Samter’s Triad: Symptoms, Diagnosis and Treatment

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Samter’s triad, also known as aspirin-exacerbated respiratory disease, is a condition of asthma, nasal polyps, and sensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs). It is named after allergist Max Samter, who published research on the subject in the 1950s and suggested the symptoms were due to disease of the whole airway.

Read on to learn more about this disease, its symptoms, and its management.

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Samter’s Triad Symptoms

Aspirin-exacerbated respiratory disease is known as Samter’s “Triad” because of the three classic findings of NSAID sensitivity, nasal polyps, and asthma.

Signs and symptoms include the following:

  • Nasal polyps, which are extra growths of tissue in the nasal cavity, which may be associated with a runny nose and discomfort
  • Sensitivity to NSAIDs, with symptoms such as difficulty breathing, coughing, rash, itching, and red, watery eyes after taking NSAIDs
  • Rhinosinusitisor inflammation of the nasal passages
  • Asthma, which usually begins later in adolescence or adulthood, later than is typical for asthma
  • Decreased sense of smell
  • High levels of blood cells called eosinophilswhich are involved in inflammation and allergic reactions

Samter’s triad is more common in women and is estimated to affect less than 1% of people, but up to 10% of people with asthma in adulthood.

What are NSAIDs?

NSAIDs are drugs with anti-inflammatory, analgesic and antipyretic properties. Commonly used NSAIDs include Aspirin (acetylsalicylic acid), Alleve (naproxen), Motrin, and Advil (ibuprofen). NSAIDs work by blocking an enzyme called cyclooxygenase (COX), which is involved in activating proteins involved in inflammation, blood clotting, and pain sensation, among other roles.

causes

The cause of aspirin-exacerbated respiratory illness still remains somewhat unclear. Scientists have found that people with AERD have different levels of various inflammatory proteins, including cysteinyl leukotriene (CysLT) and prostaglandin D2.

Only 1-2% of people with AERD appear to have a number of affected family members, suggesting the possibility of an inherited genetic cause. Another explanation that may explain the absence of heredity in most people and the late onset of symptoms may be epigenetics changes. Epigenetics refers to changes in gene expression which can be thought of as an on/off switch to make specific proteins or not.

Diagnostic

Unlike many allergic syndromes diagnosed with skin tests, AERD does not usually present with abnormalities on skin tests. Rather, it requires a medical history, physical exam, and “NSAID challenge test.”

When taking a medical history, a health care provider will ask about symptoms, reactions to medications, such as aspirin and other NSAIDs, and family history. The physical exam will include an examination of the nasal cavity to look for polyps.

In an NSAID challenge test, aspirin or another NSAID is given in a monitored setting. Symptoms are usually evident within 30 minutes to 3 hours. Pulmonary function tests, which require measuring lung volumes and exhalation force, are done as part of challenge testing.

Treatment

Treatment for AERD involves avoiding triggers, taking medication to relieve symptoms, and possible surgery.

Avoid triggers

Sensitivity to NSAIDs is a hallmark of AERD, so these drugs should be avoided. If you have an AERD, be sure to pay close attention to the ingredients of the medications. Look for NSAIDs often found in cough and cold medicines and headache medications. Tylenol (acetaminophen) can be a good alternative to NSAIDs when needed for pain or fever. However, some people with AERD may also be sensitive to Tylenol.


Avoiding drugs is not always enough. Certain spices, foods, and beverages can also trigger adverse symptoms in people with AERD. Keeping a journal of your diet and your symptoms can help uncover aggravating foods.

The following foods and beverages may contain salicylates and cause symptoms in some people with AEDR:

  • Alcohol (especially red wine and beer)
  • Certain vegetables such as broccoli, peas, radishes and sun-dried tomatoes
  • Certain fruits like avocado, cranberries, raisins, and pineapple
  • Herbs and spices like cinnamon, paprika and rosemary
  • Seeds and nuts such as almonds, pine nuts and pistachios

Medications

Symptoms of AERD can be significantly improved with certain medications. Your allergist may prescribe the following medications to help you:

  • Nasal corticosteroids, given as a nasal spray, for symptoms of rhinosinusitis.
  • Asthma medications, including steroids and rescue inhalers.
  • Biological therapies are reserved for more severe cases of AERD that do not respond to other therapies. These drugs impair the immune system and can be very effective, but at the cost of immunosuppression.

Nasal surgery

Nasal polyps can not only be uncomfortable, but also cause problems with breathing and sleeping. For those with significant symptoms of nasal polyps, surgery to remove them may be performed. Nasal polyps can grow back, so further surgery may be needed.

Desensitization therapy

It is not always possible to avoid NSAIDs, for example when aspirin is needed to treat certain forms of heart disease. In these cases, desensitization is carried out under medical observation by introducing very small doses of aspirin and slowly increasing the dose over time. Once the required dose is reached, it should be taken every day without missing a dose, otherwise the process has to start all over again.

Desensitization has also been shown to delay the growth of nasal polyps and improve other symptoms of AERD.

Summary

Samter’s triad, also known as AERD, is an immune disease characterized by nasal polyps, asthma, and sensitivity to NSAIDs. Although Samter’s triad is rare in the general population, people with asthma beginning in adulthood, especially those with nasal polyps, have a much higher likelihood of having this condition.

The causes of AERD are unclear, but epigenetic factors appear to play a role in abnormal levels of specific proteins that play a role in the immune response. Treatment may involve medication, surgery to remove nasal polyps, and avoidance or desensitization to NSAIDs.

A word from Verywell

Medication sensitivities can be extremely frightening, especially when they cause symptoms such as shortness of breath with airway obstruction, which can be life-threatening. If you’re concerned about sensitivity to NSAIDs or have been diagnosed with AERD, know which medications and foods to avoid. As asthma in the Samter’s Triad can be severe, it is essential to have an asthma action plan and to have the prescribed reliever inhalers on hand at all times.

Verywell Health only uses high quality sources, including peer-reviewed studies, to support the facts in our articles. Read our editorial process to learn more about how we fact check and ensure our content is accurate, reliable and trustworthy.

  1. Samter Society. The history of the AERD (Triad of Samter).

  2. Taniguchi M, Mitsui C, Hayashi H, et al. Aspirin-exacerbated respiratory disease (AERD): current understanding of AERD. Allergol International. 2019 Jul;68(3):289-295. doi:10.1016/j.alit.2019.05.001

  3. American Academy of Allergy, Asthma and Immunology. Nasal polyps.

  4. Kim SD, Cho KS. Samter’s triad: state of the art. Clin Exp Otorhinolaryngol. 2018;11(2):71-80. doi:10.21053/ceo.2017.01606

  5. American College of Rheumatology. NSAIDs (nonsteroidal anti-inflammatory drugs).

  6. Badrani JH, Doherty TA. Cellular interactions in respiratory diseases exacerbated by aspirin. Curr Opin Allergy Clin Immunol. 2021;21(1):65-70. doi:10.1097/ACI.0000000000000712

  7. Centers for Control and Prevention of Disasters. What is epigenetics?

  8. Samter Society. Avoid NSAIDs.

  9. Worker AD, Bleier BS. Biologic therapies versus surgical management of aspirin-exacerbated respiratory disease: a review of preliminary evidence, effectiveness, and cost. World J Otorhinolaryngol Head and Neck Surgery. 2020;6(4):230-234. doi:10.1016/j.wjorl.2020.06.002

  10. American Academy of Allergy, Asthma and Immunology. Respiratory disease exacerbated by aspirin.

By Angela Ryan Lee, MD

Angela Ryan Lee, MD, is board certified in Cardiovascular Diseases and Internal Medicine. She is a Fellow of the American College of Cardiology and holds certifications from the American Society of Nuclear Cardiology and the National Board of Echocardiography. She completed undergraduate studies at the University of Virginia with a BS in Biology, medical school at Jefferson Medical College, and an internal medicine residency and cardiovascular disease fellowship at George Washington University Hospital. His professional interests include preventive cardiology, medical journalism and health policy.

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