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Heterogeneity of NSAID-Exacerbated Respiratory Disease: has the time come for subphenotyping? Curr Opin Pulm Med 2020; 25:64-70. [PMID: 30489335 DOI: 10.1097/mcp.0000000000000530] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW NSAID-Exacerbated Disease (N-ERD) is a chronic eosinophilic inflammatory disorder of the respiratory tract occurring in patients with asthma and/or rhinosinusitis with nasal polyps, whose symptoms are exacerbated by NSAIDs. The purpose of this review is to provide an update on clinical characteristics, pathophysiology, and management of N-ERD, and to emphasize heterogeneity of this syndrome. RECENT FINDINGS Growing evidence indicates that N-ERD, which has been considered a separate asthma phenotype, is heterogenous, and can be divided in several subphenotypes varying in clinical characteristics. Pathophysiology of N-ERD is complex and extends beyond abnormalities in the arachidonic acid metabolism. Heterogeneity of pathophysiological mechanisms underlying development of airway inflammation seems to be associated with variability in response to both anti-inflammatory and disease-specific treatments (e.g., with aspirin after desensitization). SUMMARY Progress in understanding of the pathophysiology of N-ERD leads to discovery and validation of new biomarkers facilitating diagnosis and predicting the response to treatment of the chronic inflammation underlying upper (CRSwNP) and lower airway (asthma) symptoms. Better characterization of the immunophysiopathological heterogeneity of N-ERD (identification of endotypes) may allow more personalized, endotype-driven approach to treatment in the future.
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Parker AR, Ayars AG, Altman MC, Henderson WR. Lipid Mediators in Aspirin-Exacerbated Respiratory Disease. Immunol Allergy Clin North Am 2017; 36:749-763. [PMID: 27712768 DOI: 10.1016/j.iac.2016.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is a syndrome of severe asthma and rhinosinusitis with nasal polyposis with exacerbations of baseline eosinophil-driven and mast cell-driven inflammation after nonsteroidal antiinflammatory drug ingestion. Although the underlying pathophysiology is poorly understood, dysregulation of the cyclooxygenase and 5-lipoxygenase pathways of arachidonic acid metabolism is thought to be key. Central features of AERD pathogenesis are overproduction of proinflammatory and bronchoconstrictor cysteinyl leukotrienes and prostaglandin (PG) D2 and inhibition of bronchoprotective and antiinflammatory PGE2. Imbalance in the ratio of these lipid mediators likely leads to the increased eosinophilic and mast cell inflammatory responses in the respiratory tract.
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Affiliation(s)
- Andrew R Parker
- Department of Medicine, UW Medicine, University of Washington, 750 Republican Street, Seattle, WA 98109-4766, USA
| | - Andrew G Ayars
- Department of Medicine, UW Medicine, University of Washington, 750 Republican Street, Seattle, WA 98109-4766, USA
| | - Matthew C Altman
- Department of Medicine, UW Medicine, University of Washington, 750 Republican Street, Seattle, WA 98109-4766, USA
| | - William R Henderson
- Department of Medicine, UW Medicine, University of Washington, 750 Republican Street, Seattle, WA 98109-4766, USA.
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Hagan JB, Laidlaw TM, Divekar R, O'Brien EK, Kita H, Volcheck GW, Hagan CR, Lal D, Teaford HG, Erwin PJ, Zhang N, Rank MA. Urinary Leukotriene E4 to Determine Aspirin Intolerance in Asthma: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:990-997.e1. [PMID: 28202405 DOI: 10.1016/j.jaip.2016.11.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 10/21/2016] [Accepted: 11/03/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND Urinary leukotriene E4 (ULTE4) may be a biomarker that distinguishes aspirin-intolerant asthma from other asthma subtypes. OBJECTIVE To estimate the diagnostic testing accuracy of ULTE4 as a marker of aspirin intolerance in patients with asthma using previously published studies. METHODS We identified relevant clinical studies from a systematic review of English and non-English articles using MEDLINE, EMBASE, and CENTRAL (inception to February 10, 2015). Articles were screened at the abstract and full-text level by 2 independent reviewers. We included previously published studies that analyzed ULTE4 in human subjects with asthma characterized as having or not having aspirin intolerance on the basis of a specified definition: convincing history of aspirin intolerance, positive aspirin challenge, or both as the criterion standard. Individual-level data points from all included studies were obtained and analyzed. RESULTS The search strategy identified 867 potential articles, of which 86 were reviewed at the full-text level and 10 met criteria for inclusion. The sensitivity, specificity, positive predictive value, and negative predictive values of ULTE4 to determine aspirin intolerance in subjects with asthma were 0.55, 0.82, 0.75, and 0.66 (Amersham-enzyme immunoassay); 0.76, 0.77, 0.70, and 0.78 (Cayman-enzyme immunoassay); 0.70, 0.81, 0.86, and 0.79 (mass spectrometry); and 0.81,0.79, 0.65, and 0.88 (radioimmunoassay) at optimal thresholds of 192, 510, 167 to 173, and 66 to 69 pg/mg Cr, respectively. The diagnostic odds ratio for each methodology was 6.0, 11.9, 10.5, and 19.1, respectively. CONCLUSIONS ULTE4 is a marker for aspirin-intolerant asthma and could potentially be used as a clinical test to identify the risk of aspirin intolerance in subjects with asthma.
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Affiliation(s)
- John B Hagan
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn.
| | - Tanya M Laidlaw
- Department of Medicine, Harvard Medical School, Boston, Mass
| | - Rohit Divekar
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Erin K O'Brien
- Otorhinolaryngology, Head and Neck Surgery, Mayo Clinic, Rochester, Minn
| | - Hirohito Kita
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn; Department of Immunology, Mayo Clinic, Rochester, Minn
| | | | | | - Devyani Lal
- Otorhinolaryngology, Mayo Clinic, Scottsdale, Ariz
| | - Harry G Teaford
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Ariz
| | | | - Nan Zhang
- Research Biostatistics, Mayo Clinic, Scottsdale, Ariz
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Ariz
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Kowalski ML, Ansotegui I, Aberer W, Al-Ahmad M, Akdis M, Ballmer-Weber BK, Beyer K, Blanca M, Brown S, Bunnag C, Hulett AC, Castells M, Chng HH, De Blay F, Ebisawa M, Fineman S, Golden DBK, Haahtela T, Kaliner M, Katelaris C, Lee BW, Makowska J, Muller U, Mullol J, Oppenheimer J, Park HS, Parkerson J, Passalacqua G, Pawankar R, Renz H, Rueff F, Sanchez-Borges M, Sastre J, Scadding G, Sicherer S, Tantilipikorn P, Tracy J, van Kempen V, Bohle B, Canonica GW, Caraballo L, Gomez M, Ito K, Jensen-Jarolim E, Larche M, Melioli G, Poulsen LK, Valenta R, Zuberbier T. Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement. World Allergy Organ J 2016; 9:33. [PMID: 27777642 PMCID: PMC5062928 DOI: 10.1186/s40413-016-0122-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 08/19/2016] [Indexed: 01/14/2023] Open
Abstract
One of the major concerns in the practice of allergy is related to the safety of procedures for the diagnosis and treatment of allergic disease. Management (diagnosis and treatment) of hypersensitivity disorders involves often intentional exposure to potentially allergenic substances (during skin testing), deliberate induction in the office of allergic symptoms to offending compounds (provocation tests) or intentional application of potentially dangerous substances (allergy vaccine) to sensitized patients. These situations may be associated with a significant risk of unwanted, excessive or even dangerous reactions, which in many instances cannot be completely avoided. However, adverse reactions can be minimized or even avoided if a physician is fully aware of potential risk and is prepared to appropriately handle the situation. Information on the risk of diagnostic and therapeutic procedures in allergic diseases has been accumulated in the medical literature for decades; however, except for allergen specific immunotherapy, it has never been presented in a systematic fashion. Up to now no single document addressed the risk of the most commonly used medical procedures in the allergy office nor attempted to present general requirements necessary to assure the safety of these procedures. Following review of available literature a group of allergy experts within the World Allergy Organization (WAO), representing various continents and areas of allergy expertise, presents this report on risk associated with diagnostic and therapeutic procedures in allergology and proposes a consensus on safety requirements for performing procedures in allergy offices. Optimal safety measures including appropriate location, type and required time of supervision, availability of safety equipment, access to specialized emergency services, etc. for various procedures have been recommended. This document should be useful for allergists with already established practices and experience as well as to other specialists taking care of patients with allergies.
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Affiliation(s)
- Marek L. Kowalski
- Department of Immunology, Rheumatology & Allergy, Medical University of Lodz, 251 Pomorska Str, 92-213 Lodz, Poland
| | - Ignacio Ansotegui
- Department of Allergy and Immunology, Hospital Quiron Bizkaia, Bilbao, Spain
| | - Werner Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Mona Al-Ahmad
- Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Mubeccel Akdis
- Swiss institute of Allergy & Asthma research, Davos, Switzerland
| | - Barbara K. Ballmer-Weber
- Allergy Unit, Dermatology Clinic, University Hospital Zürich, University Zürich, Zürich, Switzerland
| | - Kirsten Beyer
- Kirsten Beyer, Charité Universitätsmedizin Berlin, Klinik für Pädiatrie m.S. Pneumologie und Immunologie, Berlin, Germany
| | - Miguel Blanca
- Hospital Reg. Univ. Carlos Haya, Allergy Serv, Malaga, Spain
| | - Simon Brown
- Royal Perth Hospital, Department of Emergency Medicine, Perth, WA Australia
| | - Chaweewan Bunnag
- Department of Otolaryngology, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Mariana Castells
- Brigham & Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Hiok Hee Chng
- Department of Rheumatology, Allergy & Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Frederic De Blay
- Hôpitaux Universitaires de Strasbourg, Chest Diseases Department, Strasbourg, France
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergology and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa Japan
| | - Stanley Fineman
- Emory University School of Medicine, Atlanta Allergy & Asthma, Atlanta, Georgia
| | | | - Tari Haahtela
- Helsinki University Central Hospital, Helsinki, Finland
| | | | | | - Bee Wah Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joanna Makowska
- CSK, Department of Allergy & Clinical Immunology, Lodz, Poland
| | | | - Joaquim Mullol
- Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic, Clinical & Experimental Respiratory Immunoallergy, IDIBAPS, and CIBERES, Barcelona, Spain
| | - John Oppenheimer
- UMDNJ – Rutgers Medical School, c/o Pulmonary and Allergy Associates, Summit, New Jersey, USA
| | - Hae-Sim Park
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, South Korea
| | | | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital IST, University of Genoa, Genoa, Italy
| | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Harald Renz
- Universitatsklinikum GI & MR GmbH, Institut fur Laboratoriumsmedizin & Path, Standort Marburg, Marburg, Germany
| | - Franziska Rueff
- Klinikum der Ludwig-Maximilians-Universitat, Klinik & Poliklinik fur Dermatologie & Allergologie, Munchen, Germany
| | - Mario Sanchez-Borges
- Allergy and Clinical Immunology Department, Centro Medico-Docente La Trinidadad, Caracas, Venezuela
| | - Joaquin Sastre
- Allergy Department, Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, CIBER de Enfermedades Respiratorias (CIBERES), Institute Carlos III, Madrid, Spain
| | | | - Scott Sicherer
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | | | - Vera van Kempen
- Institute for Prevention and Occupational Medicine, German Social Accident Insurance, Ruhr-University Bochum (IPA), Bochum, Germany
| | - Barbara Bohle
- Division of Experimental Allergology, Department of Pathophysiology, Allergy Research Center of Pathophysiology, Infectiology & Immunology, Medical University of Vienna, Vienna, Austria
| | - G Walter Canonica
- Allergy & Respiratory Disease Clinic, DIMI – Department Int Med, University of Genoa, IRCCS AOU, San Martino – IST, Genoa, Italy
| | - Luis Caraballo
- Immunology Department, Universidad De Cartagena, Cartagena, Colombia
| | | | - Komei Ito
- Department of Allergy, Aichi Children’s Health and Medical Center, Aichi, Japan
| | - Erika Jensen-Jarolim
- Messerli Research Institute, Medical University Vienna, University Vienna, Vienna, Austria
| | - Mark Larche
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
| | | | - Lars K. Poulsen
- Gentofte University Hospital, Lab for Allergology, Allergy Clinic, Hellerup, Denmark
| | | | - Torsten Zuberbier
- Campus Charite Mitte, Klinik fur Dermatologie & Allergologie, Berlin, Germany
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Williams AN. Diagnostic Evaluation in Aspirin-Exacerbated Respiratory Disease. Immunol Allergy Clin North Am 2016; 36:657-668. [PMID: 27712761 DOI: 10.1016/j.iac.2016.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is a distinct clinical condition characterized by chronic sinusitis with nasal polyps, asthma, and hypersensitivity reactions to nonsteroidal anti-inflammatory drugs (NSAIDs). Distinguishing AERD from other forms of chronic sinusitis, asthma, and NSAID reactivity has important clinical implications for management. The clinical history is helpful, but not adequate for confirming the diagnosis of AERD, in most cases. Diagnostic provocation challenge remains the only way to confirm or exclude the diagnosis of AERD. This article discusses the utility of the clinical history and the current evidence regarding measures that optimize the safety of performing diagnostic NSAID provocation challenges.
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Affiliation(s)
- Adam N Williams
- Department of Allergy, Asthma, and Immunology, Bend Memorial Clinic, 815 Southwest Bond Street, Bend, OR 97702, USA; School of Medicine, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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Turner AM, Tamasi L, Schleich F, Hoxha M, Horvath I, Louis R, Barnes N. Clinically relevant subgroups in COPD and asthma. Eur Respir Rev 2016; 24:283-98. [PMID: 26028640 DOI: 10.1183/16000617.00009014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
As knowledge of airways disease has grown, it has become apparent that neither chronic obstructive pulmonary disease (COPD) nor asthma is a simple, easily defined disease. In the past, treatment options for both diseases were limited; thus, there was less need to define subgroups. As treatment options have grown, so has our need to predict who will respond to new drugs. To date, identifying subgroups has been largely reported by detailed clinical characterisation or differences in pathobiology. These subgroups are commonly called "phenotypes"; however, the problem of defining what constitutes a phenotype, whether this should include comorbid diseases and how to handle changes over time has led to the term being used loosely. In this review, we describe subgroups of COPD and asthma patients whose clinical characteristics we believe have therapeutic or major prognostic implications specific to the lung, and whether these subgroups are constant over time. Finally, we will discuss whether the subgroups we describe are common to both asthma and COPD, and give some examples of how treatment might be tailored in patients where the subgroup is clear, but the label of asthma or COPD is not.
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Affiliation(s)
- Alice M Turner
- Clinical and Experimental Medicine, University of Birmingham, Queen Elizabeth Hospital Birmingham, Birmingham, UK Dept of Respiratory Medicine, Birmingham Heartlands Hospital, Birmingham, UK
| | - Lilla Tamasi
- Dept of Pulmonology, Semmelweis University, Budapest, Hungary
| | | | - Mehmet Hoxha
- Service of Allergology and Clinical Immunology, UHC "Mother Teresa", Tirana, Albania
| | - Ildiko Horvath
- Dept of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Renaud Louis
- Respiratory Medicine, CHU Sart-Tilman B35, Liege, Belgium
| | - Neil Barnes
- GlaxoSmithKline, Stockley Park West, Uxbridge, UK
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7
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Systemic expression of inflammatory mediators in patients with chronic rhinosinusitis and nasal polyps with and without Aspirin Exacerbated Respiratory Disease. Cytokine 2015; 77:157-67. [PMID: 26615369 DOI: 10.1016/j.cyto.2015.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 10/22/2015] [Accepted: 10/23/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Systemic reactions are related to the pathogenesis of Aspirin Exacerbated Respiratory Disease (AERD). With this work we wanted to study the changes in the systemic levels of inflammatory mediators in both baseline and after oral aspirin challenge in patients with and without AERD. METHODS Patients with nasal polyposis and asthma with AERD (n=20) and without (n=18) were orally challenged with aspirin in a single-blind placebo controlled study. Serum samples and urine were collected before and 6h after placebo and aspirin oral challenges. Serum levels of inflammatory mediators were assayed by using the Luminex technology and ELISA. The concentrations of 9-alpha, 11-beta prostaglandin F2, and leukotriene E4 (uLTE4) were measured in urine samples by ELISA. The expression of T-cell surface markers was analyzed in peripheral blood mononuclear cells isolated before and after the challenges. RESULTS AERD patients showed significantly higher baseline levels of s-IL-5R-alpha, uLTE4 and percentage of CD4(+)CD25(+)CD127(pos) and CD4(+)CD45RA(-)CD45RO(+) but decreased levels of TGF-β1 and number of CD4(+)CD25(+)CD127(neg) cells. Aspirin challenge induced the release of uLTE4, IL-6 and increased the number of CD4(+)CD45RA(-)CD45RO(+) memory T-cells only in AERD patients but failed to reduce the levels of sCD40L as observed in non-AERD subjects. Further, IL-8 and sIL-5R-alpha levels directly correlated with the PD20ASA and the effects of aspirin on IL-6 and number of memory T-cells was more pronounced in subjects showing more strong reaction (bronchial and nasal). CONCLUSIONS AERD patients have a differential baseline inflammatory pattern that supports the role inflammation as underlying mechanism of the disease. Systemic response to oral aspirin challenge was related to an increase in serum IL-6 and the number of circulating memory T-cells in AERD patients.
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8
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Quiralte J, Ávila-Castellano R, Cimbollek S, Kowalski ML, Makowska J. A phenotype-based classification of NSAIDs hypersensitivity: new patients, new challenges. Allergy 2014; 69:814-5. [PMID: 24798106 DOI: 10.1111/all.12377] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- J. Quiralte
- Department of Allergy; Hospital Universitario Virgen del Rocío; Seville Spain
| | - R. Ávila-Castellano
- Department of Allergy; Hospital Universitario Virgen del Rocío; Seville Spain
| | - S. Cimbollek
- Department of Allergy; Hospital Universitario Virgen del Rocío; Seville Spain
| | - M. L. Kowalski
- Department of Immunology, Rheumatology and Allergy; Medical University of Lodz; Lodz Poland
| | - J. Makowska
- Department of Immunology, Rheumatology and Allergy; Medical University of Lodz; Lodz Poland
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Laidlaw TM, Boyce JA. Pathogenesis of aspirin-exacerbated respiratory disease and reactions. Immunol Allergy Clin North Am 2012; 33:195-210. [PMID: 23639708 DOI: 10.1016/j.iac.2012.11.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Physiologic and pharmacologic studies support the hypothesis that aspirin-exacerbated respiratory disease (AERD) involves fundamental dysregulation in the production of and end-organ responsiveness to both antiinflammatory eicosanoids (prostaglandin E2) and proinflammatory effectors (cysteinyl leukotrienes). The acquired nature of AERD implies a disturbance in a potential epigenetic control mechanism of the relevant mediator systems, which may be a result of incompletely clarified environmental factors (eg, viral or bacterial infections, inhaled pollutants).
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Affiliation(s)
- Tanya M Laidlaw
- Brigham and Women's Hospital, Department of Medicine, Division of Rheumatology, Immunology and Allergy, Jeff and Penny Vinik Center for Allergic Disease Research, Boston, MA 02115, USA
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Agache I, Akdis C, Jutel M, Virchow JC. Untangling asthma phenotypes and endotypes. Allergy 2012; 67:835-46. [PMID: 22594878 DOI: 10.1111/j.1398-9995.2012.02832.x] [Citation(s) in RCA: 222] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2012] [Indexed: 01/08/2023]
Abstract
Asthma phenotypes have been developed to address the complexities of the disease. However, owing to a lack of longitudinal studies, little is known about the onset as well as the stability of phenotypes. Distinguishing phenotypes with regard to the severity or duration of the disease is essential. A phenotype covers the clinically relevant properties of the disease, but does not show the direct relationship to disease etiology and pathophysiology. Different pathogenetic mechanisms might cause similar asthma symptoms and might be operant in a certain phenotype. These putative mechanisms are addressed by the term 'endotype'. Classification of asthma based on endotypes provides advantages for epidemiological, genetic, and drug-related studies. A successful definition of endotypes should link key pathogenic mechanisms with the asthma phenotype. Thus, the identification of corresponding molecular biomarkers for individual pathogenic mechanism underlying phenotypes or subgroups within a phenotype is important. Whether newly defined asthma endotypes predict the individual course of asthma has to be validated in longitudinal studies. The accurate endotyping reflects natural history of asthma and should help to predict treatment response. Thus, understanding asthma endotypes might be useful in clinical practice.
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Affiliation(s)
- I. Agache
- Department of Allergy and Clinical Immunology; Faculty of Medicine, Transylvania University; Brasov; Romania
| | - C. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF); University of Zurich; Davos; Switzerland
| | - M. Jutel
- Department of Clinical Immunology; Wroclaw Medical University; Wroclaw; Poland
| | - J. C. Virchow
- Department of Pulmonology, Intensive Care Medicine, Zentrum f. Innere Medizin; Klinik I, University Clinic Rostock; Rostock; Germany
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Gómez E, Torres MJ, Mayorga C, Blanca M. Immunologic evaluation of drug allergy. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2012; 4:251-63. [PMID: 22950030 PMCID: PMC3423598 DOI: 10.4168/aair.2012.4.5.251] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 02/01/2012] [Indexed: 12/21/2022]
Abstract
Hypersensitivity drug reactions (HDR) consist of an individual abnormal response with the involvement of the immunological system. In addition to specific immunological mechanisms where specific antibodies or sensitised T cells participate, release of inflammatory mediators by non-specific immunological recognition may also occur. Within this category are one of the most common groups of drugs, the non-steroidal anti-inflammatory drugs. In addition to chemical drugs new emerging ones with an increasing protagonism are biological agents like humanised antibodies and others. For IgE dependent reactions both in vivo and in vitro tests can be used for the immunological evaluation. Sensitivity of these is not optimal and very often a drug provocation test must be considered for knowing the mechanism involved and/or establishing the diagnosis. For non-immediate reactions also both in vivo and in vitro tests can be used. Sensitivity for in vivo tests is generally low and in vitro tests may be needed for the immunological evaluation. Immunohistochemical studies of the affected tissue enable a more precise classification of non-immediate reactions. The monitorization of the acute response of the reactions has given clues for understanding these reactions and has promising results for the future of the immunological evaluation of HDR.
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Affiliation(s)
- Enrique Gómez
- Research Laboratory, Carlos Haya Hospital, Málaga, Spain
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12
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Rolla G, Heffler E. Aspirin-exacerbated asthma: avoiding challenge is still challenging. Int Arch Allergy Immunol 2012; 158:213-5. [PMID: 22378070 DOI: 10.1159/000333096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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13
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González-Pérez R, Poza-Guedes P, Vives-Conesa R. The nose as a target organ in the diagnosis of severe aspirin-exacerbated respiratory disease. Am J Rhinol Allergy 2011; 25:166-9. [PMID: 21679527 DOI: 10.2500/ajra.2011.25.3591] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The nasal provocation test (NPT) with lysine aspirin is a useful tool in the diagnosis of aspirin-exacerbated respiratory disease (AERD), previously reffered to as Samter's disease. The aim of the present study focuses on methodological interventions to show the usefulness of the NPT with lysine aspirin in differentiating AERD patients from aspirin-tolerant asthma (ATA) patients to improve the diagnostic efficacy and minimize the risk for adverse reactions compared with the gold standard. METHODS Thirty AERD patients comprised the active study group while the control group consisted of 25 ATA patients. A combination of objective nasal aerodynamic response (i.e., nasal inspiratory flow and nasal inspiratory resistance) was evaluated by active anterior rhinomanometry and the subjective clinical nasal and extranasal symptoms (including forced expiratory volume) were monitored throughout the challenge. RESULTS Fifty-five NPTs were successfully completed: sensitivity, 87%; specificity, 100%; positive predictive value, 100%; negative predictive value, 86%; global efficacy, 92.72%. No severe adverse reactions were recorded. CONCLUSION The present NPT with lysine aspirin proved to be a safe, efficient, and a timesaving method in the diagnosis of patients with AERD, even in those with severe rhinitis-rhinosinusitis and/or recurrent nasal polyposis.
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Affiliation(s)
- Ruperto González-Pérez
- Servicio de Alergia, Hospital Universitario N.Sra. La Candelaria, Santa Cruz de Tenerife, Spain.
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Kim JH, Park BL, Pasaje CFA, Bae JS, Park JS, Park SW, Uh ST, Choi JS, Kim YH, Kim MK, Choi IS, Cho SH, Choi BW, Park CS, Shin HD. Association of FANCC polymorphisms with FEV1 decline in aspirin exacerbated respiratory disease. Mol Biol Rep 2011; 39:2385-94. [PMID: 21670957 DOI: 10.1007/s11033-011-0989-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 05/28/2011] [Indexed: 11/24/2022]
Abstract
Aspirin exacerbated respiratory disease (AERD) is a clinical condition characterized by severe decline in forced expiratory volume in one second (FEV1) following the ingestion of non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin. The exacerbated inflammatory response in Fancc-deficient mice has been reported to be associated with hemopoietic responses that are also related to AERD pathogenesis. To investigate associations of FANCC polymorphisms with AERD and related phenotypes, this study genotyped 25 common single nucleotide polymorphisms (SNPs) in a total of 592 Korean asthmatics including 163 AERD and 429 aspirin-tolerant asthma (ATA) subjects. Logistic analysis revealed that genetic polymorphisms of the FANCC gene might not be directly related to AERD development and nasal polyposis (P > 0.05). However, the FEV1 decline by aspirin provocation showed significant associations with FANCC polymorphisms (P = 0.006-0.04) and a haplotype (unique to rs4647416G > A, P = 0.01 under co-dominant, P = 0.006 under recessive model). In silico analysis showed that the "A" allele of rs4647376C > A, which was more prevalent in AERD than in ATA, could act as a potential branch point (BP) site for alternative splicing (BP score = 4.16). Although replications in independent cohorts and further functional evaluations are still needed, our preliminary findings suggest that FANCC polymorphisms might be associated with the obstructive symptoms in allergic diseases.
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Affiliation(s)
- Jeong-Hyun Kim
- Department of Life Science, Sogang University, Seoul 121-742, Republic of Korea
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[Aspirin-Intolerance-Syndrom : a common and interdisciplinary disease]. Internist (Berl) 2011; 51:1196-8, 1200-1. [PMID: 20725708 DOI: 10.1007/s00108-010-2661-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The full clinical picture of aspirin intolerance - the association of aspirin-induced bronchial asthma, aspirin sensitivity and nasal polyps - has been described as Morbus Widal or later as the "Samter triad". Today the term Aspirin-exacerbated respiratory disease (AERD) is preferred to account for the progressive nature of this inflammatory airway condition with its unrelenting course even in the absence of non steroidal anti-inflammatory drugs (NSAID). This acquired idiosyncrasy appears to be related to an abnormal arachidonic acid metabolism. Epidemiological data suggests that 10% of all asthmatics do react with life-threatening asthma-attacks after the ingestion of aspirin (ASA) or other NSAID. Some asthmatics with nasal polyposis have been reported to suffer from aspirin intolerance. Although the exact mechanism is still unclear, it is unlikely that the pathogenesis is IgE-mediated. Patients often report chronic nasal obstruction, hyposmia, chronic rhinorrhoea, orbital edema and urticaria with flushing after the ingestion of NSAID. While a typical history and endoscopic findings can be suggestive of AERD, a definite diagnosis relies on appropriate challenge tests. AERD is often refractory to standard asthma treatment with systemic and inhaled steroids, β(2)-agonists, leukotrien-antagonists. Adaptive desactivation can induce a reversible tolerance to NSAID which also leads to an improvement in signs and symptoms of the underlying AERD.
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Pérez Novo CA, Jedrzejczak-Czechowicz M, Lewandowska-Polak A, Claeys C, Holtappels G, Van Cauwenberge P, Kowalski ML, Bachert C. T cell inflammatory response, Foxp3 and TNFRS18-L regulation of peripheral blood mononuclear cells from patients with nasal polyps-asthma after staphylococcal superantigen stimulation. Clin Exp Allergy 2011; 40:1323-32. [PMID: 20701615 DOI: 10.1111/j.1365-2222.2010.03577.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Staphylococcal superantigens may modulate airway inflammatory disease. OBJECTIVE We assessed the effect of Staphylococcus aureus enterotoxin B (SEB) on T cell activation in patients with nasal polyps and asthma, and its possible link to aspirin hypersensitivity. METHODS Leucocytes were isolated from five healthy subjects (controls), five asthmatics with nasal polyps without (NP-ATA) and five with aspirin-induced asthma (NP-AIA). Cells were incubated with increasing concentrations of SEB for 4 and 18 h. Release of T(H)1/T(H)2 cytokines was assessed by Cytometric Bead-Array. Foxp3 and TNFRS18-L expression were analysed by qPCR and flow cytometry. RESULTS After 4 and 18 h, SEB significantly increased IFN-gamma, IL-4, TNF-alpha, IL-5 and IL-2 concentrations in supernatants of both NP polyp groups compared with controls. Baseline Foxp3 was significantly decreased in both NP-asthma groups. Incubation with SEB for 4 h induced a limited up-regulation of Foxp3 in NP-AIA patients, which was switched off consecutively. Foxp3 was significantly up-regulated in the control group after 18 h, but not in the NP-asthmatic groups. In parallel, TNFRS18-L mRNA significantly increased after 18 h in the NP-asthma groups compared with control subjects. This molecule was highly expressed in CD11c(+)CD14(+) cells and its levels increased after 18 and 24 h culture in the NP-asthma patients. CONCLUSION SEB induces both T(H)1 and T(H)2 pro-inflammatory responses in patients with nasal polyps and asthma regardless of the presence of aspirin hypersensitivity. The nature of this response may be linked to a basal deficiency of Foxp3 observed in the NP-asthmatic patients and/or to the up-regulation of TNFRS18-L on monocytes/dendritic cell precursors.
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Affiliation(s)
- C A Pérez Novo
- Upper Airways Research Laboratory, Department of Otorhinolaryngology, Ghent University Hospital, De Pintelaan 185, Ghent, Belgium.
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Abstract
Aspirin-sensitive respiratory disease (ASRD) is a condition characterized by persistent and often severe inflammation of the upper and lower respiratory tracts. Patients develop chronic eosinophilic rhinosinusitis, nasal polyposis, and asthma. The ingestion of aspirin and other cyclooxygenase-1 (COX-1) inhibitors induces exacerbations of airway disease that may be life-threatening. Thus, aspirin sensitivity is a phenotypic marker for the syndrome, yet nearly all affected individuals can be desensitized by the administration of graded doses of aspirin, leading to long-term clinical benefits. Patients with aspirin sensitivity are often able to tolerate selective COX-2 inhibitors. The pathogenesis of ASRD is underpinned by abnormalities in eicosanoid biosynthesis and eicosanoid receptor expression coupled with intense mast cell and eosinophilic infiltration of the entire respiratory tract. This review focuses on the molecular, cellular, and biochemical abnormalities characterizing ASRD and highlights unanswered questions in the literature and potential future areas of investigation.
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Affiliation(s)
- Sophie P Farooque
- King's College London, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, Guy's Hospital, London SE1 9RT, England
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Rådinger M, Lötvall J. Eosinophil progenitors in allergy and asthma - do they matter? Pharmacol Ther 2008; 121:174-84. [PMID: 19059433 DOI: 10.1016/j.pharmthera.2008.10.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Accepted: 10/15/2008] [Indexed: 01/21/2023]
Abstract
Allergic inflammation is associated with marked infiltration of eosinophils in affected tissues. The eosinophil is believed to be a key effector cells in allergen induced asthma pathogenesis. However, the role of eosinophils in the clinical manifestation of asthma has recently been questioned, since therapies directed against eosinophil infiltration (i.e. anti-interleukin-5) failed to improve clinical symptoms such as airways hyper-responsiveness (AHR) in patients with asthma. Although eosinophils in peripheral blood and the airways were largely depleted after anti-IL-5 treatment, residual eosinophilia in lung tissue persisted, which permits speculation that the remaining eosinophils may be sufficient to drive the asthma symptomatology. Furthermore, recent findings suggest that primitive eosinophil progenitor cells traffic from the bone marrow to sites of inflammation in response to allergen exposure. These progenitors may then differentiate in situ and thus provide an ongoing supply of mature pro-inflammatory cells and secretory mediators that augment the inflammatory response. In the present article, we will review the evidence for these findings, and discuss the rationale for targeting hematopoiesis and their migration pathways in the treatment of allergic diseases. Furthermore, this review will highlight the hypothesis that both IL-5- and CCR3-mediated signaling pathways may need to be targeted in order to control the inflammation and AHR associated with asthma.
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Affiliation(s)
- Madeleine Rådinger
- Mast Cell Biology Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA.
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Makowska JS, Grzegorczyk J, Ciéslak M, Biénkiewicz B, Kowalski ML. Recruitment of CD34+ progenitor cells into peripheral blood and asthma severity. Ann Allergy Asthma Immunol 2008; 101:402-6. [PMID: 18939729 DOI: 10.1016/s1081-1206(10)60317-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous studies have suggested that the number of progenitor cells is elevated in the peripheral blood of asthmatic patients and that the number of progenitors correlate with the severity of the disease. OBJECTIVE To evaluate the number of leukocyte progenitor and eosinophil progenitor cells in the peripheral blood of patients with bronchial asthma in relation to disease severity. METHODS The study involved 51 patients with asthma (25 patients with a mild form and 26 with a severe form of the disease) and a group of 12 healthy controls. Using the flow cytometric method, leukocyte (CD34+ leukocytes) and eosinophil progenitors (CD34+CD125+) were detected in the peripheral blood of both asthmatic patients and healthy controls. RESULTS Patients with asthma had significantly more leukocyte progenitor cells (median, 0.06% vs 0.016%) and eosinophil progenitor cells (median, 0.046% vs 0.004%) compared with the controls. Patients with severe asthma had more leukocyte progenitor cells (0.12% vs 0.035%) and more eosinophil progenitor cells (0.102% vs 0.019%) than patients with mild asthma. The number of circulating leukocyte and eosinophil progenitor cells inversely correlated with the forced expiratory volume in 1 second percentage of predicted value (r = -0.4 and r = -0.35, respectively) and positively correlated (r = 0.63 and r = 0.65, respectively) with the dose of inhaled steroids used to control asthma. CONCLUSION These data suggest that the presence of leukocyte precursors and eosinophil progenitor cells in the peripheral blood of asthmatic patients may reflect ongoing airway inflammation.
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Affiliation(s)
- Joanna S Makowska
- Department of Immunology, Rheumatology and Allergy, Medical University of Lodz, Lodz, Poland
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Systemic and local responses in aspirin-exacerbated respiratory disease: Same or different disease? J Allergy Clin Immunol 2008; 122:430-1. [DOI: 10.1016/j.jaci.2008.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2008] [Accepted: 05/05/2008] [Indexed: 11/17/2022]
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Kowalski ML, Makowska JS. Reply. J Allergy Clin Immunol 2008. [DOI: 10.1016/j.jaci.2008.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Giavina-Bianchi P, Diniz LC, Agondi RC, Porter MH, Kalil J. Urticaria after specific bronchial challenge. J Allergy Clin Immunol 2008; 122:214-5; author reply 215. [PMID: 18468673 DOI: 10.1016/j.jaci.2008.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Accepted: 04/03/2008] [Indexed: 10/22/2022]
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