Intranasal steroids and the risk of emergency department visits for asthma

The pharmacotherapeutic management of allergic rhinitis in people with asthma

INTRODUCTION

Up to 90% of asthmatic patients have comorbid allergic rhinitis (AR). Although appropriate therapy of AR can improve asthma symptoms and management, AR is often underdiagnosed and under-treated in asthmatics.A non-systematic literature research was conducted on AR as a comorbidity and risk factor of asthma. Latest international publications in medical databases, international guidelines, and the Internet were reviewed.

AREAS COVERED

Based on the conducted literature research there is proved evidence of the necessity of diagnosis and treatment of AR in patients with asthma because it affects health care utilization. Therefore, it is recommended in national and global guidelines.

EXPERT OPINION

AR increases the risk of asthma development and contributes to the severity of an existing asthma. Early treatment of AR with drugs as intranasal steroids, antihistamines, leukotriene receptor antagonists, and especially allergen-specific immunotherapy can reduce the risk of asthma development and the concomitant medication use in addition to severity of symptoms in AR and asthma.

Immortal Time Bias With Time-Varying Exposures in Environmental Epidemiology: A Case Study in Lung Cancer Survival

Immortal time bias is a well-recognized bias in clinical epidemiology but is rarely discussed in environmental epidemiology. Under the target trial framework, this bias is formally conceptualized as a misalignment between the start of study follow-up (time 0) and treatment assignment. This misalignment can occur when attained duration of follow-up is encoded into treatment assignment using minimums, maximums, or averages. The bias can be exacerbated in the presence of time trends commonly found in environmental exposures. Using lung cancer cases from the California Cancer Registry (2000-2010) linked with estimated concentrations of particulate matter less than or equal to 2.5 μm in aerodynamic diameter (PM2.5), we replicated previous studies that averaged PM2.5 exposure over follow-up in a time-to-event model. We compared this approach with one that ensures alignment between time 0 and treatment assignment, a discrete-time approach. In the former approach, the estimated overall hazard ratio for a 5-μg/m3 increase in PM2.5 was 1.38 (95% confidence interval: 1.36, 1.40). Under the discrete-time approach, the estimated pooled odds ratio was 0.99 (95% confidence interval: 0.98, 1.00). We conclude that the strong estimated effect in the former approach was likely driven by immortal time bias, due to misalignment at time 0. Our findings highlight the importance of appropriately conceptualizing a time-varying environmental exposure under the target trial framework to avoid introducing preventable systematic errors.

Intranasal steroid use and COVID-19 mortality among patients with asthma and COPD: A retrospective cohort study

BACKGROUND

Systemic corticosteroids have been widely used for treating patients with severe acute respiratory distress syndrome. Inhaled corticosteroids may have a protective effect for treating acute coronavirus disease 2019 (COVID-19); however, little is known about the potential effect of intranasal corticosteroids (INCS) on COVID-19 outcomes and severity.

OBJECTIVE

To assess the impact of prior long-term INCS exposure on COVID-19 mortality among patients with chronic respiratory disease and in the general population.

METHODS

A retrospective cohort study was conducted. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between INCS exposure and all-cause and COVID-19 mortality, adjusted by age, sex, deprivation, exacerbations in the last year, and comorbidities.

RESULTS

Exposure to INCS did not have a significant association with COVID-19 mortality among the general population or cohorts with chronic obstructive pulmonary disease or asthma, with HRs of 0.8 (95% CI, 0.6-1.0, P = .06), 0.6 (95% CI, 0.3-1.1, P = .1), and 0.9 (95% CI, 0.2-3.9, P = .9), respectively. Exposure to INCS was, however, significantly associated with reduction in all-cause mortality in all groups, which was 40% lower (HR, 0.6 [95% CI, 0.5-0.6, P < .001]) among the general population, 30% lower (HR, 0.7; 95% CI, 0.6-0.8, P < .001) among patients with chronic obstructive pulmonary disease, and 50% lower (HR, 0.5; 95% CI, 0.3-0.7, P = .003) among patients with asthma.

CONCLUSION

The role of INCS in COVID-19 is still unclear, but exposure to INCS does not adversely affect COVID-19 mortality. Further studies are needed to explore the association between their use and inflammatory activation, viral load, angiotensin-converting enzyme 2 gene expression, and outcomes, exploring different types and doses of INCS.

[The impact of specialized management on allergic asthma outcomes]

INTRODUCTION

Allergic asthma has variable characteristics depending on the region of occurrence. Management is often organized without easy access to a specialized pneumo-allergological evaluation.

OBJECTIVES

PRIMARY: To characterize allergic asthma in patients followed at the Nancy University Hospital.

SECONDARY

To estimate the impact at 12 months of the proposed specialized management.

METHOD

Retrospective study including allergic asthmatic adults conducted between 01/01/2016 and 31/12/2018. Parameters studied (aside from descriptive parameters): asthma control score ACQ-7 (Asthma Control Questionnaire) and lung function at inclusion and at one year.

RESULTS

One hundred and fifteen patients were included (age 42±16 years, women 63%, non-smokers 70%). Even though asthma symptoms arose at 19±18 years, the specialized consultation was performed 21±17.5 years later. Frequent sensitizations involved house dust mites (49%), cat dander (43%), grasses (43%). Patients tended to underestimate the frequency of their allergies (mites 36% P=0.011, pollens 36% P=0.001, pet dander 42% P=0.003, molds 80% P=0.007). At 1-year follow-up both the ACQ-7 score (1.3±1.3 vs. 0.8±0.9; P=0.007) and the forced expiratory volume per second (81.3±20.8% vs. 86.2±21.9%; P=0.002) had improved.

CONCLUSION

The specificities of allergic asthmatics followed up in Nancy: late age of asthma onset of asthma and specialized consultation; predominant sensitization to cat dander and Betulaceae pollens; underestimation of allergies by the patient. Specialized care seems to important in the management of allergic asthma. While access to specialized care remains problematic, it could be facilitated by the creation of dedicated networks.

Sputum Metabolomic Profiling Reveals Metabolic Pathways and Signatures Associated With Inflammatory Phenotypes in Patients With Asthma

Purpose

The molecular links between metabolism and inflammation that drive different inflammatory phenotypes in asthma are poorly understood. We aimed to identify the metabolic signatures and underlying molecular pathways of different inflammatory asthma phenotypes.

Methods

In the discovery set (n = 119), untargeted ultra-high-performance liquid chromatography-mass spectrometry (UHPLC-MS) was applied to characterize the induced sputum metabolic profiles of asthmatic patients with different inflammatory phenotypes using orthogonal partial least-squares discriminant analysis (OPLS-DA), and pathway topology enrichment analysis. In the validation set (n = 114), differential metabolites were selected to perform targeted quantification. Correlations between targeted metabolites and clinical indices in asthmatic patients were analyzed. Logistic and negative binomial regression models were established to assess the association between metabolites and severe asthma exacerbations.

Results

Seventy-seven differential metabolites were identified in the discovery set. Pathway topology analysis uncovered that histidine metabolism, glycerophospholipid metabolism, nicotinate and nicotinamide metabolism, linoleic acid metabolism as well as phenylalanine, tyrosine and tryptophan biosynthesis were involved in the pathogenesis of different asthma phenotypes. In the validation set, 24 targeted quantification metabolites were significantly expressed between asthma inflammatory phenotypes. Finally, adenosine 5′-monophosphate (adjusted relative risk [adj RR] = 1.000; 95% confidence interval [CI] = 1.000–1.000; P = 0.050), allantoin (adj RR = 1.000; 95% CI = 1.000–1.000; P = 0.043) and nicotinamide (adj RR = 1.001; 95% CI = 1.000–1.002; P = 0.021) were demonstrated to predict severe asthma exacerbation rates.

Conclusions

Different inflammatory asthma phenotypes have specific metabolic profiles in induced sputum. The potential metabolic signatures may identify therapeutic targets in different inflammatory asthma phenotypes.

Comorbid allergic rhinitis and asthma: important clinical considerations

INTRODUCTION

The numerous links between allergic rhinitis and asthma have been extensively explored in the last two decades, gaining great concern within the scientific community. These two conditions frequently coexist in the same patient and share numerous pathogenetic and pathophysiological mechanisms.

AREAS COVERED

We reviewed major pathophysiological, epidemiological, and clinical links between allergic rhinitis and asthma. We also provided a comprehensive discussion of allergic rhinitis treatment according to current guidelines, with a particular focus on the relevance of allergic rhinitis therapies in patients with comorbid asthma.

EXPERT OPINION

We believe that there are several unmet needs for our patients, however, there are promising advances forecasted for the future. Although allergic rhinitis is a recognized risk factor for asthma, a proper asthma detection and prevention plan in allergic rhinitis patients is not available. Allergen immunotherapy (AIT) represents a promising preventive strategy and may deserve an earlier positioning in allergic rhinitis management. A multidisciplinary approach should characterize the journey of patients with respiratory allergies, with an adequate referral to specialized Allergy/Asthma centers. Molecular Allergy Diagnosis may provide support for optimal AIT use. Finally, a possible evolution of biological treatment can be envisaged, mainly if biosimilars decrease such therapies' costs.

Fast effectiveness of a solubilized low-dose budesonide nasal spray in allergic rhinitis

Background

Budesonide, a poorly water‐soluble corticosteroid, is currently marketed as a suspension. Budesolv is a novel aqueous formulation containing dissolved budesonide showing increased local availability in preclinical models. Budesolv contains ~85% less corticosteroid than the marketed comparator.

Objective

The study (EudraCT:2018‐001324‐19) was designed to assess non‐inferiority of Budesolv compared to Rhinocort® Aqua 64 (RA) and early onset of action.

Methods

In a three‐way cross‐over double‐blinded randomized trial, Budesolv 10 was compared to RA and placebo in grass pollen allergic rhinoconjunctivitis volunteers (n = 83 (ITT); n = 75 (PP)). On day 1, participants entered the Vienna Challenge Chamber (VCC) for 6 hours; first treatment took place at 1:45 hours after entry. Participants treated themselves for further 6 days; on day 8, the last treatment was applied before entering the VCC. Subjective symptom scores, nasal airflow and nasal secretion were measured regularly during allergen challenge.

Results

Budesolv 10 was equally effective compared to RA with respect to TNSS and nasal airflow after eight days of treatment with a strongly reduced dose (more than 80% reduction). After first dose, only Budesolv 10 showed a significant reduction of nasal and respiratory symptoms starting 90 minutes (P < .05) and 15 minutes (P < .05) after application onwards, respectively, demonstrating an early onset of efficacy. A clinically significant 1 point reduction in nasal symptom score was reached at 195 minutes (P < .05) after application.

Conclusions and clinical relevance

The novel preservative‐free, aqueous low‐dose budesonide formulation is highly efficacious even after an initial single treatment. Thus, Budesolv 10 appears to be an effective acute treatment for allergic rhinitis as well as for AR comorbidities like mild asthma and conjunctivitis.

Does unified allergic airway disease impact on lung function and type 2 biomarkers?

The concept of the unified allergic airway disease (UAD) recognises the association between allergic inflammation in the upper and lower airways. Patients with asthma and concomitant allergic rhinitis experience more asthma-related primary and secondary care visits. We therefore aimed to determine differences in asthma control (asthma control questionnaire ACQ-6), lung function (spirometry) and T2 biomarkers (FeNO and Eos) in relation to the presence of allergic rhinitis in patients with allergic asthma. Retrospectively, we evaluated a cohort of 60 consecutive patients with persistent asthma attending our research unit for screening into clinical trials. All included subjects were receiving inhaled corticosteroids (ICS) and had a positive skin prick test (SPT) to at least one common aeroallergen to fulfil the criterion of allergic asthma. Patients with UAD had a diagnosis of allergic asthma in addition to established concomitant allergic rhinitis. T2 biomarkers were significantly higher in patients with allergic rhinitis in contrast to those without. FEV₁ % predicted and FEF_25-75 % predicted were also significantly lower in patients with concomitant allergic rhinitis. However, there was no difference in ACQ-6 observed between groups. In summary, patients with allergic asthma, the presence of concomitant allergic rhinitis is associated with worse lung function and higher type 2 biomarkers.

Asthma-COPD Overlap and Chronic Airflow Obstruction: Definitions, Management, and Unanswered Questions

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is a common clinical presentation of chronic airways disease in which patients show some features usually associated with asthma, and some usually associated with COPD. There is ongoing debate over whether ACO is a discrete clinical entity, or if it is part of a continuum of airways disease. Furthermore, there is considerable variation among current definitions of ACO, which makes diagnosis potentially challenging for clinicians. Treating ACO may be equally challenging because ACO is an understudied population, and the evidence base for its management comes largely from asthma and COPD studies, the relevance of which deserves careful consideration. In this review, we synthesize the various approaches to ACO diagnosis and evaluate the role of currently available diagnostic tests. We describe the potential benefits of existing asthma and COPD therapies in treating patients with ACO, and the value of a "treatable traits" approach to ACO management. Throughout the review, we highlight some of the pressing, unanswered questions surrounding ACO that are relevant to the clinical community. Ultimately, addressing these questions is necessary if we are to improve clinical outcomes for this complex and heterogeneous patient population.

Development of an Inline Dry Powder Inhaler for Oral or Trans-Nasal Aerosol Administration to Children

Background: Dry powder inhalers (DPIs) offer a number of advantages, such as rapid delivery of high-dose inhaled medications; however, DPI use in children is often avoided due to low lung delivery efficiency and difficulty in operating the device. The objective of this study was to develop a high-efficiency inline DPI for administering aerosol therapy to children with the option of using either an oral or trans-nasal approach. Methods: An inline DPI was developed that consisted of hollow inlet and outlet capillaries, a powder chamber, and a nasal or oral interface. A ventilation bag or compressed air was used to actuate the device and simultaneously provide a full deep inspiration consistent with a 5-year-old child. The powder chamber was partially filled with a model spray-dried excipient enhanced growth powder formulation with a mass of 10 mg. Device aerosolization was characterized with cascade impaction, and aerosol transmissions through oral and nasal in vitro models were assessed. Results: Best device performance was achieved when all actuation air passed through the powder chamber (no bypass flow) resulting in an aerosol mean mass median aerodynamic diameter (MMAD) <1.75 μm and a fine particle fraction (<5 μm) ≥90% based on emitted dose. Actuation with the ventilation bag enabled lung delivery efficiency through the nasal and oral interfaces to a tracheal filter of 60% or greater, based on loaded dose. In both oral and nose-to-lung (N2L) administrations, extrathoracic depositional losses were <10%. Conclusion: In conclusion, this study has proposed and initially developed an efficient inline DPI for delivering spray-dried formulations to children using positive pressure operation. Actuation of the device with positive pressure enabled effective N2L aerosol administration with a DPI, which may be beneficial for subjects who are too young to use a mouthpiece or to simultaneously treat the nasal and lung airways of older children.

Healthcare resource utilization, expenditures, and productivity in patients with asthma with and without allergies

Objective: To compare healthcare resource utilization (HCRU), healthcare expenditures, and work productivity and activity impairment within a general asthma population with persistent asthma and evidence of allergy (PA-EA) and persistent asthma with no evidence of allergy (PA-NEA).Methods: We conducted a retrospective analysis of survey responses and claims from the Observational Study of Asthma Control and Outcomes (OSACO) study. Eligible patients with persistent asthma aged ≥12 years were sent four surveys over 15 months. Regression models were used to assess the association between: (1) PA-EA (defined as a positive response to a survey question about hay fever/seasonal allergies AND ≥1 diagnostic code for atopic conditions) and HCRU and expenditures; and (2) PA-EA and Work Productivity and Activity Impairment (WPAI)-Asthma questionnaire scores (vs. PA-NEA).Results: Adjusted data showed that, vs. PA-NEA (n = 312), patients with PA-EA (n = 971) incurred 1.34-times more all-cause prescriptions (95% confidence interval [CI], 1.20-1.48), $132.79 higher prescription costs (95% CI, $22.03-243.56), and $926.11 higher all-cause total healthcare costs (95% CI, $279.67-1572.54), per 4-month period. Patients with PA-EA were 4.1% less productive while working (95% CI, 3.75-4.48%) and experienced a 6.5% reduction in all activities (95% CI, 6.11-6.88%) vs. those with PA-NEA.Conclusions: Patients with PA-EA had greater HCRU, healthcare expenditures, and lower productivity compared with those patients with PA-NEA. These results highlight the burden of atopy in patients with persistent asthma and underscore the importance of allergic endotype identification for more vigilant disease management.

Thunderstorm-triggered asthma: what we know so far

Thunderstorm-triggered asthma (TA) is the occurrence of acute asthma attacks immediately following a thunderstorm. Epidemics have occurred across the world during pollen season and have the capacity to rapidly inundate a health care service, resulting in potentially catastrophic outcomes for patients. TA occurs when specific meteorological and aerobiological factors combine to affect predisposed patients. Thunderstorm outflows can concentrate aeroallergens, most commonly grass pollen in TA, at ground level to release respirable allergenic particles after rupture by osmotic shock related to humidity and rainfall. Inhalation of high concentrations of these aeroallergens by sensitized individuals can induce early asthmatic responses which are followed by a late inflammatory phase. Other environmental factors such as rapid temperature change and agricultural practices contribute to the causation of TA. The most lethal TA event occurred in Melbourne, Australia, in 2016. Studies on the affected individuals found TA to be associated with allergic rhinitis, ryegrass pollen sensitization, pre-existing asthma, poor adherence to inhaled corticosteroid preventer therapy, hospital admission for asthma in the previous year and outdoor location at the time of the storm. Patients without a prior history of asthma were also affected. These factors are important in extending our understanding of the etiology of TA and associated clinical indicators as well as possible biomarkers which may aid in predicting those at risk and thus those who should be targeted in prevention campaigns. Education on the importance of recognizing asthma symptoms, adherence to asthma treatment and controlling seasonal allergic rhinitis is vital in preventing TA. Consideration of allergen immunotherapy in selected patients may also mitigate risk of future TA. Epidemic TA events are predicted to increase in frequency and severity with climate change, and identifying susceptible patients and preventing poor outcomes is a key research and public health policy priority.

Prevalence of atopy and allergic rhinitis in patients with adult non-cystic fibrosis bronchiectasis

Background/aim

Non-cystic fibrosis bronchiectasis (non-CF BR) is common in developing countries.Limited data are available regarding the impact of atopy, and no data are available regarding allergic rhinitis in patients with adult bronchiectasis.The aim of this study was to evaluate the prevalence of atopy and allergic rhinitis in the clinical conditions of patients with BR.

Materials and methods

The study enrolled 101 patients who were diagnosed with non-CF BR using high-resolution computed chest tomography. Allergic rhinitis (AR) was defined by skin prick test (SPT) positivity and the presence of any nasal symptoms (watery runny nose, nasal obstruction, nasal itching, and sneezing).

Results

The mean age of patients was 48 ± 15 years (range 18–82); 55 (54.5%) patients were female. SPT positivity was detected in 37 (36.6%) cases. AR was detected in 32 (31.7%) patients with non-CF BR. AR was related to dyspnea (P = 0.04) and number of admissions to an emergency department in the previous year (P = 0.01). Forced expiratory volume in 1 s and forced vital capacity in patients with and without AR were different (P = 0.01 and P = 0.01, respectively). AR was correlated with number of admissions to an emergency department in the last year (r = 0.417, P = 0.005).

Conclusion

We concluded that atopy was detected in more than one-third of adult non-CF BR patients. This study demonstrated that non-CF BR patients might have AR; it might be important to be aware of nasal symptoms in non-CF BR patients.

Treatment of allergic rhinitis reduces acute asthma exacerbation risk among asthmatic children aged 2-18 years

BACKGROUND/PURPOSE

Asthma and allergic rhinitis (AR) frequently coexist in the same individuals in childhood and adolescence. We evaluated whether AR had an impact on acute exacerbation (AE) and whether intranasal corticosteroid (INCS) and second-generation antihistamines (SGH) for AR modified the association of AR with AE in asthmatics aged 2-6 years and 7-18 years.

METHODS

Using the National Health Research Institutes (NHRI) Database 2005 of Taiwan, we investigated patients who had been diagnosed with asthma in the years 2000 through 2012 and who had then been followed-up with for at least one year. The risk factors of AE were evaluated using multiple Cox proportional hazards regression analysis.

RESULTS

The incidence of AE was higher in the preschool group than the older group (adj. HR: 1.68, 95% CI: 1.44-1.95). The AR with INCS and/or SGH group was found to have a lower risk of AE than the non-AR group (adj. HR: 0.32, 0.44 and 0.30), but the AR without treatment group did not have a significant difference with the non-AR group. After propensity score matching, the use of INCS and/or SGH was associated with a significant reduction in the occurrence of AE among AR patients aged 2-6 years old (adj. HR: 0.38, 0.57 and 0.45) and 7-18 years old (adj. HR: 0.50, 0.52 and 0.35).

CONCLUSION

The preschool patients had a higher incidence of AE than the older patients in general. Adequate treatment with INCS and/or SGH in asthma with AR patients is important for reducing the incidence of AE of asthma.

Predictors of repeated acute hospital attendance for asthma in children: A systematic review and meta-analysis

BACKGROUND

Asthma attacks are common and have significant physical, psychological, and financial consequences. Improving the assessment of a child's risk of subsequent asthma attacks could support front-line clinicians' decisions on augmenting chronic treatment or specialist referral. We aimed to identify predictors for emergency department (ED) or hospital readmission for asthma from the published literature.

METHODS

We searched MEDLINE, EMBASE, AMED, PsycINFO, and CINAHL with no language, location, or time restrictions. We retrieved observational studies and randomized controlled trials (RCT) assessing factors (personal and family history, and biomarkers) associated with the risk of ED re-attendance or hospital readmission for acute childhood asthma.

RESULTS

Three RCTs and 33 observational studies were included, 31 from Anglophone countries and none from Asia or Africa. There was an unclear or high risk of bias in 14 of the studies, including 2 of the RCTs. Previous history of emergency or hospital admissions for asthma, younger age, African-American ethnicity, and low socioeconomic status increased risk of subsequent ED and hospital readmissions for acute asthma. Female sex and concomitant allergic diseases also predicted hospital readmission.

CONCLUSION

Despite the global importance of this issue, there are relatively few high quality studies or studies from outside North America. Factors other than symptoms are associated with the risk of emergency re-attendance for acute asthma among children. Further research is required to better quantify the risk of future attacks and to assess the role of commonly used biomarkers.

Prevalence, characteristics and management of frequently exacerbating asthma patients: an observational study in Sweden (PACEHR)

The aim of the study was to investigate the prevalence, management and characteristics of asthma patients with frequent exacerbations.Data from asthma patients (aged ≥18 years) identified in primary care medical records were linked to Swedish national health registries. Exacerbations were defined as hospitalisations, emergency visits and/or collection of oral steroids. Frequent exacerbations were defined as two or more exacerbations per year during the 3-year observation period.Of 18 724 asthma patients, 81.49% had no exacerbations and 6.3% had frequent exacerbations in the year prior to the index date. Frequent exacerbations were observed yearly for 1.8% of the patients. Frequent exacerbators were older, more often females, and had increased eosinophil and neutrophil counts, lower lung function, and more comorbidities than patients without exacerbations. There was a slight increase in asthma medication claims and a slight decrease in physician visits compared with baseline, both in the group with and the group without frequent exacerbations.Patients with frequent exacerbations were characterised by greater age, female predominance, high eosinophil and neutrophil counts, and high prevalence of comorbidities. This study indicates that the Swedish healthcare system lacks efficiency to adjust treatment and management for this patient group. With new treatment options targeting severe asthma available, identification of these patients should be in focus to ensure reduction of exacerbations.

Assessment of predictors for acute asthma attack in asthmatic patients visiting an Ethiopian hospital: are the potential factors still a threat?

BACKGROUND

Recurrent exacerbations in patients with moderate or severe asthma are the major causes of morbidity, mortality and medical expenditure. Identifying predictors of frequent asthma attack might offer the fertile ground of asthma management. However, systematic data on asthma management is scarce in Ethiopia.

OBJECTIVE

The purpose of the present study was to determine predictors of acute asthma attack in patients with asthma attending emergency department of University of Gondar Comprehensive Specialized Hospital (UOGCSH) in Gondar, northwestern Ethiopia.

METHODS

An institutional-based cross-sectional self-administered survey was conducted on 108 asthmatic patients who came to the emergency department of UOGCSH following acute asthma attack. Data were collected through interviewer administered questionnaire. Logistic regression was done to see the possible association of potential factors that may lead to asthma exacerbation.

RESULT

About half of the respondents (51.9%) were female and one third of patients (38.9%) were within the age range of between 46 and 60 years. The leading potential predictor were frequent exposure to various ongoing allergen (68.5%) followed by revelation to occupational sensitizers (67.6%). Chronic sinusitis (AOR = 3.532, 95% CL = 1.116-11.178), obstructive sleep apnea (AOR = 3.425, 95% CL = 1.255-9.356) and psychological disfunctioning (3.689 (1.327-10.255)) were among the significantly associated factors of acute asthma exacerbation.

CONCLUSIONS

Now days, the backbone for long-term asthma management is to prevent exacerbations. Chronic sinusitis, obstructed sleep apnea and psychosocial dysfunction were originated to be considerably linked with repeated exacerbations of asthma. Among those significantly associated predictors, obstructed sleep apnea were the most prevalent one.

Meta-analysis of the comorbidity rate of allergic rhinitis and asthma in Chinese children

OBJECTIVES

Allergic rhinitis (AR) and asthma often occur concomitantly and are the two most common inflammatory conditions of the airways in children. Large-scale studies investigating the comorbidity of asthma and AR in children are rare. So, we performed a meta-analysis to describe the comorbidity rate of asthma and AR in Chinese children.

METHODS

We retrieved related studies from Pubmed, Science, Springer, Elsevier, Embase, BMJ, and four Chinese biomedical databases, including Wanfang Data, VIP, CBM, and CNKI. From these individual studies, the comorbidity rate of asthma and AR in Chinese children was extracted and pooled to generate summary effect estimates in R version 3.2.3.

RESULTS

The meta-analysis included 25 cross-sectional studies. The results indicated that in China, the incidence of asthma in children with AR is 35.01% (95% CI: 32.32%-37.70%) and the incidence of AR in children with asthma is 54.93% (95% CI: 53.05%-56.80%).

CONCLUSIONS

The comorbidity of AR and asthma is high in Chinese children. Statistically, the prevalence of AR was higher in children with asthma, as opposed to the prevalence of asthma in children with AR. The comorbidity rate of AR and asthma signifies the importance of improving the recognition and treatment under both conditions by respiratory physicians and otolaryngologists.

An epidemic of thunderstorm asthma in Melbourne 2016: asthma, rhinitis, and other previous allergies

Background

On 21st November 2016, Melbourne experienced an epidemic of ‘thunderstorm asthma.’ Although previously described in the literature, risk factors and natural history remain incompletely understood.

Objective

Our aim was to follow up those presenting to the 3 Emergency Departments (EDs) in our health service during the epidemic, and assess their history for previous asthma, rhinitis, and allergies.

Methods

ED notes of all respiratory presentations within 48 hours of the thunderstorm event were reviewed and patients with acute asthma included. A standardised questionnaire was devised encompassing asthma diagnosis, undiagnosed asthma symptoms and rhinitis severity. Patients were contacted by phone within 30 days of the event.

Results

Three hundred forty-four patients were identified overall; 263 patients were contactable and completed a phone or mail questionnaire. The mean age was 32.7 ± 19.2 years (range, 6 months–87 years; 25% < 18 years) with 58% male sex. A previous diagnosis of asthma was present in 42% (n = 111), and there was no previous asthma diagnosis in 58% (n = 152). Of those who had no asthma diagnosis 53% had probable undiagnosed asthma. Overall, rhinitis prevalence was 88%, of which 72% were moderate or severe (Allergic Rhinitis and its Impact on Asthma guidelines) and 51% (n = 133) reported a history of grass pollen allergy.

Conclusion

Our data highlights the importance of atopy and rhinitis as risk factors for epidemic thunderstorm asthma. Better identification of undiagnosed asthma, and implementing treatment of asthma and rhinitis may be important.

Usefulness of House Dust Mite Nasal Provocation Test in Asthma

Purpose

We previously reported that the skin prick test was sensitive and the serum specific immunoglobulin E test was specific for predicting positive airway responses to house dust mites (HDMs) in patients with asthma. Because the nose and bronchus are one airway, the nasal provocation test would be more specific for predicting the bronchial responses to HDM than the skin test.

Methods

The allergy skin prick test and nasal and bronchial provocation tests using HDM (Dermatophagoides farinae) were performed in 41 young men (age, 19–28 years) who wanted military certification for asthma. The nasal responses to HDM was scored according to the severity of rhinorrhea, sneezing, and nose itching.

Results

The prevalence of a positive skin prick test to HDM did not significantly differ between patients with (n=24) and without (n=17) an early airway reaction (EAR; 79.2% vs 70.6%, P=0.534). However, the prevalence of a positive nasal test was significantly higher in the airway responders than in the others (37.5% vs 0%, P=0.005). The concordance of a positive response to the nasal test (κ=0.332, P=0.004) but not to the skin prick test (κ=0.091, P=0.529) was significant with an EAR. The diagnostic sensitivity of the nasal test (37.5%) was lower than that of the skin prick test (79.2%), but the specificity was higher (100% vs 29.4%).

Conclusions

The skin prick test is more sensitive, whereas the nasal test is more specific and accurate, for predicting an EAR to HDM in patients with asthma.

Future treatment for asthma

The landscape of asthma has considerably changed after 40 years of inhaled corticosteroid development and nearly 20 years since the first monoclonal antibodies (mAbs) were approved. New members of pharmacological families and more effective drug-delivery devices have been designed but the proportion of uncontrolled patients, unfortunately, remains stable. The most promising treatments now rely on targeted therapies that encourage the improvement of the characterisation of our patients. These clinical (phenotype) or new biological (endotype) tools lead to palpable personalised medicine. This review examines not only the future of mAbs and other new ways of treating asthma but also describes futuristic views based on the paradigm shifts that are ready to occur.

Adrenal insufficiency associated with long-term use of inhaled steroid in asthma

BACKGROUND

We previously reported that as many as one third of hospitalized patients with asthma treated with a low to medium daily dose of inhaled steroids (ICSs) for an average of 4.5 years showed adrenal insufficiency (AI).

OBJECTIVE

To re-examine this issue in consecutive outpatients with asthma because of possible subject selection bias.

METHODS

One hundred twenty-one consecutive adult patients with asthma under ICS treatment for at least 6 months underwent a rapid adrenocorticotrophic hormone stimulation test. AI was defined as a morning serum cortisol level no higher than 3 μg/dL or lower than 18 μg/dL before and after administration of 250 μg of adrenocorticotrophic hormone.

RESULTS

The mean durations of ICS use in the short-term (less than the median) and long-term (at least the median) users were 3.8 and 11.5 years, respectively. The proportion of subjects affected by AI tended to increase with the increasing cumulative dose of ICS (short-term users at a low to medium daily dose: mean cumulative dose 502 mg [15 of 34, 44.1%]; short-term users at a high dose of 941 mg [16 of 26, 61.5%]; long-term users at a low to medium dose of 1,077 mg [25 of 41, 61.0%]; long-term users at a high dose of 2,805 mg [13 of 20, 65.0%]), although not significantly. In short-term users, daily and cumulative ICS doses were significantly related to serum cortisol levels 60 minutes after taking adrenocorticotrophic hormone (r = -0.300 and -0.287, respectively; P < .05).

CONCLUSION

A large number of patients with asthma might have AI even with low- to medium-dose ICS treatment when ICSs are administered over a long period. Thus, it is essential that patients with asthma under ICS treatment be checked for AI much more frequently.

Pale nasal mucosa affects airflow limitations in upper and lower airways in asthmatic children

Background

Severe asthmatics are thought to have severer rhinitis than mild asthmatics. A pale nasal mucosa is a typical clinical finding in subjects with severe allergic rhinitis.

Objective

The aim of this study was to investigate whether a pale nasal mucosa affects airflow limitations in the upper and lower airways in asthmatic children.

Methods

Rhinomanometry, nasal scraping, and spirometry were performed in 54 asthmatic children (median age, 10 years). The nasal mucosa was evaluated by an otolaryngologist. Thirty-seven patients were treated with inhaled corticosteroids, and 11 patients were treated with intranasal corticosteroids.

Results

Subjects with a pale nasal mucosa (n = 23) exhibited a lower nasal airflow (p < 0.05) and a larger number of nasal eosinophils (p < 0.05) in the upper airway as well as lower pulmonary functional parameters (p < 0.05 for all comparisons), i.e., the forced vital capacity (FVC), the forced expiratory volume in 1 second, and the peak expiratory flow, compared with the subjects who exhibited a normal or pinkish mucosa (n = 31). No significant difference in the forced expiratory flow between 25%–75% of the FVC, regarded as indicating the peripheral airway, was observed between the 2 groups.

Conclusion

A pale nasal mucosa may be a predictor of eosinophil infiltration of the nasal mucosa and central airway limitations in asthmatic children. When allergists observe a pale nasal mucosa in asthmatic children, they should consider the possibility of airflow limitations in not only the upper airway, but also the lower airway.

MicroRNA in United Airway Diseases

The concept of united airway diseases (UAD) has received increasing attention in recent years. Sustained and increased inflammation is a common feature of UAD, which is inevitably accompanied with marked gene modification and tight gene regulation. However, gene regulation in the common inflammatory processes in UAD remains unclear. MicroRNA (miRNA), a novel regulator of gene expression, has been considered to be involved in many inflammatory diseases. Although there are an increasing number of studies of miRNAs in inflammatory upper and lower airway diseases, few miRNAs have been identified that directly link the upper and lower airways. In this article, therefore, we reviewed the relevant studies available in order to improve the understanding of the roles of miRNAs in the interaction and pathogenesis of UAD.

The role of antihistamines in asthma management

Histamine is an important mediator in airway inflammation. It is elevated in the airways of asthmatic patients and is responsible for many of the pathophysiological features in asthma. Antihistamines block the actions of histamine and also have effects on inflammation which is independent of histamine-H(1)-receptor antagonism. Antihistamines have been shown to have bronchodilatory effects, effects on allergen-, exercise-, and adenosine-monophosphate-challenge testing, and also to prevent allergen-induced nonspecific airways hyperresponsiveness. Clinical studies have shown mixed results, and some studies have reported beneficial effects of azelastine, cetirizine, desloratadine, and fexofenadine on asthma symptoms or physiological measures in patients with asthma. The combination of an antihistamine and a leukotriene receptor antagonist has been shown to have additive effects in certain studies. Antihistamines have also been shown to delay or prevent the development of asthma in a subgroup of atopic children. These data suggest that antihistamines may have beneficial effects in the management of asthma.

Allergic rhinitis: the "Ghost Diagnosis" in patients with asthma

Allergic rhinitis (AR) is a common comorbidity of asthma that contributes to asthma severity. Although over 80 % of asthmatics have AR, the condition is frequently underdiagnosed in subjects with asthma. AR itself is also a highly prevalent condition, affecting 10-30 % of adults and up to 40 % of children. AR has been associated with both increased risk of asthma development and asthma severity. The exact mechanisms underlying these relationships have yet to be fully elucidated, but evidence supports a role for allergen sensitization. Compared to those with asthma alone, patients with comorbid AR and asthma have greater use of health care resources, including visits to the general practitioner, emergency department and hospitalizations. Pharmacological treatment of AR reduces this health care burden. Immunotherapy for AR improves both asthma and rhinitis symptoms in addition to preventing future allergen sensitizations and asthma development. Appropriate recognition, diagnosis and treatment of AR can significantly reduce asthma morbidity and improve quality of life.

Allergic rhinitis: the "Ghost Diagnosis" in patients with asthma

Allergic rhinitis (AR) is a common comorbidity of asthma that contributes to asthma severity. Although over 80 % of asthmatics have AR, the condition is frequently underdiagnosed in subjects with asthma. AR itself is also a highly prevalent condition, affecting 10-30 % of adults and up to 40 % of children. AR has been associated with both increased risk of asthma development and asthma severity. The exact mechanisms underlying these relationships have yet to be fully elucidated, but evidence supports a role for allergen sensitization. Compared to those with asthma alone, patients with comorbid AR and asthma have greater use of health care resources, including visits to the general practitioner, emergency department and hospitalizations. Pharmacological treatment of AR reduces this health care burden. Immunotherapy for AR improves both asthma and rhinitis symptoms in addition to preventing future allergen sensitizations and asthma development. Appropriate recognition, diagnosis and treatment of AR can significantly reduce asthma morbidity and improve quality of life.

Improvement and prevention of asthma with concomitant treatment of allergic rhinitis and allergen-specific therapy

BACKGROUND

Asthma and allergic rhinitis are 2 of the most prevalent chronic medical diseases. Asthma is estimated to affect 8% of adults and 9% of children, with nearly 300 million people affected worldwide. Poorly controlled allergic rhinitis may be associated with worsening asthma symptoms over time. Various treatments have been proposed in the improvement and prevention of asthma in children and adults with allergic symptoms, which have included pharmacotherapy with antihistamines and topical intranasal corticosteroids, as well as allergen-specific immunotherapy.

METHODS

Articles were selected through PubMed and personal knowledge of the authors based on a comprehensive literature review examining whether treatment of allergic rhinitis improves and/or prevents concomitant symptoms of asthma. The largest and highest-quality studies were included in the literature review. The search selection was not standardized. Articles written in a language other than English were excluded.

RESULTS

Clinical trials have showed improvement in asthma symptoms with concomitant treatment of allergic rhinitis with antihistamines and topical intranasal corticosteroids, though improvement in objective pulmonary function parameters has not been uniformly demonstrated with antihistamine use alone. There is very strong evidence to suggest that subcutaneous and sublingual immunotherapy may in addition prevent the progression of asthma in high-risk atopic patients by inducing immunological tolerance.

CONCLUSION

Traditional pharmacotherapy with antihistamines and topical intranasal steroids has been shown to improve allergic rhinitis symptoms with concomitant allergic asthma; however, only allergen-specific immunotherapy offers long-term control in improving asthma symptoms, exacerbations, and likely ultimate prevention in developing asthma.

Optimal management of allergic rhinitis

Allergic rhinitis (AR), the most common chronic disease in childhood is often ignored, misdiagnosed and/or mistreated. Undertreated AR impairs quality of life, exacerbates asthma and is a major factor in asthma development. It can involve the nose itself, as well as the organs connected with the nose manifesting a variety of symptoms. Evidence-based guidelines for AR therapy improve disease control. Recently, paediatric AR guidelines have been published by the European Academy of Allergy and Clinical Immunology and are available online, as are a patient care pathway for children with AR and asthma from the Royal College of Paediatrics and Child Health. Management involves diagnosis, followed by avoidance of relevant allergens, with additional pharmacotherapy needed for most sufferers. This ranges, according to severity, from saline sprays, through non-sedating antihistamines, oral or topical, with minimally bioavailable intranasal corticosteroids for moderate/severe disease, possibly plus additional antihistamine or antileukotriene. The concept of rhinitis control is emerging, but there is no universally accepted definition. Where pharmacotherapy fails, allergen-specific immunotherapy, which is uniquely able to alter long-term disease outcomes, should be considered. The subcutaneous form (subcutaneous immunotherapy) in children has been underused because of concerns regarding safety and acceptability of injections. Sublingual immunotherapy is both efficacious and safe for grass pollen allergy. Further studies on other allergens in children are needed. Patient, carer and practitioner education into AR and its treatment are a vital part of management.

Bronchial thermoplasty in asthma: current perspectives

Bronchial thermoplasty (BT) is a novel therapy for patients with severe asthma. Using radio frequency thermal energy, it aims to reduce the airway smooth muscle mass. Several clinical trials have demonstrated improvements in asthma-related quality of life and a reduction in the number of exacerbations following treatment with BT. In addition, recent data has demonstrated the long-term safety of the procedure as well as sustained improvements in rates of asthma exacerbations, reduction in health care utilization, and improved quality of life. Further study is needed to elucidate the underlying mechanisms that result in these improvements. In addition, improved characterization of the asthma subphenotypes likely to exhibit the largest clinical benefit is a critical step in determining the precise role of BT in the management of severe asthma.

Japanese Guideline for Adult Asthma 2014

Adult bronchial asthma (hereinafter, asthma) is characterized by chronic airway inflammation, reversible airway narrowing, and airway hyperresponsiveness. Long-standing asthma induces airway remodeling to cause intractable asthma. The number of patients with asthma has increased, and that of patients who die from asthma has decreased (1.5 per 100,000 patients in 2012). The aim of asthma treatment is to enable patients with asthma to lead a normal life without any symptoms. A good relationship between physicians and patients is indispensable for appropriate treatment. Long-term management with antiasthmatic agents and elimination of the causes and risk factors of asthma are fundamental to its treatment. Four steps in pharmacotherapy differentiate between mild and intensive treatments; each step includes an appropriate daily dose of an inhaled corticosteroid, varying from low to high. Long-acting 02-agonists, leukotriene receptor antagonists, and sustained-release theophylline are recommended as concomitant drugs, while anti-immunoglobulin E antibody therapy has been recently developed for the most severe and persistent asthma involving allergic reactions. Inhaled 02-agonists, aminophylline, corticosteroids, adrenaline, oxygen therapy, and others are used as needed in acute exacerbations by choosing treatment steps for asthma exacerbations depending on the severity of attacks. Allergic rhinitis, chronic obstructive pulmonary disease, aspirin-induced asthma, pregnancy, asthma in athletes, and coughvariant asthma are also important issues that need to be considered.

Asthma control: how it can be best assessed?

PURPOSE OF REVIEW

A control-based asthma assessment is recommended by guidelines, but questions remain about how to assess the level of asthma control, and how current control status relates to future risks and biomarkers of disease pathogenesis. This review summarizes recent published data relating to asthma control and describes the challenges created by currently available instruments.

RECENT FINDINGS

The current literature continues to show the widespread use of various assessment instruments for asthma control, in particular those with composite scores. However, poor correlations exist between the different assessment tools, and these instruments lack diagnostic accuracy to differentiate uncontrolled asthma. Whereas the concept of asthma control has been extended to add an assessment of future risks to the clinical control, clinical asthma control as measured by current available assessment tools does not necessary relate to the intrinsic disease activity which is typically characterized by inflammation in asthma.

SUMMARY

The application of asthma control assessment represents an improvement in asthma management. The measurement of underlying disease activity potentially by biomarkers to assess disease control will lead to an improved assessment of the overall control of asthma, and further studies addressing this are needed.

Underdiagnosed and Undertreated Allergic Rhinitis in Urban School-Aged Children with Asthma

Allergic rhinitis (AR) is a risk factor for the development of asthma, and if poorly controlled, it may exacerbate asthma. We sought to describe AR symptoms and treatment in a larger study about asthma, sleep, and school performance. We examined the proportion (1) who met criteria for AR in an urban sample of school children with persistent asthma symptoms, (2) whose caregivers stated that they were not told of their child's allergies, (3) who had AR but were not treated or were undertreated for the disease, as well as (4) caregivers and healthcare providers' perceptions of the child's allergy status compared with study assessment, and (5) associations between self-report of asthma and AR control over a 4-week monitoring period. One hundred sixty-six children with persistent asthma participated in a clinical evaluation of asthma and rhinitis, including allergy testing. Self-report of asthma control and rhinitis control using the Childhood Asthma Control Test (C-ACT) and Rhinitis Control Assessment Test (RCAT) were measured 1 month after the study clinic session. Persistent rhinitis symptoms were reported by 72% of participants; 54% of rhinitis symptoms were moderate in severity, though only 33% of the sample received adequate treatment. AR was newly diagnosed for 53% during the clinic evaluation. Only 15% reported using intranasal steroids. Participants with poorly controlled AR had poorer asthma control compared with those with well-controlled AR. This sample of urban school-aged children with persistent asthma had underdiagnosed and undertreated AR. Healthcare providers and caregivers in urban settings need additional education about the role of allergies in asthma, recognition of AR symptoms, and AR's essential function in the comanagement of asthma. Barriers to linkages with allergy specialists need to be identified.

Advances in asthma drug discovery: evaluating the potential of nasal cell sampling and beyond

INTRODUCTION

Inhaled corticosteroid anti-inflammatory therapy is effective at controlling disease symptoms of asthma, but a subset of patients remains symptomatic despite optimal treatment, creating a clear unmet medical need. Moreover, none of the currently available drugs for asthma are really disease-modifying or curative. Although murine models of asthma, based on transgenic and knockout animals, may offer an integrated pathophysiological system for studying the characteristics of airway inflammation and hyperresponsiveness, these alterations are noteworthily different compared with those observed in asthmatic patients. Since a clear functional and inflammatory relationship between the nasal mucosa and bronchial tissue in patients suffering from asthma and allergic rhinitis has been recognized, using preclinical models based on human nasal cells sampling might support a prompt and effective anti-inflammatory drug discovery in asthma.

AREAS COVERED

The authors provide a review, which discusses the potential role of nasal cell sampling and its application in advanced drug discovery for asthma. The contents range from the similarities and differences between asthma and allergic rhinitis up to artificial airway models based on sophisticated human lung-on-a-chip devices.

EXPERT OPINION

Nasal cell sampling and processing have reached a great potential in asthma drug discovery. The authors believe that models of asthma, which are based on human nasal cells, can provide valuable indications of proof of pharmacological and potential therapeutic efficacy in both preclinical and early clinical settings.

Allergic rhinitis quality of life in urban children with asthma

BACKGROUND

Urban children with asthma and allergic rhinitis (AR) are at risk for experiencing worse AR-related quality of life (QOL). Although AR may be underdiagnosed and undertreated in urban minority children, research has not considered which illness-related indicators (eg, AR control) may contribute to AR QOL in this population.

OBJECTIVE

To examine associations among AR control, asthma control, allergy symptoms, asthma symptoms, and AR QOL in a sample of 195 urban caregivers and their children with asthma (7-9 years of age) from African American, Latino, and non-Latino white backgrounds. Racial and ethnic differences in AR QOL were also examined.

METHODS

Families resided in 1 of 4 cities selected as recruitment sources because of their high concentrations of ethnic minority and non-Latino white, urban families. Caregivers and children completed a series of interview-based and clinician-based assessments across one academic year and 4-week periods to track daily asthma and nasal symptoms.

RESULTS

Better AR control was associated with higher AR QOL (β = -.32, P < .01) and all QOL subscales. AR control predicted AR QOL over and above asthma control (β = -.28, P < .01). Controlling for AR control, non-Latino white children reported better QOL related to practical problems than both Latino and African American children (P < .05).

CONCLUSION

Findings suggest that strategies to enhance AR control in urban children with asthma may assist in improving AR QOL. Non-Latino white children may experience less impairment of their AR QOL because of practical problems (eg, blow nose) than African American or Latino children with asthma.

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

The strong epidemiologic and pathophysiologic link between allergic rhinitis (AR) and asthma has led to the concept of 'united airways disease' or 'respiratory allergy', implying that allergy, in its widest sense, underlies this clinical syndrome. Progression from AR to asthma is frequent and part of the 'atopic march'. Since pediatric immune responses are more adaptable and therefore may be more amenable to treatment, interventions at early childhood are characterized by a higher chance to affect the natural history of respiratory allergy. Although current treatments are quite effective in alleviating respiratory allergy symptoms, it has proven much more difficult to confirm any influence on the progression of the disease. Much more promising is the field of specific allergen immunotherapy, where current evidence, although not yet of ideal robustness, points towards a disease-modifying effect. In addition, newer or emerging, possibly more effective or more targeted interventions are promising in the preventive sense.

The role of rhinosinusitis in severe asthma

The prevalence of asthma is approximately 5% to 10% in the general population. Of these, approximately 5% to 10% are severe asthmatics who respond poorly to asthmatic drugs, including high-dose inhaled steroids. Severe asthmatics have persistent symptoms, frequent symptom exacerbation, and severe airway obstruction even when taking high-dose inhaled steroids. The medical costs of treating severe asthmatics represent ~50% of the total healthcare costs for asthma. Risk factors for severe asthma are genetic and environmental, including many kinds of aeroallergens, β-blockers, and anti-inflammatory drugs. Gastroesophageal reflux disease and factors such as denial, anxiety, fear, depression, socioeconomic status, and alcohol consumption can exacerbate asthma. Rhinitis and asthma usually occur together. There is increasing evidence that allergic rhinitis and rhinosinusitis may influence the clinical course of asthma. This review discusses the role of rhinosinusitis in severe asthma.

Impact of intranasal corticosteroids on asthma outcomes in allergic rhinitis: a meta-analysis

Given the relationship between allergic rhinitis (AR) and asthma, it can be hypothesized that reducing inflammation in the upper airway with intranasal corticosteroid (INCS) medications may improve asthma outcomes. The goal of this study was to perform a systematic review with meta-analysis of the efficacy of INCS medications on asthma outcomes in patients with AR and asthma. Asthma-specific outcomes from randomized, controlled studies evaluating INCS medications in patients with AR were evaluated, including studies that compared INCS sprays to placebo, INCS sprays plus orally inhaled corticosteroids to orally inhaled corticosteroids alone, and nasally inhaled corticosteroids to placebo. Sufficient data for meta-analysis were retrieved for 18 trials with a total of 2162 patients. Asthma outcomes included pulmonary function, bronchial reactivity, asthma symptom scores, asthma-specific quality of life, and rescue medication use. The subgroup of studies comparing INCS spray to placebo had significant improvements in FEV1 (SMD = 0.31; 95% CI, 0.04-0.58), bronchial challenge (SMD = 0.46; 95% CI, 0.12-0.79), asthma symptom scores (SMD = -0.42; 95% CI, -0.53 to -0.30), and rescue medication use (SMD = -0.29; 95% CI, -0.58 to -0.01). Nasal inhalation of corticosteroids significantly improved morning and evening peak expiratory flow. There were no significant changes in asthma outcomes with the addition of INCS spray to orally inhaled corticosteroids. Thus, the results of this meta-analysis demonstrated that intranasal corticosteroid medications significantly improve some asthma-specific outcome measures in patients suffering from both AR and asthma. This effect was most pronounced with INCS sprays when patients were not on orally inhaled corticosteroids, or when corticosteroid medications were inhaled through the nose into the lungs. Overall, intranasal corticosteroid medications improve some asthma-specific outcome measures in patients with both AR and asthma. Further research is needed to clarify the role of INCS sprays as asthma-specific therapy, as well as the role of the nasal inhalation technique as a monotherapy in patients suffering from both asthma and AR.

Current and future directions in pediatric allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a common pediatric problem that significantly affects sleep, learning, performance, and quality of life. In addition, it is associated with significant comorbidities and complications.

OBJECTIVE

The aim was to provide an update on the epidemiology, comorbidities, pathophysiology, current treatment, and future direction of pediatric AR.

METHODS

Literature reviews in each of these areas were conducted, and the results were incorporated.

RESULTS

The prevalence of AR is increasing in the pediatric population and is associated with significant morbidity, comorbidities, and complications. The mainstay of current treatment strategies includes allergen avoidance, pharmacotherapy, and allergen specific immunotherapy.

CONCLUSIONS

In the future, diagnosis will be improved by microarrayed recombinant allergen testing and therapy will be expanded to include emerging treatments such as sublingual immunotherapy and combination products.

Histopathologic and morphometric evaluation of the nasal and pulmonary airways of cats with experimentally induced asthma

BACKGROUND

Allergic rhinitis frequently occurs as a comorbid condition in asthmatic people, suggesting that the upper and lower airways may be immunologically linked. Our research group has developed an experimental aeroallergen model of asthma in cats. We hypothesized that aeroallergen sensitization and challenge would induce morphologic changes in the nasal airways of cats that mimic those observed in the bronchial airways.

METHODS

Five mixed breed cats were sensitized to Bermuda grass allergen and then serially challenged with aerosolized Bermuda grass allergen to induce an asthmatic phenotype. Four control cats were similarly treated with saline vehicle. Nasal tissues and lungs were processed for histopathological and morphometric analyses.

RESULTS

Eosinophilic inflammation, epithelial hypertrophy and mucous cell metaplasia were observed along the pulmonary axial airway mucosa of allergen-sensitized (asthmatic) cats. Mild eosinophilic inflammation was observed in the nasal airways of asthmatic cats. This alteration was confined primarily to the anterior nasal cavity, resulting in an increase in tissue eosinophils at this site compared to controls (p < 0.05). A marked increase in tissue mast cells was observed throughout all regions of the nasal airways of asthmatic cats compared to control cats (p < 0.05). There was no difference in intraepithelial mucosubstances between the nasal airways of controls and asthmatic cats. There was no correlation between upper and lower airway eosinophils or mast cells.

CONCLUSION

Cats with experimentally induced asthma exhibit morphologic changes in the nasal airways that are distinct from the alterations observed in the lungs. These results are similar to those observed in people with comorbid asthma and allergic rhinitis.

Off-label use of omalizumab in non-asthma conditions: new opportunities

Allergic diseases are mediated by IgE and, hence, neutralizing IgE to attenuate type I hypersensitivity reactions may result in clinical benefits. This has been mainly established in several large pre- and postmarketing studies of the humanized monoclonal anti-IgE antibody, omalizumab, in patients with allergic asthma. In this patient population, omalizumab has been shown to have beneficial effects in subjective and objective outcome measures, as well as resulting in reductions in medication use. Omalizumab is now globally licensed for use in severe persistent asthma. However, a growing number of reports suggest that anti-IgE treatment may also be beneficial to patients suffering from other IgE-related conditions, including allergic rhinitis, peanut allergy, latex sensitivity, atopic dermatitis, chronic urticaria and allergic bronchopulmonary aspergillosis. For these patients, and specifically for those with severe refractory disease, anti-IgE treatments might have the potential of reducing their financial burden both in terms of medical costs and of loss of productivity in missed work and school days. In this reveiw, we evaluate the evidence in support of a more extensive role for omalizumab in a number of non-asthma IgE-related conditions, and particularly where intensive treatment has not been effective. However, studies with larger numbers of well-characterized patients will be necessary to provide sound evidence regarding the benefit of IgE blockade in these challenging conditions.