The impact of age on prevalence of positive skin prick tests and specific IgE tests

Clinical practice guideline: Allergic rhinitis

OBJECTIVE

Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.

PURPOSE

The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.

ACTION STATEMENTS

The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

The Association of BCG Vaccination with Atopy and Asthma in Adults

INTRODUCTION

There are few studies investigating the association between BCG vaccination and atopy or asthma in adults.

OBJECTIVE

We investigated the association between BCG scar and the occurrence of atopy and asthma in Korean adults.

METHODS

We carried out a retrospective study of Korean adults who underwent skin prick testing, and, in some cases, spirometry and bronchial provocation tests in a secondary care hospital from April 2010 to February 2011. Atopy status was classified according to allergen/histamine (A/H) ratio of wheal (A/H ratio ≥ 1, atopy; 0 < A/H ratio < 1, intermediate; A/H ratio = 0, non-atopy). A patient with asthma was defined as one who has symptoms compatible with asthma and showed either a positive provocation testing or bronchodilator reversibility.

RESULTS

Among 200 participants, neither the presence (intermediate vs. non-atopy: adjusted odds ratio (aOR) 0.83; 95% CI 0.26, 2.60; p = 0.75, atopy vs. non-atopy: aOR 0.89; 95% CI 0.33, 2.37; p = 0.81, respectively). nor the size of BCG scar was significantly associated with atopy status. However, among those patients who underwent either bronchodilator response testing or bronchial provocation testing, the presence of BCG scar (aOR 0.33; CI 0.14, 0.77; p = 0.01) and the size of BCG scar were inversely associated with asthma. (p = 0.01) CONCLUSIONS: We found a significant association between BCG scar and asthmatic status in Korean adults, although there was no significant association between either the presence or size of BCG scar and atopy.

Clinical features of elderly chronic urticaria

BACKGROUND/AIMS

Chronic urticaria (CU) is defined as itchy wheals lasting 6 weeks or more. As the aged population increases worldwide, it is essential to identify the specific features of this disease in the elderly population.

METHODS

We investigated the prevalence and clinical features of CU in elderly patients. Medical records of 837 CU patients from the outpatient Allergy Clinic of Ajou University Hospital, Korea were analyzed retrospectively. Patients with chronic spontaneous urticaria according to the EAACI/GA2LEN/EDF/WAO guidelines were included. Patients older than 60 years were defined as elderly.

RESULTS

Of the 837 patients, 37 (4.5%) were elderly. In elderly versus nonelderly CU patients, the prevalence of atopic dermatitis (AD) was significantly higher (37.8% vs. 21.7%, respectively; p = 0.022), while that of aspirin intolerance was lower (18.9% vs. 43.6%, respectively; p = 0.003) in terms of comorbid conditions. The prevalences of serum specific immunoglobulin E antibodies to staphylococcal enterotoxin A and staphylococcal enterotoxin B were considerably higher in elderly CU patients with AD than in those without AD (37.5% vs. 0%, respectively).

CONCLUSIONS

Elderly patients with CU had a higher prevalence of AD. Therefore, there is a need to recognize the existence of AD in elderly CU patients.

Comorbidities in elderly patients with asthma: Association with control of the disease and concomitant treatment

AIM

The incidence of concomitant conditions increases with age. In elderly patients, the presence of comorbidities has been related to the course and severity of asthma. The aim of the present study was to assess the impact of comorbidities and concomitant treatment on asthma control and severity in older adults.

METHODS

A total of 93 elderly (age >65 years) and 78 younger (age 30-50 years) asthmatic patients were randomly selected from a database including 1755 asthmatics. Evaluation consisted of a questionnaire, spirometry and skin prick testing.

RESULTS

In elderly asthmatics, a higher incidence of chronic comorbidities (mean 8.4 vs 4.7; P < 0.001) and a higher number of prescribed medicines (7.4 vs 4.5, P < 0.001) were observed, but the severity of asthma and the intensity of anti-asthma treatment were similar to that seen in younger patients. Asthma control was not strikingly different between the groups. There was no correlation between the presence of comorbid conditions and asthma control, severity or frequency of exacerbations in older patients. Elderly patients treated with statins had a lower risk of asthma exacerbation (OR 0.39, 95% CI 0.18-0.84, P = 0.017), whereas treatment with proton pump inhibitors was associated with a higher risk of exacerbations in older adults (OR 1.84, 95% CI 1.07-3.18, P = 0.029) and higher disease severity in younger patients (OR 2.49, 95% CI 1.1-5.67, P = 0.029).

CONCLUSION

The higher prevalence of comorbidities observed in elderly asthmatics under specialist care do not seem to be associated with worsened asthma control or severity. However, concomitant medications can significantly affect asthma control in both elderly and younger asthmatics.

Asthma control in elderly asthmatics. An Italian observational study

BACKGROUND

The exponential increase of individuals aged >64 yrs is expected to impact the burden of asthma. We aimed to explore the level of asthma control in elderly subjects, and factors influencing it.

METHODS

A multicenter observational study was performed on consecutive patients >64 years old with a documented physician-diagnosis of asthma. Sixteen Italian centers were involved in this 6-month project.

FINDINGS

A total of 350 patients were enrolled in the study. More than one-third of elderly asthmatic patients, despite receiving GINA step 3-4 antiasthmatic therapy, had an Asthma Control Test score ≤19, with a quarter experiencing at least one severe asthma exacerbation in the previous year. Twenty-nine percent of patients (n = 101) were classified as having Asthma-COPD Overlap Syndrome (ACOS) due to the presence of chronic bronchitis and/or CO lung diffusion impairment. This subgroup of patients had lower mean Asthma Control Test scores and more exacerbations compared to the asthmatic patients (18 ± 4 compared to 20 ± 4, p < 0.01, and 43% compared to 18%, p < 0.01, respectively). Modified Medical Research Council dyspnea mMRC scores and airway obstruction, assessed on the basis of a FEV(1)/FVC ratio below the lower limit of normal, were more severe in ACOS than in asthma, without any difference in responses to salbutamol. In a multivariate analysis, the mMRC dyspnea score, FEV(1)% of predicted and the coexistence of COPD were the only variables to enter the model.

INTERPRETATION

Our results highlight the need to specifically evaluate the coexistence of features of COPD in elderly asthmatics, a factor that worsens asthma control.

Geographical variation in the prevalence of sensitization to common aeroallergens in adults: the GA(2) LEN survey

BACKGROUND

Geographical variation in the prevalence of sensitization to aeroallergens may reflect differences in exposure to risk factors such as having older siblings, being raised on a farm or other unidentified exposures.

OBJECTIVE

We wanted to measure geographical variation in skin prick test positivity and assess whether it was explained by differences in family size and/or farm exposure. We also compared prevalence in younger and older subjects.

METHODS

Within the Global Allergy and Asthma European Network (GA(2) LEN) survey, we measured the prevalence of skin prick positivity to a panel of allergens, and geometric mean serum total immunoglobulin E (IgE), in 3451 participants aged 18-75 years in 13 areas of Europe. Estimated prevalence was standardized to account for study design. We compared prevalence estimates in younger and older subjects and further adjusted for age, gender, smoking history, farm exposure, number of older siblings and body mass index (BMI).

RESULTS

Skin prick test positivity to any one of the measured allergens varied within Europe from 31.4% to 52.9%. Prevalence of sensitization to single allergens also varied. Variation in serum total IgE was less marked. Younger participants had higher skin prick sensitivity prevalence, but not total IgE, than older participants. Geographical variation remained even after adjustment for confounders.

CONCLUSION

Geographical variation in the prevalence of skin prick test positivity in Europe is unlikely to be explained by geographical variation in gender, age, smoking history, farm exposure, family size and BMI. Higher prevalence in younger, compared to older, adults may reflect cohort-associated increases in sensitization or the influence of ageing on immune or tissue responses.

Serum biomarkers in elderly asthma

OBJECTIVE

Asthma is usually misdiagnosed and under-treated in the elderly population, resulting in complications and increased severity to the patient. In this review, we describe some of the most important serum markers of asthma studied so far, reporting their outcomes and possible prediction of asthma in the elderly population.

METHODS

The PubMed electronic database was used to search for promising serum biomarkers of asthma studied in original articles published in peer-reviewed journals from 2000 to January 2013.

RESULTS

A total of 13 relevant serum biomarkers were selected, including IgE, CRP, high sensitive CRP, IL-6, IL-8, IL-17, TNF-α, neopterin, serum amyloid A, eosinophil cationic protein, leukolysin, YKL-40 and soluble CD86.

CONCLUSIONS

Although the major focus of treatment and research has been on allergic asthma, several forms of the disease are recognized, such as neutrophilic asthma, which is characteristic of older patients. Different phenotypes imply different treatments and so it becomes important to correctly determine which type of asthma the patient is suffering from. Serum markers capable of supporting a diagnosis of asthma are needed in order to counter mistreatment and misdiagnosis with other obstructive airways disease (OAD) in elderly patients. As convenient as serum markers may seem to be, a marker capable of accurately identifying asthma with sufficient specificity is yet to be found.

Rhinitis in a community elderly population: relationships with age, atopy, and asthma

BACKGROUND

Rhinitis is one of the most frequent medical conditions. However, there is sparse epidemiologic evidence for rhinitis in the elderly population.

OBJECTIVE

To investigate the prevalence of rhinitis in elderly adults and its relations to asthma and other comorbidities.

METHODS

A cross-sectional analysis was performed using the baseline dataset of the Korean Longitudinal Study on Health and Aging, a community-based elderly population cohort in Korea (≥65 years old). Structured questionnaires were used to define rhinitis, asthma, and comorbidity, and allergen skin prick tests were used to define atopy. Health-related quality of life was assessed by short-form 36 questionnaires.

RESULTS

In total, 982 elderly adults (98.2%) were included in the present study. The prevalence of rhinitis was 25.6% and did not decrease until 90 years of age. The prevalence of atopy was 17.2% (18.8% in participants with rhinitis), and atopy did not show a significant association with rhinitis. In multivariate logistic regression analyses, relations between asthma and rhinitis were significant. Among comorbid conditions, none were significantly associated with rhinitis. In the short-form 36 questionnaire analyses, rhinitis was independently related to a decrease in the physical aspects of quality of life.

CONCLUSION

The present study found a high prevalence of nonallergic rhinitis in elderly participants, which was significantly related to asthma and quality of life.

Perceived triggers of asthma: key to symptom perception and management

Adequate asthma management depends on an accurate identification of asthma triggers. A review of the literature on trigger perception in asthma shows that individuals vary in their perception of asthma triggers and that the correlation between self-reported asthma triggers and allergy tests is only modest. In this article, we provide an overview of psychological mechanisms involved in the process of asthma triggers identification. We identify sources of errors in trigger identification and targets for behavioural interventions that aim to improve the accuracy of asthma trigger identification and thereby enhance asthma control.

Management of asthma in the elderly patient

A significant number of older asthmatics, more often than in previous ages, have poorly controlled asthma, leading to increased morbidity and mortality. On the other hand, current guidelines suggest that most asthmatics can obtain achievement and maintenance of disease control and do not include sections specific to the management of asthma in the elderly so that it is more evident the contrast between poor control of asthma in the elderly and the lack of specific guidance from guidelines on asthma management in older asthmatics. Inhaled corticosteroids are the cornerstone for older asthmatics, eventually with add-on inhaled long-acting beta-agonists; inhaled short acting beta-agonists can be used as rescue medications. Triggers exacerbating asthma are similar for all ages, but inhaled viruses and drug interactions have greater clinical significance in the elderly. Older asthmatics have an increased likelihood of comorbidities and polypharmacy, with possible worsening of asthma control and reduced treatment adherence. Physicians and older asthmatics probably either do not perceive or accept a poor asthma control. We conclude that specific instruments addressed to evaluate asthma control in the elderly with concomitant comorbidities and measurements for improving self-management and adherence could assure better disease control in older asthmatics.

Hay Fever and asthma as markers of atopic immune response and risk of colorectal cancer in three large cohort studies

BACKGROUND

In a previous analysis of 12 cancers in the Cancer Prevention Study II (CPS-II) cohort including follow-up from 1982-2000, having both hay fever and asthma was associated with lower colorectal cancer mortality. The combination of these allergic conditions may be a marker for allergy-related immune responses that could inhibit colorectal carcinogenesis.

METHODS

We examined the association of having both hay fever and asthma with colorectal cancer mortality among 1,023,191 participants in CPS-I, followed from 1959-1972, and 1,102,092 participants in CPS-II, now followed from 1982-2008. We also examined associations with colorectal cancer incidence among 174,917 participants in the CPS-II Nutrition Cohort, a subgroup of CPS-II followed from 1992-2007. During the follow-up, there were 5,644 colorectal cancer deaths in CPS-I, 13,558 colorectal cancer deaths in CPS-II, and 3,365 incident colorectal cancer cases in the CPS-II Nutrition Cohort. Cox proportional hazards regression was used to calculate multivariable-adjusted relative risks (RR) and 95% confidence intervals (CI).

RESULTS

RRs for colorectal cancer mortality associated with having both asthma and hay fever, compared with neither condition, were 0.90 (95% CI, 0.74-1.09) in CPS-I, 0.79 (95% CI, 0.69-0.91) in CPS-II, and 0.83 (95% CI, 0.74-0.92) when results from both cohorts were combined in a meta-analysis. The corresponding RR for colorectal cancer incidence in the CPS-II Nutrition Cohort was 0.90 (95% CI, 0.71-1.14).

CONCLUSION

These results support an association between having both hay fever and asthma and modestly lower colorectal cancer mortality.

IMPACT

Research examining other potential markers of allergy-related immune response in relation to colorectal cancer is warranted.

The Age Impact on Serum Total and Allergen-Specific IgE

Aging is accompanied by a progressive decline in almost all functions of the immune system. To investigate a possible impact of age on IgE production, this study evaluated total and allergen-specific serum IgE levels in a large cohort of allergic patients. This study included 6,370 allergic patients (2,961 females, 3,409 males; mean age, 21.7 years; age range, 0-96 years). Total and allergen-specific serum IgE levels were measured by immunoenzymatic assay. The analysis of variance showed a significant difference (P<0.0001) in the mean value of total IgE among the different age groups of patients. Moreover, specific IgE levels for all allergens examined differed significantly among the age groups of patients (P<0.0001), with a specific trend pattern for each allergen. Total IgE increased with age, but allergen-specific IgE levels significantly decreased with age, with a trend specific for each allergen tested.

Prevalence of atopic disorders in rheumatic diseases

OBJECTIVES

The aim of this study was to assess the point prevalences of hay fever, asthma, and atopic dermatitis in OA, RA, and AS, and to compare with healthy controls.

METHODS

A total of 935 patients and healthy controls were included. Demographic and clinical features were recorded, and a questionnaire assessing the existence of atopic disorders like asthma, hay fever, and atopic dermatitis in all groups was applied. "Either atopy" implied that an individual was either diagnosed with or had symptoms of one or more of these disorders, such as asthma, hay fever, or atopic dermatitis.

RESULTS

When compared to the controls, only patients with AS had an increased risk for hay fever (OR 1.52, 95 % CI 1.00-2.41). Patients with RA had increased risks for hay fever, atopic dermatitis, and either atopy compared to the patients with OA (2.14, 95 % CI 1.18-3.89; 1.77, 95 % CI 1.00-3.18; and 3.45, 95 % CI 1.10-10.87, respectively). Steroid use had no effect on the prevalence of atopic disorders in patients with RA.

CONCLUSIONS

Patients with OA, RA, and AS seem to have similar risks for asthma, atopic dermatitis, and either atopy to healthy controls. However, the prevalence of hay fever may increase in AS. Patients with RA have a higher risk of atopy than patients with OA.

Allergic diseases in the elderly

Demographic distribution of the population is progressively changing with the proportion of elderly persons increasing in most societies. This entails that there is a need to evaluate the impact of common diseases, such as asthma and other allergic conditions, in this age segment. Frailty, comorbidities and polymedication are some of the factors that condition management in geriatric patients. The objective of this review is to highlight the characteristics of allergic diseases in older age groups, from the influence of immunosenescence, to particular clinical implications and management issues, such as drug interactions or age-related side effects.

Histamine and allergen skin reactivity in the elderly population: results from the Korean Longitudinal Study on Health and Aging

BACKGROUND

The allergen skin prick test is the most representative diagnostic test for atopy, but its use has been limited because of the belief that skin reactivity decreases with aging.

OBJECTIVE

To investigate skin reactivity and influencing factors in the elderly population.

METHODS

This cross-sectional analysis included 854 subjects (aged ≥65 years) who participated in the Korean Longitudinal Study on Health and Aging cohort (September 2005 to August 2006) and underwent allergen skin prick tests. Skin prick tests were performed with 1 mg/mL of histamine and a panel of 12 aeroallergens that are common in Korea. The wheal diameters were measured and compared to identify the factors associated with skin reactivity.

RESULTS

Older age and female sex were associated with reduced histamine skin reactivity in elderly subjects. This age-related decrease was apparent only among women, the reasons for which were not identified. In contrast to histamine, wheal response size induced by 2 major allergens, Dermatophagoides pteronyssinus and Dermatophagoides farinae, did not show sex differences and did not decrease with age among the subjects showing allergen-induced wheal size greater than 0 mm.

CONCLUSIONS

This analysis demonstrates that age and sex can independently influence histamine skin reactivity among the elderly population. The allergen-induced wheal sizes did not decrease with age. The discrepancy between histamine and allergen skin reactivity may warrant further evaluation to redefine the cutoff value for the determination of a positive skin test result in elderly subjects.

Asthma in the Elderly: Can We Distinguish It from COPD?

Asthma in older adults affects quality of life and results in a higher hospitalization rate and mortality. In common clinical practice, asthma in the elderly is underdiagnosed and undertreated or overdiagnosed and mistreated. The age-related reduction in perception of shortness of breath and the high incidence of comorbidities make the diagnosis and management more difficult and challenging for the physicians. Chronic obstructive pulmonary disease (COPD) is usually easy to distinguish from asthma, but sometimes the distinction from late-onset asthma in older patients, particularly in cigarette smokers, is difficult and may be impossible. Both diseases are characterized by the presence of airflow obstruction but have distinct pathogenesis, inflammatory pattern, and prognosis. The distinction between Asthma and COPD based simply on spirometric parameters is difficult especially in the elderly asthmatics. The combination of lung function testing, bronchial hyperresponsiveness (BHR) and atopy status, HRCT scans, and the newly developed biological techniques, allowing the assessment of biomarker profiles, could facilitate the distinction between these diseases.