From asthma in the workplace to occupational asthma

Comparison of high- and low-molecular-weight sensitizing agents causing occupational asthma: an evidence-based insight

INTRODUCTION

The many substances used at the workplace that can cause sensitizer-induced occupational asthma are conventionally categorized into high-molecular-weight (HMW) agents and low-molecular-weight (LMW) agents, implying implicitly that these two categories of agents are associated with distinct phenotypic profiles and pathophysiological mechanisms.

AREAS COVERED

The authors conducted an evidence-based review of available data in order to identify the similarities and differences between HMW and LMW sensitizing agents.

EXPERT OPINION

Compared with LMW agents, HMW agents are associated with a few distinct clinical features (i.e. concomitant work-related rhinitis, incidence of immediate asthmatic reactions and increase in fractional exhaled nitric oxide upon exposure) and risk factors (i.e. atopy and smoking). However, some LMW agents may exhibit 'HMW-like' phenotypic characteristics, indicating that LMW agents are a heterogeneous group of agents and that pooling them into a single group may be misleading. Regardless of the presence of detectable specific IgE antibodies, both HMW and LMW agents are associated with a mixed Th1/Th2 immune response and a predominantly eosinophilic pattern of airway inflammation. Large-scale multicenter studies are needed that use objective diagnostic criteria and assessment of airway inflammatory biomarkers to identify the pathobiological pathways involved in OA caused by the various non-protein agents.

Clinical aspects of work-related asthma: past achievements, persistent challenges, and emerging triggers

OBJECTIVE

The aim of this article was to address common clinical questions pertaining to work-related asthma (WRA).

METHODS

This review is based on a presentation on WRA at the American College of Chest Physicians Course on Clinical Aspects of Occupational and Environmental Lung Disease, held in Toronto in 2013, and supplemented by a PubMed search of publications to 2013.

RESULTS

Seven clinical questions are addressed in relation to definitions, causes, diagnosis, management and emerging triggers, and challenges of WRA.

CONCLUSIONS

Although knowledge is expanding in this area, there remain challenges and uncertainties, particularly in the prevention of WRA.

Time trends in occupational asthma in Belgium

OBJECTIVES

There is little information on the changes in the pattern of occupational asthma (OA) over time. The objective of this study was to evaluate the time trends in the incidence and causes of immunological OA in Belgium using workers' compensation data.

METHODS

Cases of OA were identified through a retrospective review of all claims submitted by salaried workers to the Belgian Workers' Compensation Board from 1993 to 2002. The likelihood of OA was categorized as definite, probable, or possible based upon the results of from diagnostic procedures. Time trends were evaluated using Spearman's rank correlation for crude numbers of cases and through the negative binomial regression for incidence rates of OA per industry.

RESULTS

From a total of 1852 claims, 971 were categorized as having definite, probable, or possible OA. There was a downward trend in the annual number of cases due to the main causes of OA (i.e. flour, isocyanates, woods, and enzymes) and an apparent increase in cases of latex-induced OA. The estimated average annual incidence of OA was 29.4 (95% CI: 27.6-31.3) new cases per million salaried workers during the 1993-2002 period. There was a significant decline in the overall incidence rate of OA throughout the study period from 35.5 new cases per million salaried workers in 1993 to 25.8 in 2002.

CONCLUSIONS

These compensation-based data indicate that there has been a global downward trend in the incidence of OA during the nineties, although the factors that determined this reduced incidence should be further investigated.

Data linkage to estimate the extent and distribution of occupational disease: new onset adult asthma in Alberta, Canada

BACKGROUND

Although occupational asthma is a well recognized and preventable disease, the numbers of cases presenting for compensation may be far lower than the true incidence.

METHODS

Workers' Compensation Board (WCB) claims for any reason 1995-2004 were linked to physician billing data. New onset adult asthma (NOAA) was defined as a billing for asthma (ICD-9 code of 493) in the 12 months prior to a WCB claim without asthma in the previous 3 years. Incidence was calculated by occupation, industry and, in a case-referent analysis, exposures estimated from an asthma specific job exposure matrix.

RESULTS

There were 782,908 WCB eligible claims, with an incidence rate for NOAA of 1.6%: 23 occupations and 21 industries had a significantly increased risk. Isocyanates (OR 1.54: 95% CI 1.01-2.36) and exposure to mixed agricultural allergens (OR = 1.59: 95% CI 1.17-2.18) were related to NOAA overall, as were exposures to cleaning chemicals in men (OR = 1.91:95% CI 1.34-2.73). Estimates of the number of cases of occupational asthma suggested a range of 4% to about half for the proportion compensated.

CONCLUSIONS

Data linkage of administrative records can demonstrate under-reporting of occupational asthma and indicate areas for prevention.

Sputum eosinophilia: an early marker of bronchial response to occupational agents

BACKGROUND

False-negative responses to specific inhalation challenge (SIC) with occupational agents may occur. We explored whether assessing changes in sputum cell counts would help improve the identification of bronchial reactivity to occupational agents during SICs.

METHODS

The predictive value of the changes in sputum cell counts after a negative FEV(1) response to a first challenge exposure to an occupational agent was determined using the changes in airway calibre observed during repeated challenges as the 'gold standard'. The study included 68 subjects investigated for work-related asthma in a tertiary centre. After a control day, the subjects were challenged with the suspected occupational agent(s) for up to 2 h. All subjects who did not show an asthmatic reaction were re-challenged on the following day. Additional challenges were proposed to those who demonstrated a > or = 2% increase in sputum eosinophils or an increase in nonspecific bronchial hyperresponsiveness to histamine after the second challenge day.

RESULTS

Six of the 35 subjects without changes in FEV(1) on the first challenge developed an asthmatic reaction on subsequent challenges. ROC analysis revealed that a >3% increase in sputum eosinophils at the end of the first challenge day was the most accurate parameter for predicting the development of an asthmatic response on subsequent challenges with a sensitivity of 67% and a specificity of 97%.

CONCLUSIONS

An increase in sputum eosinophils is an early marker of specific bronchial reactivity to occupational agents, which may help to identify subjects who will develop an asthmatic reaction only after repeated exposure.

Occupational asthma: current concepts in pathogenesis, diagnosis, and management

Occupational asthma (OA) may account for 25% or more of de novo adult asthma. The nomenclature has now better defined categories of OA caused by sensitizing agents and irritants, the latter best typified by the reactive airways dysfunction syndrome. Selecting the most appropriate diagnostic testing and management is driven by assessing whether a sensitizer is involved, and if so, identifying whether the sensitizing agent is a high-molecular-weight agent such as a protein or a low-molecular-weight reactive chemical such as an isocyanate. Increased understanding of the pathogenesis of OA from reactive chemical sensitizers is leading to development of better diagnostic testing and also an understanding of why testing for sensitization to such agents can be problematic. Risk factors for OA including possible genetic factors are being delineated better. Recently published guidelines for the diagnosis and management of occupational asthma are summarized; these reflect an increasingly robust evidence basis for recommendations. The utility of diagnostic tests for OA is being better defined by evidence, including sputum analysis performed in relation to work exposure with suspected sensitizers. Preventive and management approaches are reviewed. Longitudinal studies of patients with OA continue to show that timely removal from exposure leads to the best prognosis.

Prostaglandin as a target molecule for pharmacotherapy of allergic inflammatory diseases

The purpose of this review is to summarize the role of prostaglandins (PGs) in allergic inflammation and to know the value of PGs, as a target molecule for an anti-allergic drug. PGD(2) is the major PG produced by the cyclooxygenase pathway in mast cells. Our and others findings indicate that PGD(2) is one of the potent allergic inflammatory mediators and must be a target molecule of anti-allergic agent. From our data, one of PGD(2) receptor antagonists show clear inhibition of airway hypersensitivity caused by allergic reaction. Concerning the role of PGE(2) in allergic inflammation, conflicting results have been reported. Many experimental data suggest an individual role of each PGE(2) receptor, EP(1), EP(2), EP(3) and EP(4) in allergic reaction. Our results indicate the protective action of PGE(2) on allergic reaction via EP(3). In addition, one of EP(3) agonists clearly inhibits the allergic airway inflammation. These findings indicate the value of EP(3) agonists as an anti-allergic agent. In addition, some investigators including us reported that PGI(2) plays an important role for the protection of the onset of allergic reaction. However, the efficacy of PGI(2) analogue as an anti-allergic agent is not yet fully investigated. Finally, the role of thromboxane A(2) (TxA(2)) in allergic reaction is discussed. Our experimental results suggest a different participation of TxA(2) in allergic reaction of airway and skin. In this review, the role of PGs in allergic inflammation is summarized and the value of PGs as a target molecule for developing a new anti-allergic agent will be discussed.