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Beneficial effect of nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors in patients with asthma during viral infection.

To the Editor—I read with interest the report by Seymour et al. [1] regarding the induction of 5-lipoxygenase and cyclooxygenase-2 (COX-2) in the bronchial airway during experimental rhinovirus infection in nonatopic subjects and their suggestion that leukotriene-modifying agents or COX-2 inhibitors may benefit the prevention of viral induced wheezing in patients with asthma. Several years ago, I proposed that the increased prevalence of childhood asthma was related to the decreased use of aspirin in children because of the threat of Reye syndrome [2] and suggested that the use of nonsteroidal anti-inflammatory drugs (NSAIDs) that inhibit COX-2 could prevent virus-induced asthma attacks if taken at the onset of symptoms of a viral respiratory tract infection [3]. Patients with asthma have been told to avoid the use of aspirin and NSAIDs because of concern over hypersensitivity reactions to these agents. However, recent data suggest that the use of acetaminophen, the preferred analgesic and antipyretic agent, may be associated with an increased incidence and severity of asthma symptoms [4]. Indeed, Lesko et al. [5] recently reported that the use of ibuprofen, as opposed to acetaminophen, reduced by half the risk of asthma attacks in a double-blinded study of 11800 children with asthma and febrile respiratory tract infection. Therefore, in my practice, I have encouraged the use of ibuprofen for children (because aspirin and NSAID sensitivity is rare) and selective COX-2 inhibitors for adults (which appear to be safe even in patients with documented aspirin sensitivity [6, 7]) at the onset of symptoms of a respiratory viral infection. Although it seems that this treatment has been successful, this remains anecdotal in nature. Therefore, I recently performed a survey of 121 pediatric and adult patients with mild-intermittent to severe-persistent atopic asthma in my practice to ascertain retrospectively whether the treatment was truly of benefit. Viral respiratory tract infections increased asthma symptoms in 76% of the patients, and 54% of patients required systemic corticosteroids for virus–induced asthma exacerbations. NSAIDs or COX-2 inhibitors had been used by 44% of the patients to prevent virus-induced asthma exacerbations. In these patients, 83% thought NSAID or COX2 inhibitor treatment was beneficial, and 85% said they planned to take the medication in the future to prevent virus-induced asthma attacks. More important, 77% of the patients who had required systemic corticosteroids for virus-induced asthma exacerbations found the treatment to be helpful, confirming my impression that the need for steroids had decreased in these patients. These data, along with the report by Lesko et al. [5], suggest that patients with asthma prone to attacks with respiratory tract viral infections may experience benefit with use of NSAIDs and COX-2 inhibitors at the onset of symptoms of a respiratory tract viral infection. Asthma exacerbations due to viral infection continue to be the Achilles’ heel of present asthma therapy, and, hopefully, this report will encourage further study of these medications in viral-induced asthma, as Seymour et al. [1] suggest.