The Management of NSAID-ERD Patients in the Current Treatment Landscape: Aspirin Desensitization, Biologics, Both, or Neither?

Abstract

The management of nonsteroidal anti-inflammatory drug-exacerbated respiratory disease has undergone a fundamental shift over the past decade with the emergence of respiratory biologics. Characterized by the clinical triad of asthma, chronic rhinosinusitis with nasal polyps (CRSwNP), and hypersensitivity to cyclo-oxygenase-1 inhibition, the disease is marked by aggressive type 2 inflammation and eicosanoid dysregulation. This review evaluates the strategic balance between aspirin therapy after desensitization (ATAD) and targeted biologics in the modern treatment landscape. Although ATAD remains a high-value, cost-effective, disease-modifying intervention, its clinical success is often contingent on comprehensive surgical debulking and strict daily adherence. Conversely, the existing respiratory biologics available for the treatment of CRSwNP, including dupilumab, omalizumab, mepolizumab, tezepelumab, and, in Europe, depemokimab, offer potent, nonsurgical alternatives that target specific inflammatory pathways. Despite these clinical gains, the high financial cost of biologics remains a barrier compared with the pharmacoeconomic superiority of postoperative ATAD. For refractory cases, combination therapy or a stepwise strategy may be necessary. Ultimately, a multidisciplinary, individualized approach is essential to optimize outcomes in this complex patient population.