Pediatric allergic rhinitis and asthma: can the march be halted?

Long-term effects of pollen allergoid tyrosine-adsorbed subcutaneous immunotherapy on allergic rhinitis and asthma

BACKGROUND

Allergen immunotherapy (AIT) may have a long-term disease-modifying effect. The aim of this study was to demonstrate the long-term effects of pollen allergoid tyrosine-adsorbed subcutaneous AIT on allergic rhinitis (AR) and asthma (AA) in clinical practice.

METHODS

This retrospective study, funded by an AIT manufacturer, analysed the impact of AIT on AR progression and onset of need for AA medication, using a German database covering ~35% of national prescriptions during 2008-2020. Anonymized prescription data of AR patients aged 5-65 years treated with grass or tree pollen AIT between 2009 and 2013 and followed for at least 2 years after AIT cessation were compared with matched control patients with seasonal AR.

RESULTS

181,496 patients received AIT prescriptions. 5959 fulfilled the inclusion criteria. The median AIT treatment duration was 1092 days and the follow-up duration was 6.4 years. Less patients treated with AIT received prescriptions for symptomatic AR medication in the follow-up versus controls (AIT: OR: 0.37; 95% Confidence Interval (CI) 0.34, 0.40; p < .001, tyrosine-adsorbed AIT: OR: 0.27; 95% CI 0.20, 0.35 p < .001). Less asthmatic patients under AIT received prescriptions for AA medications versus controls (AIT: OR: 0.48; 95% CI 0.41, 0.55; p < .001, tyrosine-adsorbed AIT: OR: 0.48; 95% CI 0.29, 0.79; p = .004). AR and AA medication prescriptions for AIT patients were reduced in the follow-up versus baseline and controls (AIT: AR: 20.0%; 1.5 vs. 0.2 prescriptions; AA: 29.1%; 2.0 vs. 0.6 prescriptions, p < .001; tyrosine-adsorbed AIT: AR: 24.2%, 1.4 vs. 0.2 prescriptions; AA: 35.6%, 2.1 vs. 0.6 prescriptions, p < .001). The probability of AA medication onset in non-asthmatic patients during follow-up was reduced for AIT patients compared to controls (OR: 0.77, 95% CI 0.66, 0.90; p = .001). All endpoints were significant for children/adolescents and adults in stratified analyses.

CONCLUSIONS

We found evidence for long-term effects up to 9.5 years for tyrosine-adsorbed AIT.

The MaDo real-life study of dose adjustment of allergen immunotherapy liquid formulations in an indication of respiratory allergic disease: Reasons, practices, and outcomes

Sublingual allergen immunotherapy (SLIT) is a safe, effective, disease-modifying treatment for moderate-to-severe respiratory allergies. The function and responsiveness of the immune system components underlying the effects of allergen immunotherapy may vary from one patient to another. Furthermore, the severity of the symptoms of allergic disease can fluctuate over time, due to changes in environmental allergen exposure, effector cell responsiveness, and cell signaling. Hence, the allergen dose provided through SLIT can be fine-tuned to establish an optimal balance between effectiveness and tolerability. The objective of the MaDo study was to describe and understand dose adjustments of SLIT liquid formulations in France. We performed a retrospective, observational, cross-sectional, real-life study of allergists and other specialist physicians. Physicians described their patients via an anonymous case report form (CRF). The main patient inclusion criteria were age 5 years or over, at least one physician-confirmed IgE-driven respiratory allergy, and treatment for at least 2 years with one or more SLIT liquid preparations. A nationally representative sample of 33 specialist physicians participated in the study. The physicians' main stated reasons for dose adjustment were adverse events (according to 90.9% of the physicians), treatment effectiveness (60.6%), sensitivity to the allergen (42.4%) and other characteristics (30.3%: mainly symptom severity, type of allergen, and asthma). 392 CRFs (mean ± standard deviation patient age: 27.8 ± 17.5; under-18s: 42.1%; polyallergy: 30.9%) were analyzed. Respectively 53.6%, 25.8%, 15.3%, and 8.7% of the patients received house dust mite, grass pollen, birch pollen and cypress pollen SLIT. Dose adjustments were noted in 258 (65.8%) patients (at the start of the maintenance phase for 101 patients (39.2%) and later for 247 (95.7%)). Dose adjustment was not linked to sex, age, or the number of allergens administered. All measures of disease severity (including symptom severity noted on a 0-to-10 visual analogue scale by the physician) decreased significantly during SLIT. Notably, the mean AR symptom severity score decreased to a clinically relevant extent from 7.6 at SLIT initiation to 2.4 at last follow-up, and the mean asthma symptom severity score decreased from 5.0 to 1.3. The few differences in effectiveness between patients with vs. without dose adjustment were not major. For about one patient in five, a specialist physician decided to reduce or increase the SLIT liquid dose at the start of maintenance treatment and/or during maintenance treatment. This decision was influenced by a broad range of patient and treatment factors, mainly to improve tolerability to treatment and/or enhance effectiveness. In France, dose adjustment of SLIT liquid preparations as a function of the patient profile and/or treatment response is anchored in clinical practice. Precision dosing might optimize the overall benefit-risk profile of AIT for individual patients throughout their entire treatment course, enabling them to achieve both short- and long-term treatment goals, whilst maximizing the safety and tolerability.

Prognosis of COVID-19 in respiratory allergy: a systematic review and meta-analysis

Background

Do underlying allergic respiratory diseases such as asthma and rhinitis predispose to a severe coronavirus (COVID-19) infection? We conducted this systematic review to map out and synthesize evidence of published literature.

Main body of the abstract

We searched five bibliographic databases for articles published between 1 January and 15 November 2020 using keywords: “COVID” AND “Allergic disease,” “Prognosis and COVID-19,” “SARS-CoV-2,” “Asthma,” “Allergic rhinitis.” We synthesized 32 eligible articles from a total of 11,376 articles retrieved from the search process. The profile of allergic respiratory conditions was identified, and only seven studies reported on the treatment administered. No significant difference was observed concerning the prevalence of COVID-19 in individuals with allergic asthma and those with non-allergic asthma (RR = 0.61, p = 0.08). The mortality rate significantly decreased in COVID-19-infected patients with asthma than patients without asthma (RR = 0.63, p = 0.04).

Short conclusion

There is little evidence available on the role of asthma medications and risk factors influencing the prognostic outcomes for COVID-19 individuals with respiratory allergies, which invites further research.

Childhood Allergy Disease, Early Diagnosis, and the Potential of Salivary Protein Biomarkers

Allergic disease has risen to epidemic proportions since the last decade and is among the most common noncommunicable, chronic diseases in children and adolescents worldwide. Allergic disease usually occurs in early life; thus, early biomarkers of allergic susceptibility are required for preventive measures to high-risk infants which enable early interventions to decrease allergic severity. However, to date, there is no reliable general or specific allergy phenotype detection method that is easy and noninvasive for children. Most reported allergic phenotype detection methods are invasive, such as the skin prick test (SPT), oral food challenge (OFC), and blood test, and many involve not readily accessible biological samples, such as cord blood (CB), maternal blood, or newborn vernix. Saliva is a biological sample that has great potential as a biomarker measurement as it consists of an abundance of biomarkers, such as genetic material and proteins. It is easily accessible, noninvasive, collected via a painless procedure, and an easy bedside screening for real-time measurement of the ongoing human physiological system. All these advantages emphasise saliva as a very promising diagnostic candidate for the detection and monitoring of disease biomarkers, especially in children. Furthermore, protein biomarkers have the advantages as modifiable influencing factors rather than genetic and epigenetic factors that are mostly nonmodifiable factors for allergic disease susceptibility in childhood. Saliva has great potential to replace serum as a biological fluid biomarker in diagnosing clinical allergy. However, to date, saliva is not considered as an established medically acceptable biomarker. This review considers whether the saliva could be suitable biological samples for early detection of allergic risk. Such tools may be used as justification for targeted interventions in early childhood for disease prevention and assisting in reducing morbidity and mortality caused by childhood allergy.

Allergies, Allergic Comorbidities and the Home Environment in Pediatric Asthma in Southern Florida

Background: Environmental exposure is critical in sensitization to environmental allergens and pediatric asthma morbidity, especially in tropical climates where children are perennially exposed to bioaerosols, such as pollen and mold spores, and endotoxins. Objective: This cross-sectional study examines the association of allergies, associated allergic comorbidities, and the home environment separately and synergistically in pediatric asthma, including in asthma prevalence, severity of asthma, and undiagnosed asthma, in South Florida. Methods: An online survey was administered to the parents of children attending two of the University of Miami pediatric clinics from June to October 2016. Descriptive, factor, and multivariate regression analyses were used to analyze the data. Results: Of 163 children, 22% (36) children had physician-diagnosed asthma; 10% and 32% had allergic rhinitis diagnosis and rhinitis symptoms, respectively, in the past. The allergy diagnosis age was 2.3 years higher than the asthma diagnosis age (p < 0.01). Children with ≥ 2 allergies were 12.8 times more likely to have physician-diagnosed asthma than those without allergies (p < 0.01). Children with allergies and allergic rhinitis were 4.3 (p < 0.05) times more likely to have asthma, and those with asthma were 15 (p < 0.05) times more likely to have an asthma attack than those without known allergies and allergic rhinitis. Conclusion: Allergies and associated comorbidities are risk factors of asthma, asthma persistence, and multiple allergies exacerbate their effects. Early screening for allergies and treatment are warranted to manage asthma. Since the home environment plays an important role in sensitization to allergens, further research is needed to assess home-environment-mediated allergic conditions in the onset and persistence of asthma.

Placebo effects in allergen immunotherapy-An EAACI Task Force Position Paper

The placebo (Latin "I will please") effect commonly occurs in clinical trials. The psychological and physiological factors associated with patients' expectations about a treatment's positive and negative effects have yet to be well characterized, although a functional prefrontal cortex and intense bidirectional communication between the central nervous system and the immune system appear to be prerequisites for a placebo effect. The use of placebo raises certain ethical issues, especially if patients in a placebo group are denied an effective treatment for a long period of time. The placebo effect appears to be relatively large (up to 77%, relative to pretreatment scores) in controlled clinical trials of allergen immunotherapy (AIT), such as the pivotal, double-blind, placebo-controlled (DBPC) randomized clinical trials currently required by regulatory authorities worldwide. The European Academy of Allergy and Clinical Immunology (EAACI) therefore initiated a Task Force, in order to better understand the placebo effect in AIT and its specific role in comorbidities, blinding issues, adherence, measurement time points, variability and the natural course of the disease. In this Position Paper, the EAACI Task Force highlights several important topics regarding the placebo effect in AIT such as a) regulatory aspects, b) neuroimmunological and psychological mechanisms, c) placebo effect sizes in AIT trials, d) methodological limitations in AIT trial design and e) potential solutions in future AIT trial design. In conclusion, this Position Paper aims to examine the methodological problem of placebo in AIT from different aspects and also to highlight unmet needs and possible solutions for future trials.

Management/Comorbidities of School-Aged Children with Asthma

Asthma is a complex heterogeneous disease characterized by reversible airflow obstruction. After appropriate diagnosis, the management in school-aged children centers on 3 broad domains: pharmacologic treatment, treatment of underlying comorbidities, and education of the patient and caregivers. It is important to understand that the phenotypic differences that exist in the school-aged child with asthma may impact underlying comorbid conditions as well as pharmacologic treatment choices. Following initiation of therapy, asthma control must be continually evaluated in order to optimize management.

Update in Pediatric Asthma: Selected Issues

Asthma is a complex condition that affects 14% of the world's children and the approach to management includes both pharmacologic as well as non-pharmacologic strategies including attention to complex socioeconomic status phenomena. After an historical consideration of asthma, allergic and immunologic aspects of asthma in children and adolescents are presented. Concepts of socioeconomic aspects of asthma are considered along with environmental features and complications of asthma disparities. Also reviewed are links of asthma with mental health disorders, sleep disturbances and other comorbidities. A stepwise approach to asthma management is discussed that includes pharmacologic and non-pharmacologic strategies in the pediatric population. The role of immunotherapy and use of various immunomodulators are considered as well.

Immunotherapy with grass pollen tablets reduces medication dispensing for allergic rhinitis and asthma: A retrospective database study in France

BACKGROUND

Moderate-to-severe allergic rhinitis (AR) may increase the risk of developing or worsening asthma, whereas treatment of AR with subcutaneously or sublingual allergen immunotherapy (SLIT) may slow this progression.

METHODS

In a retrospective real-world analysis, prescription fulfilment data were gathered from French retail pharmacies between 1 March 2012 and 31 December 2016. Using linear regression analyses, patients having received at least two prescriptions of grass pollen SLIT tablets over at least 2 successive years were compared with control patients having received symptomatic medications only.

RESULTS

A total of 1099 SLIT patients and 27 475 control patients were included in the main analysis. With regard to symptomatic AR medication dispensing, we observed a 50% decrease in the pre-index/follow-up ratio in the SLIT group, a 30% increase in the control group without age matching (P < 0.0001 vs SLIT) and a 20% increase in the control group with age matching (P < 0.0001 vs SLIT). During the follow-up, 11 (1.8%) and 782 (5.3%) patients initiated asthma treatment in the SLIT and control groups, respectively. The relative risk of medication dispensing for new asthma was lower in the SLIT group (by 62.5% [29.1%-80.1%] without age matching (P = 0.0025) and by 63.7% [31.5%-80.7%] with age matching; P = 0.0018). SLIT was also associated with slower progression of asthma medication dispensing during the follow-up period, relative to the control group (regression coefficient: -0.58 [-0.74 to 0.42] without age matching (P < 0.0001) and -0.61 [-0.76 to -0.46] with age matching; P < 0.0001).

CONCLUSION

Prescription of grass pollen SLIT tablets reduced the dispensing of AR and asthma medications in real life.

Real-world benefits of allergen immunotherapy for birch pollen-associated allergic rhinitis and asthma

BACKGROUND

Real-world evidence is sparse on the benefits of allergen immunotherapy [AIT; subcutaneous/sublingual immunotherapy (SCIT/SLIT)], the only disease-modifying intervention for allergic rhinitis (AR) with long-term efficacy. This real-life study evaluated the effect of six AITs (native pollen SLIT/SCIT, four allergoid SCITs) vs symptomatic medication use, on AR symptoms and asthma symptoms/onset, in patients with birch pollen-associated AR and/or asthma.

METHODS

In this retrospective cohort analysis of a German longitudinal prescription database, AIT patients received ≥2 successive seasonal treatment cycles; non-AIT patients had ≥3 AR prescriptions in three seasons or previous month. Patients were matched for: index year, age, gender, main indication at index, number of seasonal cycles within treatment period, baseline AR/asthma treatment prescriptions. Multiple regression analysis compared prescription data in AIT and non-AIT groups as proxy for clinical status/disease progression.

RESULTS

Up to 6 years of follow-up, significantly more AIT (65.4%) vs non-AIT (47.4%) patients were AR medication-free; odds ratio (OR) [95% confidence interval (CI)]: 0.51 [(0.48-0.54); P < 0.001] (28.6% covariate-adjusted reduction vs non-AIT; P < 0.001), and significantly more AIT (49.1%) vs non-AIT (35.1%) patients were asthma medication-free [OR (95% CI): 0.59 (0.55-0.65); P < 0.001] (32% reduction vs non-AIT; P < 0.001), or reduced existing asthma medication use (32% covariate-adjusted reduction vs non-AIT; P < 0.001). During treatment, new-onset asthma risk was significantly reduced in the AIT vs non-AIT group (OR: 0.83; P = 0.001).

CONCLUSIONS

Birch pollen AIT demonstrated real-world benefits up to 6 years post-treatment cessation through significantly reduced AR and asthma medication intake, and significantly decreased risk of new-onset asthma medication use on-treatment.

Mechanisms by Which Atopic Dermatitis Predisposes to Food Allergy and the Atopic March

The Atopic march denotes the progression from atopic dermatitis (AD) to the development of other allergic disorders such as immunoglobulin (Ig) E-mediated food allergy, allergic rhinitis and asthma in later childhood. There is increasing evidence from prospective birth cohort studies that early-onset AD is a risk factor for other allergic diseases or is found in strong association with them. Animal studies now provide mechanistic insights into the pathways that may be responsible for triggering the progression from the skin barrier dysfunction seen in AD to epicutaneous sensitization, food allergy and allergic airway disorders. Recent large randomized controlled trials have demonstrated the efficacy of early interventions targeted at AD and food allergy prevention. These show great promise for research into future strategies aimed at prevention of the atopic march.

Does allergy explain why some children have severe asthma?

Asthma is a common disease in childhood with a minority of affected children having severe therapy-resistant asthma (STRA). Children with STRA can be differentiated from those with mild-moderate disease by greater allergic sensitization, increased eosinophilic airway inflammation, increased airway remodelling and reduced corticosteroid responsiveness. The aetiology of STRA in children is multifactorial but allergy seems to play a key role. Many children with asthma have coexisting allergic disease, and severe rhinitis seems to be an important driver of STRA in children. Allergies to foods, moulds, pollen and pets have also been associated with severe asthma exacerbations. Identifying allergens that are driving asthma symptoms in children with STRA may provide additional strategies for improving their disease control. Avoidance strategies may be possible. Additional monoclonal antibody therapy with Omalizumab or Mepolizumab may be helpful in children with clinically important polysensitization.

Small-airway dysfunction precedes the development of asthma in children with allergic rhinitis

BACKGROUND

Epidemiological evidence suggests the existence of a direct link between allergic rhinitis (AR) and asthma. Several studies also support the presence of small-airway dysfunction (SAD) in non-asthmatic children with AR. However, it remains unknown whether SAD can predict the progression of AR to asthma. Our objective was to explore the existence of SAD in non-asthmatic children with AR and to assessed its ability to predict the development of asthma.

METHODS

Seventy-three 6-year-old children with intermittent moderate-severe AR but without asthma symptoms/medication within the last two years, underwent spirometry and measurement of respiratory resistance (Rrs) and reactance (Xrs) before and after bronchodilation (BD) (300mcg salbutamol). Lung function measurements were performed in the absence of nasal symptoms and repeated at AR exacerbation. SAD was defined as >30% decrease in Rrs or >50% increase in Xrs at 6 or 8Hz post-BD. Participants were followed for five years.

RESULTS

Twenty-three children (31.5%) developed asthma; this group presented significant post-BD changes in Rrs and Xrs, but only at AR exacerbation. The ability of these changes to predict the development of asthma was exceptional and superior to that of the spirometric parameters. SAD (22 children, 30.1%), emerged as the single most efficient predictor of asthma, independently of other risk factors such as parental asthma, personal history of eczema and type of allergic sensitisation.

CONCLUSION

SAD precedes the development of asthma in children with AR. Changes in respiratory impedance at AR exacerbation may assist in identifying those at risk to progress to asthma.

Do Paediatric Investigation Plans (PIPs) Advance Paediatric Healthcare?

Since 2007, new drugs need a paediatric investigation plan (PIP) for EU registration. The PIPs' justifications can be traced back to concerns expressed by Shirkey that label warnings against paediatric use made children "therapeutic orphans", and the American Academy of Pediatrics' claim that all children differ considerably from adults. US legislation first encouraged, then also required, separate, adult-style safety and efficacy studies in all paediatric subpopulations. This triggered paediatric regulatory studies by the pharmaceutical industry. There were also negative outcomes, as a result of using the legal definition of childhood as a medical/physiological term. The "therapeutic orphans" concept became dogma that supported/expanded adult-style regulatory testing into all age groups even when poorly justified in adolescents or where other methods are available to generate needed data. PIPs are especially problematic because they lack the limitations imposed on the Food and Drug Administration's (FDA's) regulatory actions and more practical approaches used in the USA. Many PIP studies are medically senseless or even questionable and/or unfeasible with poor risk/benefit ratios. For example, physiologically mature adolescents have been exposed to treatments and doses known to be suboptimal in adults. Unfeasible PIP studies in rare diseases may harm patients by preventing their participation in more beneficence-driven studies. PIP-required studies can prevent effective treatment of allergic rhinitis during years of placebo treatment, exposing minors to the risk of disease progression to asthma. The PIP system should be revised; more should be done by key players, including institutional review boards/ethics committees, to ensure that all paediatric clinical studies are medically justified, rather than legislation driven, and can produce scientifically valid results.

Grass pollen sublingual immunotherapy tablets provide long-term relief of grass pollen-associated allergic rhinitis and reduce the risk of asthma: findings from a retrospective, real-world database subanalysis

BACKGROUND

We assessed real-world, long-term effectiveness of two marketed sublingual immunotherapy (SLIT) tablets for allergic rhinitis (AR), and their impact on allergic asthma (AA) onset/progression.

METHODS

Retrospective, longitudinal German prescription database subanalysis of AR patients receiving 5- or 1-grass pollen SLIT tablets (n = 1,466/1,385), versus patients not using allergy immunotherapy (AIT) (n = 71,275). Primary endpoint: change over time in AR symptomatic medication prescriptions after treatment cessation; secondary endpoints: new asthma onset, and change over time in asthma medication prescriptions during treatment/follow-up periods.

RESULTS

Mean number of AR medication prescriptions was significantly decreased during follow-up (of up to 6 years) with both SLIT tablets versus the non-AIT group (p < 0.001). Over the full-analysis period, proportions of patients with new-onset asthma were 8.8% (odds ratio: 0.676, p = 0.011), 10.3% (odds ratio: 0.720, p = 0.060) and 11.6% in the 5- and 1-grass pollen SLIT tablet and non-AIT groups, respectively. For all treatment-analysis periods, both SLIT tablet groups were associated with fewer asthma medication prescriptions versus non-AIT controls.

CONCLUSIONS

These findings confirm the real-world benefits of 5- and 1-grass-pollen SLIT tablets in slower AR progression, reduced risk of new asthma onset in the non-asthmatic population, and slower asthma progression in the asthmatic population.

Efficacy of a leukotriene receptor antagonist for pediatric cedar pollen allergy complicated by asthma

Leukotriene receptor antagonists (LTRAs) are identified as a monotherapy for asthma and allergic rhinitis; however, their use in children for treatment of these diseases has not been examined. Accordingly, the present study investigated the efficacy of pranlukast dry syrup for children with both pollinosis and asthma. The subjects were children receiving treatment for asthma who were also diagnosed with cedar pollen allergy. Patients were divided into a group that received continuous treatment with pranlukast (group A; n=20) and a group that commenced add-on treatment for pollinosis following the onset of symptoms (group B; n=20). Patients in group B were randomly allocated to subgroup B1 (add-on treatment with pranlukast dry syrup) or subgroup B2 (add-on treatment with a second-generation antihistamine). In both groups, nasal and ocular symptoms were evaluated every day and recorded in a diary. Exacerbation of nasal obstruction was demonstrated in group B; however, not in group A. There was a significant difference in symptoms observed between the two groups during the late peak pollen period (P<0.05). The incidence of nasal obstruction (defined as a nasal obstruction score ≥3 or use of a nasal steroid spray) was significantly lower in group A compared with group B (P<0.05). The maximum scores for sneezing and nasal obstruction during the late peak of the pollen season were lowest in group A, followed by subgroup B1 and subgroup B2. The present study demonstrated that long-term administration of LTRA for the management of asthma may improve nasal symptoms of pollinosis during the pollen season in children with pollinosis and asthma.

Specific immunotherapy in allergic rhinitis

Allergic rhinitis is a common condition, with significant impact on quality of life depending on severity and quality of control. Allergen-specific immunotherapy (allergen-SIT) is the only known treatment able to alter the natural course of allergic rhinitis. Although well known to allergologists, it has yet to be fully adopted by the ENT community. This review, based on the most recent meta-analyses and clinical studies, shows that SIT significantly reduces symptoms and medication requirements (nasal corticosteroids, H1-antihistamines) in allergic rhinitis. It can reduce the risk of progression to asthma and, if initiated early enough, of developing new sensitizations. Immunobiological analysis shows an altered inflammatory profile following SIT, with immune tolerance involving T-regulatory lymphocyte induction and IgG production. Sublingual SIT with drops is as effective as subcutaneous SIT and is simpler to use, with less anaphylactic risk. Standardization of trial protocols in terms of treatment response assessment and side effect grading is recommended to improve comparative studies. Sublingual SIT with tablets has recently been introduced, providing a good opportunity for ENT practitioners to adopt the SIT approach in rhinitis triggered by allergy to pollens and, in the near future, to house dust mites.

Subclinical lower airways correlates of chronic allergic and non-allergic rhinitis

The upper and lower airways behave as a physiological and pathophysiological unit. Subclinical lower airways abnormalities have been described in patients with rhinitis without asthma. These are expressed as bronchial hyperreactivity, abnormalities in lung function and bronchial inflammation, likely as a result of the same phenomenon with systemic inflammatory impact that reaches both the nose and the lungs, which for unknown reasons does not always have a full clinical expression. Patients with rhinitis are at increased risk of developing asthma; therefore, most authors suggest a careful clinical evaluation and monitoring of these patients, especially if symptoms related to inflammation in the lower airways are observed. Although current treatments, such as H1-antihistamines, intranasal steroids and allergen immunotherapy, are quite effective for the management of rhinitis, it is difficult to prove their capacity to prevent asthma among subjects with rhinitis. Evidence showing that the treatment of rhinitis has a favourable impact on indicators of bronchial hyperreactivity and inflammation among subjects that have no symptoms of asthma is more frequently described. In this review, we address the frequency and characteristics of lower airway abnormalities in subjects with rhinitis, both in paediatric and adult populations, their likely predictive value for the development of asthma and the possibilities for therapeutic intervention that could modify the risk of subjects with rhinitis towards presenting asthma.

Treatment of allergic children - Where is the progress (for the practicing allergist)?

For any kind of therapeutic intervention in allergic diseases such as environmental control, pharmacological, or immunomodulating treatment including educational programs, children are addressed separately from adults. Health authorities like the Food and Drug Administration in the United States of America or the European Medicine Agency in Europe request a specific 'Pediatric investigational plan' with studies addressing dose-response relationship, safety, and efficacy for infants, children, and adolescents. During the last 2 years, promising advances have been reported for the treatment of a variety of allergic and immunologic disorders. This review summarizes the progress in the treatment of pediatric asthma and allergic diseases, based on publications of approximately the last 2.5 years (end of 2013 until May 2016) in and beyond this journal. Meanwhile, it highlights areas with promising novel therapeutic approaches, which are likely to change treatment for allergic children in the near future.

Epidemiology and economic burden of asthma

BACKGROUND

The "asthma epidemic" is on the rise, with the Center for Disease Control (CDC) epidemiological studies reporting a 3.0% asthma prevalence in the United States in 1970, 5.5% in 1996, and 7.8% in 2006 to 2008. This results in an immense economic burden, with asthma costing an estimated $56 billion in the United States in 2007, which is a 6% increase from the $53 billion that was spent in 2002.

METHODS

A review of the current literature and CDC reports were used to thoroughly examine and summarize the epidemiology and economic burden of asthma domestically and globally.

RESULTS

Asthma shows a male predominance before puberty, and a female predominance in adulthood. Studies show Puerto Ricans to be the most commonly affected ethnicity, and a higher prevalence of asthma is found in lower income populations. Asthma is related to some of the more common otolaryngologic diseases such as allergy and obstructive sleep apnea. The condition results in significant morbidity, such as an increase in emergency department visits and a decrease in productivity due to missed school and works days.

CONCLUSION

Epidemiological statistics report an undisputable increase of asthma both domestically and worldwide, which means the economic burden of this disease is also on the rise. Better access to healthcare, improved asthma education, and bridging the gap between ethnic and racial disparities in the treatment and management of asthma may help to control this epidemic, promote better outcomes, and prevent continued rising costs related to the management of this widespread disease.

Contributing factors to the development of childhood asthma: working toward risk minimization

Asthma is the most common chronic disease in childhood, and considerable research has been undertaken to find ways to prevent its development and reduce its prevalence. For such interventions to be successful, risk factors for asthma emergence should be identified and clearly defined. Data are robust for some of them, including atopy, viral infections and exposure to airborne irritants, whereas it is less conclusive for others, such as aeroallergen exposure and bacterial infections. Several interventions for asthma prevention, including avoidance and pharmacotherapy, have been attempted. However, most of them have furnished equivocal results. Various issues hinder the establishment of risk factors for asthma development and reduce the effectiveness of interventions, including the complexity of the disease and the fluidity of the developing systems in childhood. In this review, we revisit the evidence on pediatric asthma risk factors and prevention and discuss issues that perplex this field.

Five-grass-pollen sublingual immunotherapy tablet for the treatment of grass-pollen-induced allergic rhinoconjunctivitis: 5 years of experience

Oralair(®) (OA) (Stallergenes, Antony, France) is a unique pre- and co-seasonal 5-grass-pollen sublingual immunotherapy tablet launched in 2008, and now approved in 31 countries worldwide for the treatment of grass-pollen allergic rhinitis and rhinoconjunctivitis. OA is the first oral treatment with a consistent, well-balanced allergen extract that mimics natural exposure and sensitization. A wealth of data exists from over 5 years of clinical and real-world experience demonstrating the efficacy and safety of OA for grass-pollen-allergy treatment. OA is highly effective from the first pollen season in all patient subgroups, including children and those with comorbid mild asthma, irrespective of sensitization status and symptom severity. OA also has sustained long-term benefits for symptom control and quality of life. This article provides an overview of the pharmacodynamics and pharmacology of OA; its efficacy, safety, tolerability and cost-effectiveness for the treatment of allergic rhinitis and rhinoconjunctivitis and its role in clinical practice.

Lessons learned from mice and man: mimicking human allergy through mouse models

The relevance of using mouse models to represent human allergic pathologies is still unclear. Recent studies suggest the limitations of using models as a standard for assessing immune response and tolerance mechanisms, as mouse models often do not sufficiently depict human atopic conditions. Allergy is a combination of aberrant responses to innocuous environmental agents and the subsequent TH2-mediated inflammatory responses. In this review, we will discuss current paradigms of allergy - specifically, TH2-mediated and IgE-associated immune responses - and current mouse models used to recreate these TH2-mediated pathologies. Our overall goal is to highlight discrepancies that exist between mice and men by examining the advantages and disadvantages of allergic mouse models with respect to the human allergic condition.