigators aim to recruit 80 patients in 4 groups but so far have recruited 132 individuals. Participants completed a questionnaire designed to assess self-reported rates of alcohol-associated upper respiratory symptoms (rhinorrhea, nasal congestion) and lower respiratory symptoms (wheezing, dyspnea).

Among the patients with aspirin-exacerbated respiratory disease, 79% reported either upper or lower alcohol-related respiratory symptoms compared with 44% of aspirin-tolerant patients (P = .001)

Table 1. Prevalence of Upper and Lower Respiratory Alcohol-Induced Symptoms

Patients (n = 132)	All Respiratory Symptoms (%)	P-Value
Aspirin-exacerbated respiratory disease (n = 40)	79	= .001
Aspirin-tolerant asthma (n = 41)	44	= .001
Aspirin-tolerant chronic rhinitis (n = 20)	35	= .001
Healthy control participants (n = 28)	14	< .001

Table 2. Frequency of Upper Respiratory Alcohol-Induced Symptoms

Patients (n = 132)	Upper Respiratory Symptoms (%)	P-Value
Aspirin-exacerbated respiratory disease (n = 40)	74	< .001
Aspirin-tolerant asthma (n = 41)	34	< .001
Aspirin-tolerant chronic rhinitis (n = 20)	35	= .003
Healthy control participants (n = 28)	14	<.001

Table 3. Frequency of Lower Respiratory Alcohol-Induced Symptoms

Patients (n = 132)	Lower Respiratory Symptoms (%)	P-Value
Aspirin-exacerbated respiratory disease (n = 40)	51	= .012
Aspirin-tolerant asthma (n = 41)	24	= .012
Aspirin-tolerant chronic rhinitis (n = 20)	0	< .001
Healthy control participants (n = 28)	0	<.001

The effects of alcohol did not seem to be dose-dependent, noted Dr. Laidlaw. "For many of them, it's within several sips."

In terms of type of alcohol, one half of the aspirin-exacerbated patients and 35% of the aspirin-tolerant patients reported equivalent symptoms with all types of alcohol. However, 29% of the aspirin-exacerbated patients and 12% of the aspirin-tolerant patients reported red wine as a specific trigger. White wine and liquor were each reported by 6% of aspirin-exacerbated patients and 12% of aspirin-tolerant patients. Others flagged beer as the culprit (9% of aspirin-exacerbated patients compared with 29% of aspirin-tolerant patients).

Red Wine a Trigger

Dr. Laidlaw said that the majority of patients experiencing symptoms decreased their alcohol consumption as a result of their reaction.

Clinicians should be aware that alcohol-related reactions are significantly more common in patients with asthma, she said, adding that the mechanism of action is not well understood.

One hypothesis is that it may be due to alcohol-induced increases in cysteinyl leukotrienes, she suggested.

Asked by Medscape Medical News to comment on this study, Jonathan Bernstein, MD, from the University of Cincinnati in Ohio, said, "This is an interesting hypothesis and warrants further investigation, but they're going to need to tie it to some mechanistic effect."

He pointed out, "I have people who drink alcohol and flush or get headaches or congestion — alcohol is a trigger for allergic rhinitis — but alcohol-induced asthma is not a common problem."

Dr. Bernstein, who is also editor-in-chief of the Journal of Asthma, questioned whether the problem could be related to sulfites. "There's cross-reactivity between sulfites and aspirin," he said. "Alcohol and aspirin may have common pathways of action. An explanation in my mind is that this is working through chemoreceptors."

This study was funded by the National Institutes of Health and a contribution from the Vinik family. Dr. Laidlaw and Dr. Bernstein have disclosed no relevant financial relationships.

The American Academy of Allergy, Asthma & Immunology (AAAAI) 2013 Annual Meeting. Abstract L7. Presented at a press conference February 23, 2013.