If you have asthma and reach for an over-the-counter painkiller like ibuprofen or aspirin for a headache, you could be setting off a silent storm in your lungs. For about 7% of people with asthma, these common drugs don’t just fail to help-they can trigger breathing emergencies. This isn’t an allergy. It’s something called NSAID-Exacerbated Respiratory Disease, or NERD. And it’s more common than most people realize.
What Exactly Is NERD?
NERD, also known as Aspirin-Exacerbated Respiratory Disease (AERD), isn’t just a bad reaction to medicine. It’s a chronic condition where the body’s inflammatory response goes haywire after taking NSAIDs. These include aspirin, ibuprofen, naproxen, diclofenac, and others. The reaction usually hits within 30 minutes to three hours. Symptoms can include sudden nasal congestion, runny nose, wheezing, chest tightness, and full-blown asthma attacks. In rare cases, it can lead to life-threatening bronchospasm.
What makes NERD different from regular asthma is how it develops. Most people with NERD already have chronic rhinosinusitis with nasal polyps-swellings inside the nose that block airflow. These polyps often appear years before asthma symptoms start. Many patients report having stuffy noses and reduced sense of smell for 1 to 5 years before their asthma diagnosis. By the time they’re diagnosed with NERD, they’re usually in their 30s or 40s. It’s rare for someone under 20 to be diagnosed.
Why Do NSAIDs Trigger This?
It’s not about being allergic to the drug. It’s about how your body handles inflammation. Normally, your body breaks down fatty acids into compounds that either calm inflammation (like prostaglandin E2) or stir it up (like leukotrienes). NSAIDs block an enzyme called COX-1, which shuts down the calming pathway. That forces your body to overproduce the inflammatory leukotrienes instead.
This imbalance is especially bad in people with NERD. Studies show their nasal and lung tissues already make less protective prostaglandin E2. When they take an NSAID, it’s like flipping a switch-suddenly, the inflammatory floodgates open. That’s why even low-dose aspirin (75mg) can trigger a reaction in the most sensitive people.
Who’s at Risk?
Not everyone with asthma has NERD. But certain patterns make it more likely:
- You have chronic rhinosinusitis with nasal polyps (40-50% of these patients have NERD)
- You’re female (about 70% of diagnosed cases are women)
- You’re between 20 and 50 years old
- You’re overweight or have a history of smoking
- You’ve had asthma for a while, especially if it’s hard to control
- You have a family history of asthma or allergic rhinitis
If you fit even two of these, you should be cautious. Many people don’t connect their asthma flare-ups to painkillers. They blame pollen, cold air, or stress-until they end up in the ER after taking Advil for a migraine.
What Medications Are Safe?
The good news: not all pain relievers are dangerous. Acetaminophen (paracetamol) is generally safe for most NERD patients at doses under 1,000mg. About 5-10% may still react to higher doses, so start low and watch for symptoms.
COX-2 inhibitors like celecoxib are another option. These drugs don’t block COX-1 the same way, so they don’t trigger the same cascade. Clinical studies show they’re well-tolerated in NERD patients.
But here’s the catch: many cold and flu medicines, arthritis creams, and even some toothpastes contain NSAIDs. Always check the label. Ingredients like ibuprofen, naproxen, ketoprofen, or diclofenac can hide in plain sight. Don’t assume something labeled "natural" or "herbal" is safe-some contain willow bark, which acts like aspirin.
What to Do If You React
If you’ve ever had sudden wheezing, chest tightness, or nasal swelling after taking an NSAID, stop using them immediately. Keep a record of what you took, when, and what happened. Bring this to your doctor.
Your GP might refer you to an allergist or respiratory specialist. They can perform a supervised aspirin challenge test-a controlled exposure in a clinic setting-to confirm NERD. This isn’t risky if done properly, and it’s the only way to be 100% sure.
Is There a Long-Term Fix?
Yes-and it’s surprising. Aspirin desensitization is a real treatment. Under medical supervision, patients are slowly given increasing doses of aspirin over days or weeks. Once the body adjusts, they can tolerate daily aspirin without reactions. For many, this leads to fewer nasal polyps, less need for surgery, and better asthma control.
It’s not for everyone. You need to be stable, motivated, and under specialist care. But for those who qualify, it’s life-changing.
What About Children?
Studies show short-term use of NSAIDs in children with asthma can increase the risk of flare-ups by nearly 50%. One large study in Taiwan tracked over a million kids and found ibuprofen, aspirin, and diclofenac were linked to more emergency visits for asthma. Long-term use didn’t show the same risk, but that doesn’t mean it’s safe. If your child has asthma, stick with acetaminophen unless your doctor says otherwise.
How to Stay Safe
Here’s what you need to do right now:
- Stop using any NSAID if you’ve had a reaction-even once.
- Keep a list of safe pain relievers (acetaminophen, celecoxib) and share it with every doctor you see.
- Read every medicine label. Look for: ibuprofen, naproxen, aspirin, diclofenac, ketoprofen, indomethacin.
- Ask pharmacists: "Is this safe for someone with NSAID-sensitive asthma?" Don’t assume they know.
- Wear a medical alert bracelet if you’ve had a severe reaction.
- Discuss aspirin desensitization with a specialist if your asthma is hard to control.
What’s Next for NERD Research?
Scientists are now looking at biomarkers like blood eosinophils and urinary LTE4 levels to better identify NERD early. There’s also promising work on LXA4 and its derivatives-natural compounds that could help restore balance in the inflammatory system without triggering reactions.
For now, the best tool is awareness. NERD is underdiagnosed because doctors don’t always ask about painkiller use. And patients don’t always connect the dots. If you have asthma and nasal polyps, and you’ve ever had a sudden breathing problem after taking ibuprofen-don’t ignore it. You’re not overreacting. You might just need to stop reacting to the medicine.
Can I take acetaminophen if I have NSAID-sensitive asthma?
Yes, acetaminophen (paracetamol) is generally safe for most people with NSAID-sensitive asthma at doses up to 1,000mg per dose. About 5-10% of patients may still react to higher doses, so start with the lowest effective amount and monitor for symptoms like wheezing or nasal congestion.
Are all NSAIDs equally dangerous for people with NERD?
Most NSAIDs that strongly inhibit COX-1-like aspirin, ibuprofen, naproxen, and diclofenac-are equally likely to trigger reactions. The risk isn’t about the brand, but the chemical class. Even low-dose aspirin (75mg) can cause a reaction in highly sensitive individuals. COX-2 inhibitors like celecoxib are usually safe because they don’t affect COX-1.
Can NERD develop suddenly, even if I’ve taken NSAIDs for years?
Yes. NERD often develops gradually. Many people take NSAIDs for years without issues, then suddenly have a reaction in their 30s or 40s. This is especially common if they’ve developed chronic rhinosinusitis or nasal polyps over time. The condition doesn’t appear overnight, but the first reaction can feel sudden.
Should I avoid NSAIDs if I have asthma but no nasal polyps?
If you have asthma without nasal polyps or chronic sinusitis, your risk of NERD is low-around 1-2%. But if you’ve ever had a reaction to an NSAID, even once, avoid them. Don’t assume you’re safe just because you don’t have polyps. Always check with your doctor before using NSAIDs if your asthma is moderate to severe.
Is aspirin desensitization worth considering?
For people with severe NERD, especially those with recurring nasal polyps or poorly controlled asthma, aspirin desensitization can be very effective. It reduces polyp regrowth, improves breathing, and often cuts down on steroid use. But it requires specialist supervision, takes weeks to complete, and isn’t suitable for everyone. Talk to a respiratory allergist if you’re interested.
