Vernal keratoconjunctivitis: An update

Vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) are potentially severe and complex disease in its management among the various allergic eye diseases. In this regard, studies clarified the etiopathogenetic mechanisms. The workup should be multidisciplinary. The treatment includes topical and systemic medications with anti-inflammatory and immunosuppressant activity. However, a definition of nationally- and internationally-shared diagnostic protocols would also be needed and validated access to therapeutic options of proven safety and efficacy to avoid the use of galenic preparations, up to now still essential in the management of moderate-severe VKC. Finally, recognizing VKC and AKC, among rare diseases, at a national and international level would be an essential step to allow the management of VKC with adequate timings and settings within the National Health System.

Treating allergic conjunctivitis: A once-daily medication that provides 24-hour symptom relief

BACKGROUND

Allergic conjunctivitis (AC) is a common ocular inflammatory manifestation of allergen exposure in sensitized individuals. Signs and symptoms of AC can decrease quality of life, interfere with productivity, and lead to considerable economic burden. Consistent suppression of conjunctival inflammation is necessary for managing AC, but currently available medications require frequent administration and exhibit limited duration of action.

METHODS

In this review, we summarized AC pathogenesis, diagnosis, and current treatment options as well as their limitations. Findings from the literature were discussed in the context of the unmet need for a once-daily medication with sustained 24-hour effectiveness.

RESULTS

Topical pharmacologic treatments are the most common approach for managing extant AC; however, most available medications require multiple daily instillations. Dual-acting antihistamine-mast cell stabilizing agents are currently considered first-line therapeutics for AC because they provide acute relief of signs and symptoms and block persistent inflammation to promote regression of AC. Recent studies of a newly-developed, higher-concentration formulation of a dual-acting antihistamine-mast cell stabilizer have demonstrated that this formulation provides a 24-hour duration of action with once-daily dosing.

CONCLUSIONS

Dual-acting AC medications exhibit a high degree of overall effectiveness and are well tolerated for chronic use. A newly available once-daily medication that manages signs and symptoms of AC for a full 24 hours may be considered a treatment of choice for patients experiencing seasonal or perennial AC. ClinicalTrials.gov NCT01743027 and NCT01479374.

Spirometric abnormalities in patients with allergic rhinitis: Indicator of an "asthma march"?

BACKGROUND

Allergic rhinitis (AR) may precede and promote the onset of asthma. However, few studies addressed this issue mainly concerning bronchial physiological parameters. The aim of this study was to assess forced expiratory flow at 25-75% (FEF(25-75)), forced expiratory volume at 1 second (FEV(1)), and response to bronchodilation test in a large group of AR patients.

METHODS

Sixteen hundred five adult AR patients were evaluated. Clinical examination, assessment of nasal obstruction perception by visual analog scale, spirometry, and bronchodilation test were performed in all patients.

RESULTS

There were 8.4% of patients with abnormal FEV(1) values, 24.7% had impaired FEF(25-75), and 66.1% had reversibility with bronchodilation. A trend of spirometric impairment seems to exist in these patients. Age, gender, and duration of rhinitis may be risk factors for these findings. Different grades of bronchial impairment seem to exist.

CONCLUSION

This study highlights the close link between upper and lower airways and suggests the possible existence of a progression from AR toward asthma, such as an "asthma march." Therefore, asthma should be suspected and carefully investigated in AR patients.

Monosensitization and polysensitization in allergic rhinitis

BACKGROUND

Polysensitization is common in patients with allergic rhinitis (AR) and may affect clinical feature. However, there are patients who remain monosensitized.

OBJECTIVE

This cross-sectional study aimed at evaluating a large cohort of AR patients to define the percentage and the features of mono- and poly-sensitized subjects.

METHODS

This observational cross-sectional study included a large group of AR patients: 2415 subjects (1958 males, mean age 24.6 ± 5 years) were consecutively evaluated. Symptom severity, type and number of sensitizations, and AR duration were considered.

RESULTS

621 patients (25.7%) were monosensitized: 377 to Parietaria, 194 to house dust mites, 19 to birch, 17 to grasses, 12 to molds, 2 to olive, and 1 to cypress. There was no difference between mono- and polysensitized patients concerning the duration of rhinitis (6 ± 2.14 years vs 6 ± 3.7). Severity of symptoms was higher in polysensitized patients than in monosensitized (p<0.05); in addition, there was a difference among monosensitized patients: Parietaria-allergy induces the most severe symptoms.

CONCLUSION

This study conducted in a large AR population might suggest that monosensitized and polysensitized AR patients could constitute two different categories. In addition, the specific type of allergy may condition the clinical feature.

Impact of allergic rhinitis on bronchi: an 8-year follow-up study

BACKGROUND

Allergic rhinitis is considered a strong risk factor for the onset of asthma. However, few studies addressed this issue from a functional point of view. The aim of this study was to follow up a group of patients with allergic rhinitis to investigate the onset of possible spirometric abnormalities and/or bronchial hyperreactivity (BHR).

METHODS

Eighty-nine patients with moderate-severe persistent allergic rhinitis were prospectively and consecutively evaluated; 940 controls were also included in the study. Clinical examination, skin-prick test, spirometry, and methacholine challenge were performed in all patients every 2 years for 8 years.

RESULTS

The number of patients with forced expiratory flow at 25 and 75% of pulmonary volume of <70% of predicted significantly increased during the observation time. At baseline, no subjects had BHR; whereas 34 patients had BHR after 8 years. Sensitization to mites, birch, and Parietaria as well as rhinitis duration are risk factors for these changes.

CONCLUSION

This study highlights the close link between upper and lower airways and suggests that spirometry should be performed in patients with allergic rhinitis.

Polysensitization as a challenge for the allergist: the suggestions provided by the Polysensitization Impact on Allergen Immunotherapy studies

INTRODUCTION

Polysensitization, that is, sensitization to more than one allergen family, is a common feature of patients with allergic rhinitis (AR) and significantly impairs their quality of life (QoL). Allergen-specific immunotherapy is the only causal treatment for AR. However, the polysensitization phenomenon may represent a crucial obstacle as far as it concerns the choice of the allergen extract to be used for immunotherapy.

AREAS COVERED

A series of real-life based multi-center studies, named POLISMAIL (Polysensitization Impact on Allergen Immunotherapy), have been designed with the aim of evaluating the behavior of allergists in managing polysensitized AR patients. The effect of immunotherapy treatment in these patients was also evaluated. A single allergen extract was used in two-thirds of patients, whereas a mix of two allergens was chosen in the remaining. The severity grade of AR and the QoL were significantly improved by immunotherapy. Both outcomes confirmed that immunotherapy with one or two allergen extracts achieves a significant improvement in polysensitized patients.

EXPERT OPINION

In conclusion, POLISMAIL studies demonstrate that polysensitization should not represent a counter-indication for prescribing immunotherapy. The choice of limiting sublingual immunotherapy to one to two allergen extracts, preferably separated and at high dosages, is sufficient and effective in improving symptoms and QoL.

Lower airways may also be affected in asymptomatic patients with recent onset of allergic rhinitis

OBJECTIVES/HYPOTHESIS

It is well known that there is a close association between allergic rhinitis (AR) and asthma, and AR is a strong risk factor for the onset of asthma. AR duration is significantly associated with a possible bronchial involvement. The aim of this study was to investigate the presence of possible spirometric abnormalities and bronchial hyperreactivity (BHR) in a large group of patients with recent onset of AR.

STUDY DESIGN

Observational cross-sectional study.

METHODS

A total of 1,539 AR patients were consecutively evaluated. Clinical examination, skin prick test, spirometry, and methacholine challenge were performed on all patients.

RESULTS

: There were 362 (23%) patients with FEF(25-75) values <70% of predicted. The methacholine challenge was positive in 74.43% of patients, and 72.22% of the population presented a polysensitization. At multivariable analysis, an FEV(1) value lower than 92% of predicted, as well as increasing severity of BHR and polysensitization appeared to be independent predictors of a reduced FEF(25-75) value.

CONCLUSIONS

This study shows that reduced FEF(25-75) values may be present in some patients with recent onset of AR. FEV(1) <92%, severity of BHR, and polysensitization may be considered risk factor for this phenomenon.

Isolation and phenotypic characterization of mucosal nasal lymphocytes by direct ex vivo analysis

Cellular inflammation of the nasal mucosa demonstrates a local immune response which plays an important role in allergic rhinitis. The aim of the present study was to characterize nasal mucosal lymphocytes regarding their activation and differentiation state by direct ex vivo flowcytometric analysis. Lymphocytes from the inferior turbinates were isolated by a mechanical method of preparation and, for comparison, from peripheral blood by Ficoll gradient centrifugation. Patients suffering from rhinitis or difficulty in nasal breathing were divided into an allergic (pollen-allergy, n = 13) and non-allergic group (n = 24). Expression of different T- and B-cell markers was determined by flowcytometric analysis. CD4+ T-cells from the nasal mucosa exhibited a memory phenotype (CD45RO+, 97%), were highly activated (CD69+, 43-73%), and showed low expression of the cutaneous lymphocyte antigen (CLA+, 5%). Nasal CD20+ B-lymphocytes expressed significantly higher levels of mIgE and lower levels of CD23 and CD80 than peripheral B-cells. Subsets of CD80+ (4%) and CD86+ (6%) CD20+ B-lymphocytes were identified in the nasal mucosa. No significant differences between allergic and non-allergic individuals were determined. As expected, the data show profound phenotypical differences between circulating peripheral blood and nasal mucosal lymphocytes. Activated memory lymphocytes are present in the nasal mucosa from allergic, but also non-allergic patients and may indicate to a significant role of a local inflammatory state without systemic criteria for allergy. In our study, we show that direct ex vivo isolation of lymphocytes is practicable method and offers a new technique to examine the local nasal allergic immune response using a multiparametric phenotypical analysis.

Impact of allergic rhinitis on asthma: effects on spirometric parameters

BACKGROUND

Close association exists between allergic rhinitis and asthma. Moreover, allergic rhinitis is a strong risk factor for the onset of asthma in adults. This study was aimed at evaluating a large group of patients with moderate-to-severe and persistent allergic rhinitis alone for investigating the presence of spirometric abnormalities and possible risk factors related to it.

METHODS

A total of 392 patients with persistent allergic rhinitis were prospectively and consecutively evaluated. Clinical examination, skin prick test and spirometry were performed in all patients.

RESULTS

There were 24 (6.1%) patients with forced vital capacity (FVC < 80%) of predicted, 50 (12.8%) with forced expiratory volume in the first second (FEV(1) < 80%) of predicted and 341 (87.0%) with forced expiratory flow at 25% and 75% of the pulmonary volume (FEF(25-75)) < 80% of predicted. The logistic regression analysis evidenced that rhinitis duration (OR(Adj): 1.9/year) and sensitization to house dust mites (OR(Adj): 8.2) were significantly associated with impaired values of 2 or 3 spirometric parameters.

CONCLUSION

This study highlights the close link between upper and lower airways and the role of some risk factors, such as duration and mites sensitization, as early prognostic markers of bronchial involvement in patients with moderate-to-severe and persistent allergic rhinitis alone.

Randomized placebo-controlled trial comparing montelukast and cetirizine for treating perennial allergic rhinitis in children aged 2-6 yr

Leukotriene receptor antagonists (LTRAs) were recently added to the method of treating allergic rhinitis (AR). However, in children under 6 yr old, there has been no study about its efficacy in treating AR. We aim to compare the clinical efficacy of montelukast, cetirizine and placebo in the treatment of children from 2 to 6 yr old with perennial allergic rhinitis (PAR), to see if there are any significant differences. Sixty children were selected and treated with montelukast, or cetirizine, or placebo once daily. The efficacy of the three agents was compared with the Pediatric Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ) and Total Symptom Score (TSS) by diary. In addition, we also examined serum IgE, serum eosinophil cationic protein (ECP), blood eosinophil counts, nasal airway resistance (NAR) and eosinophil percentage in nasal smears. The results revealed that both montelukast and cetirizine were significantly efficacious compared with placebo in NAR, eosinophil percentage in nasal smears, PRQLQ, TSS and all symptom items except nasal itching, throat itching and tearing. For nasal itching, only cetirizine was significantly efficacious. On the other hand, for night sleep quality, montelukast was significantly superior to cetirizine.

Bronchial hyperreactivity and spirometric impairment in patients with seasonal allergic rhinitis

We previously demonstrated in a group of patients with perennial allergic rhinitis alone, impairment of spirometric parameters and high percentage of bronchial hyperreactivity (BHR). Thus, the present study aimed at evaluating a group of subjects suffering from seasonal allergic rhinitis alone to investigate the presence of spirometric impairment and BHR both during and outside the pollen season.

METHODS

One-hundred rhinitics sensitized to pollen allergens only were evaluated during and outside the pollen season. Spirometry and methacholine bronchial challenge were performed.

RESULTS

Four rhinitics showed impaired values of FEV1 without referred symptoms of asthma during the pollen season. FEF 25-75 values were impaired in 17 rhinitics during the pollen season and in 11 rhinitics outside the pollen season (P<0.05). Fifty-four patients showed positive methacholine bronchial challenge both during and outside the pollen season. PD20/FEV1 methacholine was lower during the pollen season than outside (P<0.05). In BHR positive patients, reduced values of FVC (P<0.05), FEV1 (P<0.05), and FEF 25-75 (P<0.01) were significantly demonstrated in comparison with BHR negative rhinitics. There was a relationship between BHR degree and FEF 25-75 values only during the pollen season (P<0.001).

CONCLUSIONS

This study evidences that an impairment of spirometric parameters may be observed also in patients with seasonal allergic rhinitis alone during the pollen season. A high percentage of these patients had BHR. A close relationship between upper and lower airways is confirmed also in the model of pollen allergy. Thus, a careful evaluation of lower airways should be performed also in those patients with seasonal allergic rhinitis alone.

Bronchial hyperreactivity and spirometric impairment in patients with perennial allergic rhinitis

BACKGROUND

Allergic disorders are characterized by a systemic involvement of the immune response. There is a clear link between allergic rhinitis and asthma. Bronchial hyperreactivity (BHR) may be present in rhinitics. Smaller airways may also be impaired in mild asthma. This study aimed at evaluating a group of subjects suffering from perennial allergic rhinitis alone to investigate the presence of BHR and spirometric impairment.

METHODS

One hundred rhinitics sensitized only to perennial allergens were evaluated. Spirometry and methacholine bronchial challenge were performed.

RESULTS

Five rhinitics showed reduced values of forced expiratory volume/1 s (FEV(1)) without symptoms of asthma. Forty-eight rhinitics had reduced forced expiratory flow at 25 and 75% of pulmonary volume (FEF(25-75)) values. Seventy-two patients showed a positive methacholine challenge. In this group, reduced values of FVC (p < 0.05), FEV(1) (p < 0.05), and FEF(25-75) (p < 0.01) were demonstrated in comparison with BHR-negative rhinitics. There was a relationship between the degree of BHR and FEV(1) values (p < 0.05) and FEF(25-75) values (p < 0.01).

CONCLUSIONS

This study evidences that an impairment of spirometric parameters may be observed in patients with perennial allergic rhinitis alone. A high percentage of these patients have BHR. Thus, new management strategies should be employed in rhinitics.