Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)

Sublingual immunotherapy in daily medical practice: effectiveness of different treatment schedules - IPD meta-analysis

OBJECTIVE

To compare the effectiveness of perennial and co-seasonal high-dose sublingual immunotherapy (SLIT) treatments as well as ultra-rush and classical titrations in a real-world setting for pollen allergens.

METHODS

An individual patient data (IPD) meta-analysis was performed of three open, prospective observational studies on high-dose SLIT using IR-standardised allergen extracts in patients with allergic rhinitis with and without asthma.

RESULTS

In total, 1052 patients aged 24.9 years (mean) were treated with SLIT and included in this IPD meta-analysis. Individual studies and total data pool analyses revealed consistent improvements in rhinoconjunctivitis symptom scores. Stratified analyses revealed consistent improvements in symptomatic score and medication score regardless of the type of sensitisation and type of treatment. Ultra-rush titration resulted in considerably more pronounced improvement in symptom scores than classical titration, possibly due to better compliance of patients receiving that supervised titration. Adverse events occurred in 24% of patients during titration and in 18% of patients during maintenance treatment. The vast majority of events (89% and 87%) were mild-to-moderate, predominantly local symptoms in the oral cavity. There were no differences detected between the study titration or treatment schedules. No serious adverse reactions were reported. Nearly all patients (88%) decided to continue SLIT after completion of the studies.

CONCLUSION

High-dose SLIT with seasonal allergens given as co-seasonal or perennial treatment appears to be effective and well-tolerated in daily medical practice. Improved compliance under ultra-rush titration and seasonal SLIT treatment may further enhance effectiveness. Randomised controlled trials are requested for the further evaluation of these findings.

Ambient air pollution and respiratory health effects in mail carriers

Mail carriers represent an occupational group suffering from respiratory symptoms and lung function impairment. Although environmental conditions may play role, information on the effects of air pollution exposure in this population is lacking. The present study was conducted in Athens, Greece, in order to investigate the adverse effects of long-term air pollution exposure on respiratory outcomes in mail carriers. A total of 226 mail carriers and 73 office employees were enrolled. Information on respiratory symptoms, medical, occupational, residential and smoking history was obtained through a questionnaire. Flow-volume curves were performed in the workplace using a portable spirometer. Individualised personal exposure assessment has been applied based on long-term residential and occupational subject history linked with geographical air pollution distribution. Furthermore, personal measurements were obtained for forty-one mail carriers using NO(2) and O(3) passive samplers, assuming that current air pollution exposure is sufficiently representative of long-term, previous exposure to make a plausible link with current health status. The analysis based on exposures estimated on the basis of residential and work addresses showed that the most exposed to PM(10) postal workers have rhinitis at a higher rate (OR=1.67, 95% CI: 1.01-2.75). In mail carriers there is indication that those exposed to higher concentrations of Omicron(3) or PM(10) have a greater possibility to present rhinitis (OR=1.63, 95% CI: 0.93-2.88 and OR=1.70, 95% CI: 0.96-3.03, respectively). The effect of O(3) on rhinitis became even more apparent in the analysis based on exposures assessed by personal measurements (OR=6.74, 95% CI: 1.24-36.55). Exposure to NO(2) was significantly associated with decrements in lung function. For office employees the exposure to air pollutants was not associated to any adverse respiratory outcome. Our findings suggest that air pollution is a contributing factor for the occurrence of rhinitis and lung function impairment in mail carriers.

Noninvasive methods for assessment of airway inflammation in occupational settings

The present document is a consensus statement reached by a panel of experts on noninvasive methods for assessment of airway inflammation in the investigation of occupational respiratory diseases, such as occupational rhinitis, occupational asthma, and nonasthmatic eosinophilic bronchitis. Both the upper and the lower airway inflammation have been reviewed and appraised reinforcing the concept of 'united airway disease' in the occupational settings. The most widely used noninvasive methods to assess bronchial inflammation are covered: induced sputum, fractional exhaled nitric oxide (FeNO) concentration, and exhaled breath condensate. Nasal inflammation may be assessed by noninvasive approaches such as nasal cytology and nasal lavage, which provide information on different aspects of inflammatory processes (cellular vs mediators). Key messages and suggestions on the use of noninvasive methods for assessment of airway inflammation in the investigation and diagnosis of occupational airway diseases are issued.

Towards evidence-based medicine in specific grass pollen immunotherapy

When initiating grass pollen immunotherapy for seasonal allergic rhinoconjunctivitis, specialist physicians in many European countries must choose between modalities of differing pharmaceutical and regulatory status. We applied an evidence-based medicine (EBM) approach to commercially available subcutaneous and sublingual Gramineae grass pollen immunotherapies (SCIT and SLIT) by evaluating study design, populations, pollen seasons, treatment doses and durations, efficacy, quality of life, safety and compliance. After searching MEDLINE, Embase and the Cochrane Library up until January 2009, we identified 33 randomized, double-blind, placebo-controlled trials (including seven paediatric trials) with a total of 440 specific immunotherapy (SIT)-treated subjects in seven trials (0 paediatric) for SCIT with natural pollen extracts, 168 in three trials (0 paediatric) for SCIT with allergoids, 906 in 16 trials (five paediatric) for natural extract SLIT drops, 41 in two trials (one paediatric) for allergoid SLIT tablets and 1605 in five trials (two paediatric) for natural extract SLIT tablets. Trial design and quality varied significantly within and between SIT modalities. The multinational, rigorous trials of natural extract SLIT tablets correspond to a high level of evidence in adult and paediatric populations. The limited amount of published data on allergoids prevented us from judging the level of evidence for this modality.

Risk of first-generation H(1)-antihistamines: a GA(2)LEN position paper

BACKGROUND

First-generation H(1)-antihistamines obtained without prescription are the most frequent form of self-medication for allergic diseases, coughs and colds and insomnia even though they have potentially dangerous unwanted effects which are not recognized by the general public.

AIMS

To increase consumer protection by bringing to the attention of regulatory authorities, physicians and the general public the potential dangers of the indiscriminate use first-generation H(1)-antihistamines purchased over-the counter in the absence of appropriate medical supervision.

METHODS

A GA(2)LEN (Global Allergy and Asthma European Network) task force assessed the unwanted side-effects and potential dangers of first-generation H1-antihistamines by reviewing the literature (Medline and Embase) and performing a media audit of US coverage from 1996 to 2008 of accidents and fatal adverse events in which these drugs were implicated.

RESULTS

First-generation H(1)-antihistamines, all of which are sedating, are generally regarded as safe by laypersons and healthcare professionals because of their long-standing use. However, they reduce rapid eye movement (REM)-sleep, impair learning and reduce work efficiency. They are implicated in civil aviation, motor vehicle and boating accidents, deaths as a result of accidental or intentional overdosing in infants and young children and suicide in teenagers and adults. Some exhibit cardiotoxicity in overdose.

CONCLUSIONS

This review raises the issue of better consumer protection by recommending that older first-generation H(1)-antihistamines should no longer be available over-the-counter as prescription- free drugs for self-medication of allergic and other diseases now that newer second- generation nonsedating H(1)-antihistamines with superior risk/benefit ratios are widely available at competitive prices.

The POLISMAIL lesson: sublingual immunotherapy may be prescribed also in polysensitized patients

Polysensitization is a feature of allergic rhinitis (AR) that significantly impairs the quality of life (QoL) of AR patients. Allergen-specific immunotherapy is the only causal therapy for AR. However, the polysensitization phenomenon may represent a crucial obstacle as far as it concerns the choice of the allergen extract which should be used for immunotherapy. Therefore, a real-life based multi-centre study, named POLISMAIL, has been designed which aims at evaluating the behaviour of some allergists managing polysensitized AR patients. The effect of two-year SLIT treatment in those patients was also evaluated. A single allergen extract was used for two-thirds of patients, whereas a mix of two allergens was chosen for the remaining patients. The severity grade of AR and the type of diagnosis were significantly improved by 2-year SLIT. In addition, SLIT significantly improved QoL. Both outcomes confirm that SLIT with one or two allergen extracts achieves a significant improvement in polysensitized patients. In conclusion, the POLISMAIL study demonstrates that polysensitization should not represent a counter-indication for prescribing immunotherapy. The choice to limit SLIT to 1-2 allergen extracts was sufficient and effective in improving symptoms and QoL.

Impact of pretreatment nasal symptoms on treatment outcome in allergic rhinitis

OBJECTIVE

The Allergic Rhinitis and its Impact on Asthma (ARIA) classification of allergic rhinitis (AR) is based on the severity and duration of nasal symptoms. Whether nasal symptoms have an impact on treatment outcome is unclear. The aim of this study was to evaluate the correlation between pretreatment nasal symptoms and therapeutic response in AR.

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

Sixty-nine AR patients were classified according to ARIA class: mild or moderate-severe intermittent AR (MIAR or MSIAR) and mild or moderate-severe persistent AR (MPAR or MSPAR). All patients were treated over 28 days with 220 microg of intranasal triamcinolone acetonide once daily. Nasal symptoms, peak expiratory flow index, and global symptom control were used to evaluate treatment outcome.

RESULTS

At 28 days after treatment, MSPAR patients showed the worst global symptom control, followed by MSIAR, MPAR, and MIAR (mean global symptom controls were 76.5%, 83.8%, 87.7%, and 89.0%, respectively). Pretreatment total nasal symptom score was inversely correlated with global symptom control (rho = -0.405, P < 0.001), but positively correlated with percent total nasal symptom score and peak expiratory flow index improvements (rho = 0.271, P = 0.024; and rho = 0.371, P = 0.002, respectively). Blocked nose had the best inverse correlation with global symptom control (rho = -0.389, P = 0.001).

CONCLUSION

A worse treatment outcome despite more clinical improvements during the treatment period in a higher severity score suggests the therapeutic predictive value of pretreatment nasal symptom scoring and the need for more dosing and continuing medication in higher scores, especially in blocked nose.

Assessment of allergic rhinitis websites in Korea

Objectives

The internet has become an important source of medical information and a great amount of information related to allergic rhinitis (AR) is available on the internet. However, the quality of this information is still a matter of debate. Therefore, this study was conducted to assess the AR-related information on Korean websites.

Methods

The key word "allergic rhinitis" was entered into 4 popular search engines, and this led to identifying 40 websites. After being categorized according to authorship, the informational value of these websites was evaluated using 4 different assessment tools such as the Journal of the American Medical Association (JAMA) benchmarks, the DISCERN questionnaire, the Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 Update and the Health On the Net (HON) code.

Results

The 40 websites containing AR-related information were categorized according to their authorship as Western physician: 20, Oriental physician: 14, commercial: 1, and others: 5. The mean citation frequencies of the JAMA benchmarks and the ARIA 2008 Update concepts was 1.23 out of 4 and 4.33 out of 8, respectively, while the mean DISCERN score was 1.92 out of 5. When the websites were evaluated based on the type of authorship, the mean citation frequencies of the ARIA 2008 Update concepts were Western physician: 5.35, Oriental physician: 2.64. Additionally, three websites authored by Western physicians and 13 authored by Oriental physicians contained unreliable information. Among these 16 websites, only 3 websites met the requirements for the HON code "Justification".

Conclusion

AR-related information available on Korean websites is of variable quality and not all of the information provided is justifiable. Thus, performing surveillance of the medical information on these websites is necessary. Furthermore, common criteria that can be used to evaluate the websites created by both Western and Oriental physicians are also needed.

Asthmatics without rhinitis have more fixed airway obstruction than those with concurrent rhinitis

PURPOSE

Rhinitis and asthma usually occur together. There are increasing evidences that allergic rhinitis (AR) may influence the clinical course of asthma. The aim of this study is to evaluate clinical parameters and therapeutic response in patients with between asthma and asthma with AR.

METHODS

Four-hundred eighty-five patients with asthma and 428 asthmatics with AR, who had lesser than 50 years old and smoked less than 10 pack-years were recruited. We compared FEV1 and FEV1/FVC following bronchodilator, atopy, IgE, emphysema on HRCT, and aspirin intolerance between two groups. Also we compared physiologic fixed airway obstruction defined using FEV1/FVC and FEV1 less than 75% following anti-asthmatic drug for 1 year.

RESULTS

46.8% (428/913) asthmatics suffered from AR. There were no differences of total IgE, body mass index, PC20, sputum eosinophils and emphysema on HRCT between two groups. The age in asthmatics was higher than that in those with AR. FEV1/FVC was lower in asthmatics than in those with AR. The prevalence of atopy was higher in asthmatics with AR than in asthmatics. Aspirin intolerance was higher in asthmatics with AR than in asthmatics (42/218 vs 13/109, P=0.001). Fixed airway obstruction were more observed in asthmatics than in those with AR (39/319 vs 28/355, P=0.001) after anti-asthmatic drug for 1 year.

CONCLUSIONS

Asthmatics with AR had more atopy and aspirin intolerance than asthmatics, and asthmatics had poor response to anti-inflammatory drugs than those with concurrent rhinitis, indicating that asthmatics have more fixed airway obstruction than those with concurrent rhinitis.

The pathophysiology, diagnosis and treatment of allergic rhinitis

Treatment of AR requires a stepwise approach depending on the severity and duration of symptoms. Treatment options for AR consist of allergen avoidance, pharmacotherapy, immunotherapy and surgery. For the mechanisms of AR, anti-IgE antibody and specific antibody to cytokines such as IL-4 or IL-5 that correlate with allergic inflammation have recently emerged. SLIT is currently widely used due to its efficacy, safety and convenience, which replaces subcutaneous immunotherapy. Although allergen avoidance and immunotherapy are theoretically ideal, antihistamines and intranasal corticosteroids will play the main role in the management of AR until an innovative treatment develops. However, patients' main symptom, the duration and severity of AR, patients' compliance, safety of medication and cost-effectiveness should be considered when treatment options are chosen. In conclusion, physicians should be aware of etiology, pathophysiology, symptoms, signs and diseases related to AR in order to make a correct diagnosis and choose a proper treatment option for each patient.

Willingness to pay for allergy-vaccination among Danish patients with respiratory allergy

OBJECTIVE

The aim of this study was to elicit willingness to pay (WTP) for allergen-specific subcutaneous injection immunotherapy (SCIT) in a cohort of respondents suffering from allergic-rhinoconjunctivitis (a-RC)/asthma, and to investigate how patients self-select to SCIT according to need.

METHODS

A random sample of the general population was screened for a-RC/asthma and asked if they were willing to consider SCIT. They were asked to state their WTP for SCIT by way of a discrete choice question (DC-q), an open-ended WTP question (o-WTP-q), and questions relating to their sociodemographic background and the severity of their a-RC/asthma. The characteristics of respondents demanding SCIT were compared with the characteristics of respondents who have actually received SCIT to establish possible barriers to demand.

RESULTS

Our results suggest that respondents do well in self-selecting themselves to SCIT on the basis of need according to disease burden measured in terms of a-RC classification, number of contacts with a general practitioner, number of sick days, and potential quality-adjusted life-year loss. Mean WTP for SCIT was estimated at 655 euros (median, 267 euros) (o-WTP-q) and 903 euros (95 percent confidence limit, 348-1,459) (DC-q).

CONCLUSION

Characteristics of respondents, who consider SCIT and are willing to pay for SCIT, suggest that allergy sufferers select themselves appropriately according to need and not according to other characteristics, such as income or education. There is a significant discrepancy between those who hypothetically consider SCIT and those demanding SCIT in real life. This study suggests that there are barriers to entry related to age and education, but not to income.

Immediate and dual response to nasal challenge with Dermatophagoides pteronyssinus in local allergic rhinitis

BACKGROUND

Local allergic rhinitis (LAR) is characterized by in situ production of specific IgE (sIgE) antibodies and a positive response to a nasal allergen provocation test (NAPT) in the absence of atopy.

OBJECTIVE

The aim of this study was to investigate the immunological mechanisms involved in the immediate and late responses after nasal exposure to Dermatophagoides pteronyssinus (DP) in patients with LAR.

METHODS

A total of 40 subjects with LAR to DP were studied and compared with 50 healthy controls. Immediate and late responses to NAPT-DP were assessed using a visual analogue scale of nasal symptoms and acoustic rhinometry. Tryptase, ECP, total and sIgE-DP were measured in the nasal lavage by immunoassay at baseline, 15 min, 1, 6 and 24 h after nasal challenge.

RESULTS

NAPT-DP was positive in all patients, with significant increases in tryptase (45%), ECP (65%) and sIgE-DP (25%) (P<0.05). Sixty percent of the LAR patients presented an immediate response to NAPT-DP and 40% a dual response. Immediate responders showed a fast release of tryptase with a peak at 15 min after NAPT-DP, and a progressive increase in nasal ECP and sIgE-DP from 1 to 24 h after challenge, with a peak at 24 h. Dual responders presented persistently higher levels of tryptase from 15 min to 6 h after challenge, and a similar pattern of nasal release of ECP and sIgE-DP to immediate responders. There were no isolated late responders. NAPT-DP was negative in all healthy controls, with no increases in tryptase, ECP, or total and sIgE-DP in nasal secretions.

CONCLUSIONS

The results demonstrated the existence of immediate and dual responses to a NAPT with DP in LAR patients, with the local presence of sIgE and mast cell/eosinophil activation.

Fluticasone reverses oxymetazoline-induced tachyphylaxis of response and rebound congestion

RATIONALE

Chronic use of intranasal decongestants, such as oxymetazoline, leads to tachyphylaxis of response and rebound congestion, caused by alpha-adrenoceptor mediated down-regulation and desensitization of response.

OBJECTIVES

We evaluated if tachyphylaxis can be reversed by intranasal fluticasone propionate, and the relative alpha(1)- and alpha(2)-adrenoceptor components of tachyphylaxis using the alpha(1)-antagonist prazosin.

METHODS

In a randomized, double-blind, placebo-controlled, crossover design, 19 healthy subjects received intranasal oxymetazoline, 200 microg three times a day for 14 days, followed by the addition of fluticasone, 200 microg twice a day for a further 3 days. At Days 1, 14, and 17, participants received a single dose of oral prazosin, 1 mg, or placebo with measurements made before and 2 hours later.

MEASUREMENTS AND MAIN RESULTS

Outcomes evaluated were peak nasal inspiratory flow, nasal resistance, blood flow, and oxymetazoline dose-response curve (DRC). On Day 14 versus Day 1, inspiratory flow decreased (mean difference, 95% confidence interval) (-47.9 L x min(-1); -63.9 to -31.9; P < 0.001) and the DRC shifted downward (24.8 L x min(-1); 20.3-29.3; P < 0.001). On Day 17 versus Day 14, after fluticasone, inspiratory flow increased (45 L x min(-1); 30-61; P < 0.001) and the DRC shifted upward (26.2 L x min(-1); 21.7-30.7; P < 0.001). On Day 1, prazosin reduced inspiratory flow (-52.6 L x min(-1); -19.2 to -86) compared with baseline. This effect was abolished on Day 14 (7.9 L x in(-1); -41.3 to 25.5).

CONCLUSIONS

Oxymetazoline-induced tachyphylaxis and rebound congestion are reversed by intranasal fluticasone. Further studies are indicated to evaluate if combination nasal sprays of decongestant and corticosteroid are an effective strategy to obviate tachyphylaxis and rebound in rhinitis. Clinical trial registered with www.clinicaltrials.gov (NCT 00487032).

Endonasal phototherapy with Rhinolight for the treatment of allergic rhinitis

Allergic rhinitis, although not life threatening, significantly affects the quality of the patient's daily life. The three major steps in the treatment of the condition are avoidance of allergens, treatment of symptoms (in particular, antihistaminics and topical nasal corticosteroids) and specific immunotherapy. Avoidance of the allergen is usually not possible and symptom relief is often limited, despite the availability of a number of pharmacological options. Specific immunotherapy demands a high level of cooperation on the part of the patient for at least 3 years. Endonasal phototherapy with the Rhinolight device (Rhinolight Ltd, Szeged, Hungary) for the treatment of immunoglobulin E-mediated allergic rhinitis is a new option that utilizes the immunosuppressive effects of UV radiation. The method directs a combination of UV-B (5%), UV-A (25%) and visible light (70%) into the nasal cavity, and its effectiveness has been demonstrated in one double-blind, placebo-controlled study. The results of additional studies have been presented at various medical conferences and in abstracts. Reports in the literature confirm that phototherapy is a well-established and successful treatment of atopic dermatitis and other skin diseases.

Serum resistin in persistent allergic rhinitis: preliminary data in adults

BACKGROUND

Adipokines may exert pro-inflammatory activities in allergic rhinitis. Resistin is a new adipokine. Only one study reported that resistin may be involved in allergic rhinitis. However, that study was conducted in children. Therefore, the present study aimed at confirming these findings also in adult patients with persistent allergic rhinitis (PER).

METHODS

The study included 85 PER patients subjects 25 (11 males, mean age 35.4 years) with mild symptoms and 60 (27 males, mean age 36.8 years) with moderate-severe ones. All subjects were consecutively evaluated. A skin prick test and blood sampling for assessing serum resistin levels were performed in all subjects.

RESULTS

Patients with moderate-severe symptoms had higher resistin levels than mild ones (p=0.02).

CONCLUSION

This study provides the preliminary evidence that resistin serum levels depend on symptom severity also in adults with PER.

Steroid sparing effects of intranasal corticosteroids in asthma and allergic rhinitis

BACKGROUND

Treating allergic rhinitis may have a downstream anti-inflammatory effect on the lower airways. We conducted a dose ranging study in asthma and persistent allergic rhinitis to evaluate if intranasal corticosteroids exhibit a sparing effect on the dose of inhaled corticosteroid.

METHODS

Twenty five participants were randomized to receive two weeks of 100 microg/day (Low dose) or 500 microg/day (High dose) of inhaled fluticasone propionate both with intranasal placebo; or inhaled fluticasone 100 microg/day with intranasal fluticasone 200 microg/day (Combined) in a double-blind cross-over fashion.

RESULTS

Low dose fluticasone produced a shift of 1.20 doubling-dilutions (95% CI, 0.63, 1.77); Combined fluticasone, 1.79 doubling-dilutions (95% CI, 0.77, 2.80) and high dose fluticasone, 2.01 doubling-dilutions (95% CI, 1.42, 2.61) in methacholine PC(20) from respective baselines. There was a significant difference between high and low doses: 0.82 doubling dilutions (95%CI, 0.12, 1.50) but not between combined and low dose 0.58 doubling dilutions (95% CI, -0.78, 1.95). Combined treatment alone produced improvements in peak nasal inspiratory flow (P < 0.001), rhinitis quality of life (P = 0.004) and nasal NO (P = 0.01); reduced blood eosinophil count (P = 0.03), and serum eosinophil cationic protein (P = 0.02). All treatments significantly improved tidal NO, FEV(1) and asthma quality of life.

CONCLUSIONS

High-dose fluticasone was superior to low dose fluticasone for methacholine PC20, demonstrating room for further improvement. Combined treatment was not significantly different from low dose fluticasone and we could not demonstrate a steroid sparing effect on methacholine PC20. Combined treatment alone produced improvements in upper airway outcomes and suppressed systemic inflammation but not adrenal function.

[GA2LEN (Global Allergy and Asthma European Network), the perspective of the German speaking centers]

Allergic diseases represent a major health problem in Europe. They are increasing in prevalence, severity and costs. GA2LEN (Global Allergy and Asthma European Network), an FP6 Network of Excellence, was created in 2005 as a vehicle to ensure excellence in research bringing together research and clinical institutions to combat fragmentation in the European research area and to tackle allergy as a whole. GA2LEN benefited greatly from the voluntary efforts of researchers who are strongly committed to this model of pan-European collaboration. The network was organized in order to increase networking for scientific projects in allergy and asthma around Europe and to make GA2LEN the world leader in the field. Besides these activities, research has been jointly made and the first papers are being published. GA2LEN achievements in general can be grouped as those for a durable infrastructure built up during the project phase those which are project-related work based on these novel infrastructures, and the development and implementations of guidelines. The major achievements of GA2LEN are reported in this paper.

Safety of a depigmented, polymerized vaccine for the treatment of allergic rhinoconjunctivitis and allergic asthma

BACKGROUND

Clinical efficacy of specific immunotherapy (SIT) with depigmented, polymerized allergen extracts is well documented in placebo-controlled trials, and safety data are encouraging although further data are required.

METHODS

We enrolled 768 patients (51% men; mean age, 31 years) in this prospective multicenter study on safety and clinical effects of Depigoid (Laboratorios LETI, S.L., Madrid, Spain). Immunotherapy consisted of four injections of increasing doses of Depigoid at weekly intervals followed by monthly maintenance injections. All adverse events were documented. Moreover, nose, eye, and lung symptoms were assessed at baseline after 3 and 6 months. Results were compared with the scores of the preceding season.

RESULTS

Rates for local and systemic reactions that might possibly be related to the study medication were 2.36 and 4.56/1000 injections, respectively. With 5923 injections given, 14 local reactions were reported (5 patients), and 27 systemic reactions were reported, including 20 of grade 1 (6 patients) and 7 of grade 2 (4 patients). The best safety profile was seen for patients vaccinated against house-dust mites. Reductions in nose, eye, and lung symptoms as well as in concomitant medication compared with either the preceding season (pollen-sensitized patients) or the baseline (house-dust mite-sensitized patients) were observed at the end of study.

CONCLUSION

In this large multicenter study on 768 patients with allergic rhinoconjunctivitis and allergic asthma under daily practice conditions SIT with Depigoid was well tolerated with low rates of local and systemic reactions. Furthermore, SIT resulted in considerable reductions in symptoms and concomitant medication.

Risk factors for allergic rhinitis in Costa Rican children with asthma

BACKGROUND

Risk factors for allergic rhinitis (AR) in asthmatics are likely distinct from those for AR or asthma alone. We sought to identify clinical and environmental risk factors for AR in children with asthma.

METHODS

We performed a cross-sectional study of 616 Costa Rican children aged 6-14 years with asthma. Candidate risk factors were drawn from questionnaire data, spirometry, methacholine challenge testing, skin testing, and serology. Two outcome measures, skin test reaction (STR)-positive AR and physician-diagnosed AR, were examined by logistic regression.

RESULTS

STR-positive AR had high prevalence (80%) in Costa Rican children with asthma, and its independent risk factors were nasal symptoms after exposure to dust or mold, parental history of AR, older age at asthma onset, oral steroid use in the past year, eosinophilia, and positive IgEs to dust mite and cockroach. Physician-diagnosed AR had lower prevalence (27%), and its independent risk factors were nasal symptoms after pollen exposure, STR to tree pollens, a parental history of AR, inhaled steroid and short-acting beta2 agonist use in the past year, household mold/mildew, and fewer older siblings. A physician's diagnosis was only 29.5% sensitive for STR-positive AR.

CONCLUSIONS

Risk factors for AR in children with asthma depend on the definition of AR. Indoor allergens drive risk for STR-positive AR. Outdoor allergens and home environmental conditions are risk factors for physician-diagnosed AR. We propose that children with asthma in Costa Rica and other Latin American nations undergo limited skin testing or specific IgE measurements to reduce the current under-diagnosis of AR.

Ultra-short course immunotherapy in children and adolescents during a 3-yrs post-marketing surveillance study

Ultra-short course immunotherapy (uSCIT) has shown good efficacy and tolerability in children and adolescents with seasonal allergic rhinitis (SAR), conjunctivitis and/or asthma in clinical studies. Here, we investigate the efficacy of uSCIT in the juvenile subpopulation of a 3-year post-marketing surveillance (PMS) study. To assess the differences in the efficacy of uSCIT between adults and children respectively adolescents enrolled in a PMS study. In a prospective open study 422 patients aged 6-18 years with SAR, conjunctivitis and/or asthma received four pre-seasonal injections with pollen allergoids formulated with monophosphoryl lipid A (MPL, Pollinex Quattro) over a minimum of 3 weeks. Efficacy was evaluated by response to therapy and consumption of anti-allergic medication during the pollen season. Tolerability was evaluated by patients' acceptance of therapy. These results were compared with the adult subpopulation of this study. Response to treatment was assessed as good or very good in 94% of patients, mirroring findings for the entire cohort. Further improvements were noted in patients receiving subsequent courses of therapy. Anti-allergic medication use decreased from 83% to 24% of patients after the first treatment course (p < 0.0001). Therapy was well accepted by children/adolescents and considered 'very good' or 'good' by 93% of juveniles. No serious adverse events or cases of anaphylaxis were reported. This subanalysis indicated that uSCIT with Pollinex Quattro had similar efficacy and tolerability in children/adolescents and adults. The convenient dosing regimen and favourable safety profile of uSCIT may support a wider uptake of uSCIT in this patient population.

Peripheral Th-17 cells in allergic rhinitis: New evidence

BACKGROUND

Th17 is a subset of T helper lymphocytes exerting inflammatory activities. Recently, it has been reported that serum IL-17 levels are high in patients with severe birch allergy.

AIM OF THE STUDY

It was to compare the cytokine profile and the frequency of peripheral allergen-specific T helper producing IL-17 in patients with allergic rhinitis.

METHODS

Twelve patients with persistent allergic rhinitis due to pollens and 5 healthy non-allergic subjects were evaluated during the pollen season. Th17 were evaluated by intracellular staining in T cell compartment ex-vivo and after short activation by allergens and control antigens.

RESULTS

Ex-vivo PBMNC evaluation showed that allergic patients had higher frequencies of IL-17 producing T cells. Functional analysis after antigen-specific CD4+ T cell expansion demonstrated that allergic patients had higher frequencies of IL-17 producing T cells than normal subjects.

CONCLUSION

This preliminary study contributes to the knowledge concerning the possible role of Th-17 cells in the response to allergens.

Allergic rhinitis: prevalence and possible risk factors in a Gulf Arab population

BACKGROUND

Epidemiological studies mainly from Europe, the USA and Asia indicate a high prevalence of allergic rhinitis (AR) in modern societies. However, little is known about AR among the heterogeneous population of the United Arab Emirates (UAE).

OBJECTIVES

To estimate the prevalence of AR and its independent risk factors in Al-Ain City, UAE.

METHODS

We used a validated, self-administered questionnaire modified from the ISAAC study to collect data from a two stage randomly selected sample of 10 000 school children. Overall, 7550 subjects (aged 13 years and above, siblings, and their parents) responded. We assessed the prevalence of AR (both crude and standardized prevalence of previous 12 months) as well as the independent relationship of AR with age, gender, education, nationality and family history by means of logistic regression.

RESULTS

The response rate was 76%. A total of 6543 subjects (median age 30 years) were included in the final analysis. Self-reported prevalence of AR (having symptoms in the past 12 months) was 36%, while adjusted values for sex/age yielded a prevalence of 32%. Regression analysis revealed that AR was independently associated with family history, Arab origin, younger age, female gender and higher education.

CONCLUSIONS

The relatively high prevalence of AR found in this study may be attributable to modernization and genetic factors. Further studies on the impact of rapid environmental and cultural changes on AR in the Arab countries are needed and currently planned in conjunction with GA(2)LEN (Global Allergy and Asthma European Network).

Current management of allergic rhinitis in children

Over the last 20 years, there has been significant progress in our understanding of the pathophysiology of allergic rhinitis, including the discovery of new inflammatory mediators, the link between asthma and allergic rhinitis ('one airway-one disease' concept) and the introduction of novel therapeutic modalities. These new insights have been documented in the Allergic Rhinitis and its Impact on Asthma guidelines and have led to the creation of evidence-based management algorithms. We now understand the importance of a common strategy for treating allergic inflammation of the upper and lower airway as a way of improving outcome, reducing hospital admissions, providing better quality of life and perhaps, altering the natural course of the 'allergic march'. A therapeutic ladder is suggested: Whereas for mild intermittent allergic rhinitis, allergen avoidance should be the first line of treatment with subsequent addition of a second generation topical or oral antihistamine, nasal saline or cromoglycate, in cases of moderate to severe allergic rhinitis, a nasal steroid is the treatment of choice. If a patient with moderate/severe persistent allergic rhinitis fails to improve after 4 wk of adequate treatment, patient compliance or the diagnosis must be re-assessed. In such cases, when the diagnosis is in doubt, a careful clinical examination including nasal endoscopy is mandatory to assess for other potential causes of nasal obstruction. In children who suffer from concomitant allergic rhinitis and asthma, a management algorithm that addresses concurrently asthma and allergic rhinitis is vital, both from a theoretical and from a practical point of view: Parents overwhelmingly prefer a single strategy for the treatment of their child's upper and lower airway symptoms; however, the overall quality of life in children with severe asthma can be significantly improved if rhinitis is adequately addressed.

Prevalence of rhinitis in Polish population according to the ECAP (Epidemiology of Allergic Disorders in Poland) study

The prevalence of allergic disorders, especially allergic rhinitis (AR), has dramatically increased in the past few decades and multicentre, standardized, randomized epidemiological studies are required to quantify this phenomenon in Poland.

AIM

The aim of the study was to estimate the prevalence of rhinitis and allergic rhinitis in Poland.

MATERIAL AND METHOD

The ECAP study was conducted using the ECRHS II and ISAAC questionnaires translated into the Polish language and validated, in selected nine regions of Poland, including eight cities and one rural area. The respondents within the regions were selected by means of multistage proportional stratified random sampling based on the identity number (PESEL) as the operat. The survey was conducted in 20,454 subjects (response rate of 41.9%) and 18,617 questionnaires were valid. Approximately 25% of the subjects (n=4783) were subsequently evaluated by clinicians (response rate of 43.4%).

RESULTS

Rhinitis was self-reported by 36.08% of the respondents (37.8% of 6- 7-year-olds, 34.5% of 13- 14-year-olds, and 36.0% of adults). The lowest prevalence rate was in the rural region (22.9%). Allergic rhinitis (AR) was self-reported by 22.54% of the respondents (23.6% of 6- 7-year-olds, 24.6% of 13- 14-year-olds, and 21.0% of adults). Again, the lowest prevalence rate was in the rural region (16.0%). AR was more frequent in males (24.0%) than in females (21.2%) (OR = 1.079; 95% CI: 1.044-1.116). AR was actually diagnosed by a clinician in 28.9%, including intermittent AR in 47.7% and persistent AR in 52.3%. Seasonal AR was diagnosed in 15.55%, and perennial rhinitis in 15.2%.

CONCLUSION

Allergic rhinitis is common in Poland as it affects nearly 25% of the population and it is a major social problem. Standards of early detection and prevention of allergic rhinitis should be introduced.

Vernal keratoconjunctivitis--a rare but serious comorbidity of allergic rhinitis and eustachian tube dysfunction

OBJECTIVE

To determine the prevalence of symptoms and signs of allergic rhinitis (AR) in children with vernal keratoconjunctivitis (VKC) and evaluate eustachian tube (ET) function using tympanometry.

METHODS

The patients underwent an otolaryngological examination and symptoms of rhinorrhoea, nasal obstruction, nasal itching and sneezing were evaluated for the diagnosis of AR. Tympanometry was performed by a middle ear analyzer (Impedance audiometer AZ 26, Interacoustics A/S, Assens, Denmark). Blood samples were collected for determination of peripheral blood eosinophil count (PBEC) and serum total immunoglobulin E (IgE). Allergen sensitivity was also determined by skin prick test.

RESULTS

The study included 26 males (96.3%) and 1 female (3.7%) with a mean age of 12.1+/-4.4 years. Eight out of 27 subjects (29.6%) had blood eosinophilia and 11 out of 27 subjects had elevated serum IgE (40.7%). A positive skin prick test was identified for at least one allergen in 40% of patients (10/25 subjects). Symptoms and signs of AR were found in 10 subjects (37%). Median serum IgE level in subjects with AR (262.5 kU/L) was higher than without AR (40.2 kU/L) (p=0.08), whereas there were no differences in PBEC or eosinophilia percentage (p>0.05). Mean middle ear pressures in the right and left ears were -66.4 daPa (range between -268 and 4 daPa) and -57.3 daPa (range between -308 and 0daPa), respectively. The tympanometry results were abnormal in 5 subjects (18.5%) (3 type C and 2 type B tympanogram). Three out of 10 VKC patients with AR (30%) and 2 out of 17 VKC patients without AR (11.8%) had abnormal tympanograms (p=0.33).

CONCLUSION

AR is commonly associated with VKC and subjects with AR are almost three times more likely to have ET dysfunction than those without. Therefore, opthalmologists should refer VKC patients to otolaryngologists to delineate associated AR and ET dysfunction. Conversely, patients with OME and/or AR who have persistent allergic eye symptoms may well benefit from opthalmologic evaluation for seasonal allergic conjunctivitis and VKC.

Comparison of Azelastine versus Triamcinolone Nasal Spray in Allergic and Nonallergic Rhinitis

Background

Intranasal antihistamine has not been thoroughly studied in the treatment of rhinitis of different etiologies. This study was designed to show the comparative efficacy of nasal antihistamine and nasal corticosteroid in patients with allergic rhinitis (AR) and nonallergic rhinitis (NAR).

Methods

A comparison of the efficacy of azelastine nasal spray (AZENS) versus triamcinolone acetonide nasal spray (TANS) on total nasal symptom scores (TNSS), nasal peak inspiratory flow rate (nPIFR), and nasal cytology was studied in a 2-week randomized parallel-group trial. The Epworth Sleepiness Scale (ESS) and health-related quality of life (HRQoL) were also analyzed.

Results

The study group consisted of 132 patients (100 women and 32 men) with a mean age of 33.14 ± 12.52 years. Sixty-nine patients had AR and 63 had NAR. Although TNSS including sneezing, itching, rhinorrhea, congestion—but not anosmia—significantly improved in both groups, intranasal azelastine reduced ocular symptoms greatly compared with intranasal triamcinolone (p = 0.05). Patients with NAR seemed to respond more to TANS, whereas AZENS was more useful in AR. The nPIFR improved in AR and NAR, with no significant difference between the treatment groups. Neither intranasal azelastine nor intranasal triamcinolone changed cytology in nasal lavage. Both medications were well tolerated, but AZENS led to more adverse events than TANS (56.9 and 19%, respectively; p = 0.001), mainly because of bitter taste. Scores on each domain of generic HRQoL (36-Item Short-Form Health Survey) and mini–rhinitis QoL questionnaires, as well as ESS score, significantly improved in both groups, irrespective of rhinitis etiology.

Conclusions

In this first comparative demonstration, AZENS appears to be as effective as triamcinolone in symptom scores, nPIFR, ESS, and HRQoL, equally in AR and NAR.

Peripheral TH-17 cells in children with allergic rhinitis: preliminary report

Th17 is a subset of T helper lymphocytes and exerts pro-inflammatory activities. Recently, it has been reported that serum IL-17 levels are high in the most severe patients with birch allergy studied both outside and during the pollen season. This study aims to compare the frequency of peripheral IL-17-producing T cells in children with allergic rhinitis and in healthy controls. Ten children with allergic rhinitis and 5 healthy non-allergic subjects were evaluated. Th17 were evaluated by intracellular staining in ex-vivo T cell compartment. Ex- vivo PBMNC evaluation showed that allergic patients had higher frequencies of IL-17 producing T cells, both concerning CD4+ and CD8+ cells. In particular, there is a subset co-expressing IL-17 and IFN-gamma both for CD4+ and CD8+ cells. In conclusion, this preliminary study suggests a possible role of Th-17 cells in the response to allergens in children.

Difficult-to-control asthma management through the use of a specific protocol

The present study is a critical review of difficult-to-control asthma, highlighting the characteristics and severity of the disease. It also presents a protocol for the management of patients with this asthma phenotype. The protocol, which was based on relevant studies in the literature, is described and analyzed.

Relationship between mode of delivery in childbirth and prevalence of allergic diseases in Korean children

Purpose

We tested the hypothesis that cesarean section might increase the risk for allergic diseases compared to vaginal delivery, by depriving the newborn of exposure to maternal microflora.

Methods

We evaluated the prevalence of allergic diseases, allergic inflammation, and allergic sensitization according to mode of delivery for 279 Korean children aged ≤16 years. Data were extracted from medical records and a questionnaire filled out by parents. Logistic regression was used to determine the association between cesarean section and the outcomes of interest.

Results

Of the 279 children, 179 (62.6%) were delivered vaginally and 100 (37.4%) by cesarean section. There were no differences in the prevalence of allergic diseases, allergic inflammation, or allergic sensitization according to mode of delivery. Children born by cesarean section had no higher risk of allergic disease than those delivered vaginally, regardless of a parental history for allergic disease. Adjusted odds ratios (95% confidence intervals) for cesarean section compared to vaginal delivery were not statistically significant for any outcome considered: asthma, 0.76 (0.37-1.57), allergic rhinitis, 1.14 (0.61-2.10), atopic dermatitis, 1.01 (0.59-1.71).

Conclusions

Delivery by cesarean section may not be associated with the subsequent development of asthma, allergic rhinitis, or atopic dermatitis in Korean children.

Therapeutic management of allergic diseases

Allergic diseases are characterized by the activation of inflammatory cells and by a massive release of mediators. The aim of this chapter was to describe succinctly the modes of action, indications, and side effects of the major antiallergic and antiasthmatic drugs. When considering the ideal pharmacokinetic characteristics of a drug, a poorly metabolized drug may confer a lower variability in plasma concentrations and metabolism-based drug interactions, although poorly metabolized drugs may be prone to transporter-based disposition and interactions. The ideal pharmacological properties of a drug include high binding affinity, high selectivity, and appropriate association and dissociation rates. Finally, from a patient perspective, the frequency and route of administration are important considerations for ease of use.

Pharmacokinetics in special populations

Pharmacokinetics are typically dependent on a variety of physiological variables (e.g., age, ethnicity, or pregnancy) or pathological conditions (e.g., renal and hepatic insufficiency, cardiac dysfunction, obesity, etc.). The influence of some of these conditions has not always been thoroughly assessed in the clinical studies of antiallergic drugs. However, the knowledge of the physiological grounds of the pharmacokinetics can provide some insight for predicting the potential alterations and guiding the initial prescription strategies. It is important to recognize that both pharmacokinetic and pharmacodynamic differences between populations should be considered. The available information on drugs used for the therapy of allergic diseases is reviewed in this chapter.

Clinical studies of combination montelukast and loratadine in patients with seasonal allergic rhinitis

BACKGROUND

Concomitant use of montelukast and loratadine may improve symptoms of seasonal allergic rhinitis (SAR) more than treatment with either drug alone.

OBJECTIVE

We compared the efficacy of this combination versus placebo, nasal beclomethasone, montelukast, and loratadine in study 1 and versus placebo, montelukast, and loratadine in study 2.

METHODS

Patients were randomly allocated to double-blind treatment with intranasal beclomethasone 200 mu g/twice daily (study 1 only), placebo, montelukast 10 mg+loratadine 10 mg, montelukast 10 mg, or loratadine 10 mg once daily. The primary endpoint was the Composite Symptom Score (CSS): average of daily diary scores for Daytime Nasal Symptoms and Nighttime Symptoms.

RESULTS

In study 1, improvements in the change from baseline in CSS were seen for montelukast+loratadine (least-squares means [95% CI] = -0.43 [-0.51, -0.35]), beclomethasone (-0.57 [-0.64, -0.49]), montelukast, and loratadine. All treatments were significantly better than placebo; montelukast+loratadine had a significantly greater effect on CSS than montelukast alone but no difference compared to loratadine was detected. Beclomethasone provided significantly greater improvement versus montelukast+loratadine on the primary and secondary endpoints except for the rhinoconjunctivitis quality-of-life score. In study 2, the combination treatment was similar to montelukast, loratadine, and placebo for the primary and secondary endpoints.

CONCLUSION

In study 1, montelukast+loratadine had a significantly greater effect on CSS than placebo and montelukast alone; however, in all comparisons, nasal beclomethasone had a greater effect on daily symptoms. In contrast, the combination of montelukast+loratadine in study 2 did not provide greater improvement compared with placebo, montelukast, or loratadine monotherapy, perhaps due to a large placebo effect.

Variable expression of cysteinyl leukotriene type I receptor splice variants in asthmatic females with different promoter haplotypes

BACKGROUND

Cysteinyl leukotrienes are potent inflammatory mediators implicated in the pathogenesis of asthma. Human cysteinyl leukotriene receptor 1 (CYSLTR1) gene contains five exons that are variably spliced. Within its promoter few polymorphisms were described. To date, there has been no evidence about the expression of different splice variants of CysLT1 in asthma and their association with CYSLTR1 promoter polymorphisms.The goal of our study was to investigate CysLT1 alternative transcripts expression in asthmatic patients with different CYSLTR1 promoter haplotypes.The study groups consisted of 44 patients with asthma, diagnosed according to GINA 2008 criteria and 18 healthy subjects. Genomic DNA and total RNA was extracted from peripheral blood mononuclear cells. Real-time PCR was performed with specific primers for transcript I [GenBank:DQ131799] and II [GenBank:DQ131800]. Fragments of the CYSLTR1 promoter were amplified by PCR and sequenced directly to identify four single nucleotide polymorphisms: C/T [SNP:rs321029], A/C [SNP:rs2637204], A/G [SNP:rs2806489] and C/T [SNP:rs7066737].

RESULTS

The expression of CysLT1 transcript I and II in asthma did not differ from its expression in healthy control group. However, in major alleles homozygotic CAAC/CAAC women with asthma we found significantly higher expression of transcript I as compared to heterozygous CAAC/TCGC women in that loci. CysLT1 transcript I expression tended to negative correlation with episodes of acute respiratory infection in our asthmatic population. Moreover, expression of CysLT1 transcript II in CAAC/CAAC homozygotic women with asthma was significantly lower than in CAAC/CAAC healthy control females.

CONCLUSIONS

Genetic variants of CYSLTR1 promoter might be associated with gender specific expression of CysLT1 alternative transcripts in patients with asthma. CysLT1 splice variants expression might also correlate with the susceptibility to infection in asthmatic population.

Chronic cough in upper airway diseases

BACKGROUND

The epidemiological, pathophysiological and clinical links between upper and lower airways are nowadays clearly demonstrated. Most of asthmatics are suffering from rhinitis while up to 40% of rhinitic patients have asthma. Asthmatics and COPD patients are also prone to develop concomitant chronic rhinosinusitis (CRS). This study aimed to determine the predictive value of cough for concomitant asthma in patients suffering from upper airway diseases.

METHODS

This cross-sectional study described a group of 143 consecutive patients suffering simultaneously from common upper and lower airway disorders. Both ENT-specialists and respiratory physicians consecutively examined the patients in Ghent University Hospital from October 2004 till October 2006. This study was based on the demographic characteristics, upper and lower airway conditions.

RESULTS

Forty-seven percent of the patients included in the study were males and the mean age of studied population was 43.6 years. The major complaint was chronic cough. When present, patients with chronic cough have an increased risk of suffering from a concomitant asthma in both allergic rhinitis (OR=5.8) and CRS with nasal polyps (OR=10.4), but not in CRS without polyps.

CONCLUSIONS

Chronic cough was found to be a key symptom of associated asthma in allergic rhinitis and CRS with nasal polyps. Interestingly, chronic cough in CRS without nasal polyps did not show the same predictive value: this suggests different pathophysiological mechanisms.

Clinical profile, outcomes and improvement in symptoms and productivity in rhinitic patients in Karachi, Pakistan

Background

Rhinitis can cause a heavy toll on patients because of its bothersome effects on productivity. This retrospective study was conducted to explore the clinical profile, outcomes and improvement in the symptoms and productivity resulting from treatment of allergic rhinitis in Pakistan.

Methods

We carried out a retrospective file review of all allergic rhinitis patients who presented to the Ear, Nose, Throat Consulting Clinic from January, 2006 to June, 2008 using a structured proforma especially designed for this purpose. Data was entered and analyzed using SPSS v. 16.0.

Results

The charts of 169 patients were reviewed. The mean age of the patients was 35.2 ± 9.1 years. Sixty percent patients were male. Ninety eight patients (58%) reported allergy symptoms to be present at both home and work. One hundred and two patients (60.4%) had symptoms severe enough to cause absence from work or academic activities. Up to seventy one percent patients were spending between 1000 - 3000 Pakistani Rupees (1 US$= 83.3 Pakistani rupees) on the treatment of allergic rhinitis per year. One hundred and fifty one patients (89.3%) reported an improvement in rhinitic symptoms and productivity while 18 patients (10.7%) didn't. This improvement was significantly associated with satisfaction with treatment (p < 0.001).

Conclusion

Allergic rhinitis, a ubiquitous disease, was seen to cause a strain on patients in the form of recurrent treatment-related expenses as well as absenteeism from work or other daily activities. Symptoms and productivity improved significantly after treatment.

Serum lactoferrin level as a serologic biomarker for allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a very common disease and a risk factor for allergic asthma. The discovery of new biomarkers for the early detection of AR would improve the clinical outcomes and reduce socio-economic burden. We sought to identify a novel serologic marker for detection of AR using a proteomic approach.

METHODS

To identify the proteins involved in AR, comparative proteomics was applied using nasal lavage fluids (NLFs) taken before and after a nasal provocation test (NPT) with Dermatophagoides pteronyssinus (Dpt) in a subject with AR sensitized to Dpt. The clinical relevance of the identified proteins was evaluated by ELISA using NLFs and sera from the three study groups: Dpt-sensitive AR; asymptomatic Dpt-sensitive controls; and non-atopic healthy controls. The sensitivities and specificities of the candidate proteins for predicting AR were determined using receiver operating characteristic (ROC) curves.

RESULTS

In proteomic analysis, lactoferrin expression was up-regulated after NPT. The validation study using ELISA showed a significantly lower serum lactoferrin level in the AR group than those of the other two groups (P<0.05, respectively). To discriminate between subjects with or without AR, the optimal serum cut-off level of lactoferrin was set at <307 ng/mL using the ROC curve. The sensitivity and specificity for predicting AR were 81.4% and 58%. When combined with serum Dpt-specific IgE level, the sensitivity and specificity for predicting AR were 76.7% and 79.2%.

CONCLUSION

These results suggest that the serum lactoferrin level is associated with the phenotype of Dpt-sensitive AR, and in combination with the serum Dpt-specific IgE level, may be a potential serologic marker for early detection of AR.

The atopic march: what's the evidence?

OBJECTIVE

To review and compile data from published studies that provide support for the existence of the atopic march.

DATA SOURCES

Relevant articles and references found via a PubMed search using the following keywords: atopic march, allergic march, atopic dermatitis, eczema, atopic eczema, atopy, rhinitis, wheeze, bronchiolitis, and asthma.

STUDY SELECTION

All articles were reviewed and the most relevant were selected for inclusion in this review and for the compilation and graphical presentation of disease trends.

RESULTS

Data on the prevalence of each phenotype of the atopic march confirm the temporal pattern of progression from eczema to allergic rhinitis and asthma. However, the atopic march as it is currently defined, is lacking precision, which affects its usefulness. Early events in the atopic march, such as eczema, may be more useful with more careful refinement of the phenotype into atopic and nonatopic eczema.

CONCLUSION

Evidence supports that the atopic march is a useful paradigm to describe the clinically observed progression of atopy in certain children. There may be more precise phenotypes of the early stages of the atopic march that may improve its utility in predicting the development of later atopic, comorbid chronic disease.

Inhaled corticosteroid therapy with nebulized beclometasone dipropionate

Inhaled corticosteroids (ICS) are the most effective anti-inflammatory agents for the management of chronic persistent asthma and are therefore recommended as first-line antiasthmatic therapy in children and adults. In various settings, the administration of ICS via nebulizer rather than hand-held inhaler (HHI) may have certain advantages, as many patients with HHI fail to use these devices properly or efficiently. In particular, young children, the elderly, the acutely ill, and those with restricted dexterity may be unable to coordinate inhalation with actuation of the device or to generate sufficient inspiratory flow to operate breath-actuated devices effectively. Compliance with nebulized therapy may also be better than that with a pressurized metered-dose inhaler (pMDI) plus spacer. Systematic reviews conclude that there is no significant difference in clinical effects between nebulizers and HHI. Performance and clinical effect of nebulization are influenced by several technical aspects such as the nebulizer-drug combination, nebulizer type, output and lung deposition. Among the currently available ICS, nebulized beclometasone dipropionate (BDP) has been in clinical use for more than 35 years, and has demonstrated marked clinical efficacy and a favorable tolerability profile in children and adults with chronic persistent asthma. The clinical efficacy of nebulized beclometasone is discussed in the present review using data from 13 published studies, which included a total of 1250 patients. Three multicenter, randomized, double-blind studies showed that nebulized BDP is as effective as BDP via pMDI plus spacer in a 2:1 dose ratio. Controlled trials involving 497 adults and children demonstrated similar clinical efficacy between nebulized BDP and either nebulized fluticasone propionate or nebulized budesonide. In all these trials, treatment-related adverse effects were generally uncommon, most were mild-to-moderate in severity, and most were associated with the respiratory system. Meta-analyses show that BDP, like other inhaled corticosteroids, has no major influence on patient height, urinary cortisol concentration, or bone metabolism, thus suggesting the absence of growth retardation or any marked effect on adrenal function or the hypothalamic-pituitary-adrenal axis when used in the approved dose range. Overall, nebulized BDP appears to have a particularly important place in asthma therapy: as a general alternative to HHIs (e.g. in patients with poor HHI compliance); when patients such as children or the elderly are unable to operate HHIs because of poor hand-lung coordination, lack of cooperation, or low inspiratory flow rate; and when high dosages of ICS are required, such as in adults with severe, corticosteroid-dependent asthma.

Minimal persistent inflammation in allergic rhinitis: implications for current treatment strategies

Patients with allergic rhinitis have traditionally been placed into 'seasonal' and 'perennial' categories, which do not account for the subclinical inflammatory state that exists in many patients. In subjects with seasonal and perennial allergic rhinitis, even subthreshold doses of allergen have been found to cause inflammatory cell infiltration in the nasal mucosa, including increases in expression of cellular adhesion molecules, nasal and conjunctival eosinophilia, and other markers of inflammation, which do not result in overt allergy symptoms. This state - which has been termed 'minimal persistent inflammation'- may contribute to hyperreactivity and increased susceptibility to development of clinical symptoms as well as common co-morbidities of allergic rhinitis, such as asthma. Treating overt allergy symptoms as well as this underlying inflammatory state requires agents that have well-established clinical efficacy, convenient administration, potent anti-inflammatory effects and proven long-term safety, so that long-term continuous administration is feasible. Of the three major classes of commonly used allergic rhinitis medications - intranasal corticosteroids, anti-histamines, and anti-leukotrienes - intranasal corticosteroids appear to represent the most reasonable therapeutic option in patients who would benefit from continuous inhibition of persistent inflammation.