Prevalence and rate of diagnosis of allergic rhinitis in Europe

Satisfaction, Qol and adherence of patients allergic to dust mites and/or pollens undergoing sublingual immunotherapy

Aim: Sublingual immunotherapy (SLIT) changes history of allergic respiratory disease (ARD). However, adherence is a barrier for optimal outcomes. Patients & methods: In the QUALI study, 859 patients with house-dust mite (HDM) and/or pollen induced ARD uncontrolled with symptomatic treatment and undergoing SLIT for at least 6 months or including one pre-coseason (pollen) were collected. Results & conclusion: SLIT significantly improved allergic rhinoconjunctivitis (ARC) and asthma symptom control, leading to reduced medication, meaningful health-related quality of life gain, improved nasal, ocular and bronchial symptoms and everyday life activities. Patients were highly satisfied and most of them adhered to SLIT, being forgetfulness the main non-adherence motive. SLIT is a quick effective treatment against persistent moderate-to-severe symptoms in ARC and asthma but it should been improve forgetfulness, as non-adherence reason.

Greenness and its composition and configuration in association with allergic rhinitis in preschool children

BACKGROUND

Few studies focus on the associations of green space composition and configuration with children's allergic rhinitis (AR).

METHODS

A multi-center population-based cross-sectional study was performed in 7 cities in mainland of China between 2019 and 2020, recruiting 36,867 preschool children. Information on the current AR symptoms and demographics were collected by questionnaire. Exposure to residential greenness was estimated by Normalized Difference Vegetation Index (NDVI, 1000 m buffer) around the residences. Greenness composition was estimated in 3 main categories: forest, grassland, shrubland. Configuration of each category and total greenness (a spatial resolution of 10 m × 10 m) was estimated by 6 landscape pattern metrics to quantify their area, shape complexity, aggregation, connectivity, and patch density. Exposure to daily ambient particulate matter (PM1, PM2.5 and PM10, a spatial resolution of 1 km × 1 km) was estimated. Multilevel logistic regression models were applied to analyze the associations of greenness and its composition and configuration with AR, and mediation effects by PMs were examined by mediation analysis models.

RESULTS

The prevalence of self-reported current AR in preschool children was 33.1%. Two indicators of forest, Aggregation Index of forest patches (AIforest) (odds ratio (OR):0.92, 95% Confidential Interval (CI): 0.88-0.97), and Patch Cohesion of forest (COHESIONforest) (OR: 0.93, 95% CI:0.89-0.98) showed significantly negative associations with AR symptoms. Mediation analyses found the associations were partially mediated by PMs. Age, exclusive breastfeed duration and season were the potential effect modifiers. The associations varied across seven cities.

CONCLUSION

Our findings suggest the inverse associations of the aggregation and connectivity of forest patches surrounding residence addresses with AR symptoms. Since the cross-sectional study only provides associations rather than causation, further studies are needed to confirm our results as well as the underlying mechanisms.

Genetically predicted N-methylhydroxyproline levels mediate the association between naive CD8+ T cells and allergic rhinitis: a mediation Mendelian randomization study

Background

Allergic rhinitis (AR), a prevalent chronic inflammatory condition triggered by immunoglobulin E (IgE), involves pivotal roles of immune and metabolic factors in its onset and progression. However, the intricacies and uncertainties in clinical research render current investigations into their interplay somewhat inadequate.

Objective

To elucidate the causal relationships between immune cells, metabolites, and AR, we conducted a mediation Mendelian randomization (MR) analysis.

Methods

Leveraging comprehensive publicly accessible summary-level data from genome-wide association studies (GWAS), this study employed the two-sample MR research method to investigate causal relationships among 731 immune cell phenotypes, 1400 metabolite levels, and AR. Additionally, employing the mediation MR approach, the study analyzed potential mediated effect of metabolites in the relationships between immune cells and AR. Various sensitivity analysis methods were systematically employed to ensure the robustness of the results.

Results

Following false discovery rate (FDR) correction, we identified three immune cell phenotypes as protective factors for AR: Naive CD8br %CD8br (odds ratio (OR): 0.978, 95% CI = 0.966-0.990, P = 4.5×10-4), CD3 on CD39+ activated Treg (OR: 0.947, 95% CI = 0.923-0.972, P = 3×10-5), HVEM on CD45RA- CD4+ (OR: 0.967, 95% CI = 0.948-0.986, P = 4×10-5). Additionally, three metabolite levels were identified as risk factors for AR: N-methylhydroxyproline levels (OR: 1.219, 95% CI = 1.104-1.346, P = 9×10-5), N-acetylneuraminate levels (OR: 1.133, 95% CI = 1.061-1.211, P = 1.7×10-4), 1-stearoyl-2-arachidonoyl-gpc (18:0/20:4) levels (OR: 1.058, 95% CI = 1.029-1.087, P = 5×10-5). Mediation MR analysis indicated a causal relationship between Naive CD8br %CD8br and N-methylhydroxyproline levels, acting as a protective factor (OR: 0.971, 95% CI = 0.950-0.992, P = 8.31×10-3). The mediated effect was -0.00574, accounting for 26.1% of the total effect, with a direct effect of -0.01626. Naive CD8+ T cells exert a protective effect on AR by reducing N-methylhydroxyproline levels.

Conclusion

Our study, delving into genetic information, has substantiated the intricate connection between immune cell phenotypes and metabolite levels with AR. This reveals a potential pathway to prevent the onset of AR, providing guiding directions for future clinical investigations.

Efficacy of 300 IR house dust mite immunotherapy as a function of disease activity: Tertile analysis in clinical trials

BACKGROUND

The symptoms of house dust mite (HDM)-induced allergic rhinitis (AR) vary with changes in exposure related to the weather or the domestic environment. In allergen immunotherapy (AIT) studies, a certain level of AR disease activity is necessary to demonstrate treatment efficacy; the latter can be underestimated if a substantial proportion of the patient population is weakly symptomatic.

OBJECTIVE

To better estimate the real treatment effect of a HDM sublingual AIT (SLIT) tablet, we analysed the results of natural field studies in detail by applying a tertile approach.

METHODS

We used data from three randomised, controlled trials (RCT) in a total of 2585 patients with AR treated with the 300 index of reactivity (IR) HDM SLIT-tablet or placebo. The study centres were grouped into tertiles according to the level of combined symptom and medication scores in patients in the placebo group. In each tertile, the difference between SLIT and placebo was assessed through an analysis of covariance.

RESULTS

In the three RCTs, combined scores were found to be similar in the SLIT and placebo groups in the low tertiles. The treatment effect of the 300 IR HDM tablet increased in the medium and high tertiles, with notably significant differences versus placebo in the highest tertile and greater (ranging from -21% to -39%) than in the entire study population (-13% to -20%). The positive relationship between treatment efficacy and the combined score in each tertile was independent of the RCT and the score used.

CONCLUSION AND CLINICAL RELEVANCE

Application of the tertile approach to AIT studies in a field in which many variables interact strongly might provide more accurate and meaningful measurements of efficacy and benefit for patients, better reflecting their real-life condition.

Research progress of traditional Chinese medicine in the treatment of allergic rhinitis

Allergic rhinitis, one of the common diseases in otolaryngology, has shown an increasing incidence under the influence of various geographical, cultural and economic factors, making it a common and serious global public health problem. Modern medicine uses medication as the primary therapy for allergic rhinitis, but poor symptom control and easy relapse are the disadvantages of this treatment. However, Traditional Chinese medicine, with its long history, has treated allergic rhinitis by symptomatic treatment according to pattern differentiation with its unique insights and methods, which are effective and safe in numerous clinical studies. Therefore, this paper describes TCM decoction, acupuncture, moxibustion, acupoint application, catgut-embedding therapy and ear acupuncture in the treatment of AR. This study aims to provide more personalized and precise treatment for allergic rhinitis patients by investigating the mechanism of action, clinical research and development of traditional Chinese medicine treatments.

Incidence of grass and weed sensitization in Bangkok, Thailand: a clinical study

Background

Allergic rhinitis (AR) is a prevalent public health concern globally, significantly impacting quality of life. In Thailand, the prevalence of AR is rising, with grass and weed pollen identified as primary outdoor triggers.

Objectives

This study aimed to (1) assess patterns of pollen sensitization in Thai AR patients and (2) investigate correlations between demographics/clinical data and SPT results.

Methods

A total of 121 individuals aged ≥18 years with clinically diagnosed AR were recruited. Skin prick testing (SPT) was performed using a panel of commonly encountered tropical grass and weed pollen extracts. SPT wheal sizes and clinical symptom scores were recorded. Correlations between SPT outcomes and symptom scores were analyzed.

Results

Among the participants, 104 (85.95%) exhibited positive SPT reactions to at least one pollen type. Nutsedge (76/121), para grass (57/121), and Bermuda grass (48/121) were the most frequently identified allergens. Hurricane grass elicited the strongest reaction, evidenced by the highest average wheal size (6.2 mm). Poly-sensitization was observed in 77 (63.6%) of the SPT-positive individuals, with most cases involving two different pollen extracts (35/77). Notably, AR severity positively correlated with both average wheal size and the number of positive SPT tests.

Conclusion

This study highlights nutsedge, para grass, and Bermuda grass as major allergenic pollen sources for Thai AR patients. Including nutsedge, hurricane grass, and careless weed in clinical SPT panels is recommended for improved diagnostic accuracy. Additionally, the positive correlation between AR severity and pollen reaction strength emphasizes the importance of implementing patient education and avoidance strategies.

Farit NA. The Efficacy of Elonide Nasal Corticosteroids in Managing Allergic Rhinitis: A Randomized, Double-Blinded Trial

Background: Mometasone furoate nasal spray is efficacious in relieving allergic rhinitis symptoms. The objectives of this study were, firstly, to compare the efficacy of Elonide to Nasonex® and a placebo and secondly, to investigate the side effects of Elonide. Method: This was a prospective, single-centered, double blinded, randomized, placebo-controlled, non-inferiority trial. A total of 163 participants from the Otorhinolaryngology Clinic, Hospital Canselor Tuanku Muhriz (HCTM), were randomized into three treatment groups receiving Elonide (n = 56), Nasonex® (n = 54), and placebo (n = 53) nasal sprays using an online randomizer (Random.org). Treatment was administered for 4 weeks. The primary outcome measure was the Total Nasal Resistance (TNR), and the secondary outcomes were the Visual Analogue Score (VAS) and the Rhinoconjunctivitis Quality of Life Questionnaire (RQOLQ) score. Side effects were recorded. Results: There were significant improvements for all groups from baseline. The Elonide group had the greatest mean difference for all primary and secondary outcomes compared to Nasonex® and the placebo (0.77 ± 2.44 vs. 0.35 ± 1.16, p = 1.00 vs. 0.17 ± 0.82, p = 0.01). Elonide is non-inferior to Nasonex (p = 1.00) and superior to the placebo (p < 0.05). The highest side effects reported were for Nasonex (n = 14, 26%), followed by the placebo (n = 8, 16%) and Elonide (n = 6, 12%); headaches (n = 9, 17%) and sore throat (n = 9, 17%) were the most common. Conclusions: Elonide has similar efficacy to Nasonex® when compared to a placebo in the treatment of AR in adults. Elonide is safe and tolerable, with fewer side effects and no adverse side effects.

Anti-allergic effect of Cyclopia (honeybush) extracts via anti-degranulation activity in a murine allergy model for inhaled antigen

The anti-allergic effects of extracts prepared from two species of honeybush, Cyclopia genistoides and Cyclopia subternata, were demonstrated in vivo in a murine allergy model for inhaled antigen induced with ovalbumin (OVA) inhalation to mimic pollen allergy. Intake of the extracts increased the production of OVA-specific immunoglobulin (Ig) E (IgE), IgG1, and IgG2a antibodies in serum and significantly suppressed anaphylactic reaction-induced body temperature decline. Moreover, the extracts significantly inhibited antigen-antibody-induced degranulation in RBL-2H3 cells. They also inhibited body temperature decline when the allergic mice were given them after antigen sensitization, indicating that anti-degranulation activity is the major mechanism underlying the anti-allergic effect of Cyclopia extracts. Despite their qualitative and quantitative differences in phenolic composition, the two extracts exhibited similar effects, suggesting that several active compounds might be involved in the activity. Therefore, oral administration of either Cyclopia extract potentially exerts a systemic anti-allergic effect, supporting the increased consumption of honeybush tea for general wellness and improved quality of life.

House dust mite sublingual allergen immunotherapy tablet is safe and well-tolerated in Dutch clinical practice

Background

Half (49%) of clinically diagnosed allergic rhinitis (AR) patients are sensitized to house dust mite (HDM). If allergen avoidance and symptomatic medication fail, allergen immunotherapy may be indicated.

Objective

We investigated safety and tolerability of HDM-sublingual immunotherapy by HDM-SLIT tablets in Dutch daily clinical practice.

Methods

Daily intake of 12 SQ-HDM SLIT-tablet was investigated in a prospective, multicenter, observational study (EUPAS43753). It comprised 4 consultations in 1 year. Data on safety, tolerability, treatment satisfaction, symptomatic medication, compliance, and clinical effectiveness (Control of Allergic Rhinitis and Asthma Test; CARAT) were collected. Descriptive and longitudinal regression data analysis were performed.

Results

Adult patients (n = 415), mean (SD) age 36.6 (12.2) years, 61.4% female and 36% asthmatic were included. The preponderance (65.1%) experienced adverse events (AEs). These, mostly mild (67%), AEs comprised: oral allergic reactions (58.6%), respiratory (12.4%) and gastrointestinal symptoms (9.4%). Sixty (14.5%) patients stopped due to AEs and 76 (18.3%) for non-AE reasons. CARAT scores improved clinically significant by 6 points and symptomatic medication use decreased from 96.1% to 77.4%. Most patients (74.5%) tolerated the treatment and were compliant (>86.5%). The majority of patients (62.4%) and investigators (69.4%) were satisfied with treatment.

Conclusions

HDM SLIT-tablet is a safe and well-tolerated AR treatment. AEs occur often but are mostly mild and decreasing during the first year. CARAT scores improved and symptomatic medication use decreased suggesting better control of AR with treatment. Compliance, tolerability, and treatment satisfaction are good. However, patient follow-up and compliance remain important points of attention when initiating treatment.

Comorbidity Between Inflammatory Bowel Disease and Asthma and Allergic Diseases: A Genetically Informed Study

BACKGROUND

Little is known about shared origins between inflammatory bowel disease (IBD) and allergic diseases (asthma, allergic rhinitis, and eczema). We aimed to expand current knowledge on the etiological sources of comorbidities between these disorders using a range of genetically informed methods.

METHODS

Within-individual and familial co-aggregation analysis was applied to 2 873 445 individuals born in Sweden from 1987 to 2014 and their first- and second-degree relatives. Quantitative genetic modeling was applied to 38 723 twin pairs to decompose the genetic and environmental sources for comorbidity. Polygenic risk score analysis between IBD and allergic diseases was conducted in 48 186 genotyped twins, and linkage disequilibrium score regression was applied using publicly available data to explore the genetic overlap.

RESULTS

IBD was associated with asthma (adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 1.30 to 1.40), allergic rhinitis (aOR, 1.27; 95% CI, 1.20 to 1.34), and eczema (aOR, 1.47; 95% CI, 1.38 to 1.56), with similar estimates for ulcerative colitis or Crohn's disease. The ORs for familial co-aggregation decreased with decreasing genetic relatedness. Quantitative genetic modeling revealed little evidence of common genetic factors between IBD and allergic diseases (eg, IBD and allergic rhinitis; genetic correlation ra = 0.06; 95% CI, -0.03 to 0.15) but did reveal some evidence of unique environmental factors between IBD and eczema (re = 0.16; 95% CI, 0.00 to 0.32). Molecular genetic analyses were similarly null for IBD and allergic diseases, except for a slight association between Crohn's disease polygenic risk score and eczema (OR, 1.09; 95% CI, 1.06 to 1.12).

CONCLUSIONS

We found little evidence to support a shared origin between IBD and any allergic disease but weak evidence for shared genetic and unique environmental components for IBD and eczema.

[Pitfalls in the diagnosis of house dust mite allergy]

House dust mite (HDM) is the most significant indoor allergen, responsible for not only many cases of rhinoconjunctivitis but also for many cases of bronchial asthma, rendering it of considerable socioeconomic relevance. Besides symptomatic treatment and avoidance measures, allergen immunotherapy (AIT) is crucial, as the only causal, disease-modifying therapeutic approach. However, high diagnostic certainty is essential for initiating AIT. The challenge in making a correct diagnosis lies in interpreting the demonstrated HDM sensitization regarding its clinical relevance (clinically silent sensitization vs. allergy). While the risk of allergy increases with the level of IgE titers against HDM extract, Der p 1, or Der p 2, as well as with the breadth of the molecular sensitization profile against HDM components (Der p 1, Der p 2, Der p 23), no threshold can be defined for the presence of allergy, nor can sensitization to a specific component be confidently considered allergy inducing. It should be noted that at least in Southern Bavaria, the prevalence of Der p 23 sensitization is too low to be considered a major allergen, and Der p 23 is not able to molecularly differentiate all HDM sensitizations when added to the two major allergens Der p 1 and Der p 2. Evidently, HDM possesses a diverse profile of allergens, with some relevant ones possibly yet to be described. Unfortunately, patient history does not provide a sufficient assessment of the clinical relevance of a demonstrated HDM sensitization, necessitating allergen provocation testing before initiating AIT with HDM, despite the relatively large effort involved.

Carrageenan-Containing Nasal Spray Alleviates Allergic Symptoms in Participants with Grass Pollen Allergy: A Randomized, Controlled, Crossover Clinical Trial

Purpose

Nonpharmacological, barrier-forming nasal sprays are used to manage symptoms of allergic rhinitis. We aim to evaluate the safety and effectiveness of Callergin (investigational product, IP), a nasal spray containing barrier-forming iota-carrageenan, in the treatment of allergic rhinitis (AR).

Methods

In this randomized, controlled, crossover trial, adults with grass pollen allergy underwent a treatment sequence with IP, VisAlpin (comparator product, CP), and no treatment in random order. Treatment blocks consisted in prophylactic administration of the assigned treatment or no treatment, followed by a 3-hr allergen exposure, and were separated by a washout period of 7 days. Primary endpoint was a mean change from baseline in "Total Nasal Symptom Score" (TNSS, sum of rhinorrhea, itching, sneezing, and congestion scores) over 3 hr, recorded every 15 min during the challenge period.

Results

A total of 42 participants underwent randomization. Exposure to grass pollen for 3 hr induced a notable TNSS increase from baseline in all participants at all times. Mean TNSS change from baseline over 3 hr was lower when participants received IP compared to no treatment, although the difference did not reach statistical significance (untreated 6.96 ± 2.30; IP 6.59 ± 1.93; difference 0.37 points [95% CI (confidence interval) -0.17 to 0.91]; p=0.170). In a post-hoc analysis, mean TNSS at 3 hr was significantly reduced after IP treatment compared to no treatment (untreated 8.29 ± 2.64; IP 7.70 ± 2.56; difference 0.60 points [95% CI -0.10 to 1.29] p=0.028). While all individual nasal symptoms contributed to this effect, rhinorrhea (p=0.013) and congestion (p=0.076) contributed most. Consistently, nasal secretion weight was slightly reduced with IP treatment (p=0.119). IP was safe and well-tolerated, with similar incidence of adverse events across treatment groups.

Conclusion

Prophylactic treatment with the iota-carrageenan nasal spray IP is safe, well-tolerated, and alleviates nasal allergy symptoms in adults with grass pollen-induced AR.

Trial Registration

NCT04531358.

Integration of network pharmacology and proteomics to elucidate the mechanism and targets of traditional Chinese medicine Biyuan Tongqiao granule against allergic rhinitis in an ovalbumin-induced mice model

ETHNOPHARMACOLOGICAL RELEVANCE

Biyuan Tongqiao granule (BYTQ) is a traditional Chinese medicine that has been used in China to clinically treat patients with allergic rhinitis (AR), yet its underlying mechanism and targets remains unclear.

AIM OF THE STUDY

The study aimed to investigate the potential mechanism of BYTQ against AR using the ovalbumin (OVA) -induced AR mice model. Integrating network pharmacology and proteomics to investigate possible targets of BYTQ for AR.

MATERIALS AND METHODS

The compounds in BYTQ were analyzed using UHPLC-ESI-QE-Orbitrap-MS. The OVA/Al(OH)3 were used to induce the AR mice model. The nasal symptoms, histopathology, immune subsets, inflammatory factors, and differentially expressed proteins were examined. Proteomics analysis elucidated the potential mechanisms of BYTQ to improve AR, which was further validated by Western blot (WB) assay. The compounds and potential targets of BYTQ were systematically elucidated by integrating network pharmacology and proteomics analysis to explore the mechanism. The binding affinity between key potential targets and corresponding compounds was then validated using molecular docking. Molecular docking results were verified by a western blotting and cellular thermal shift assay (CETSA).

RESULTS

A total of 58 compounds were identified from BYTQ. BYTQ significantly suppressed AR symptoms by inhibiting the release of OVA-specific immunoglobulin E (IgE) and histamine, improving the pathological injury of nasal mucosal tissue, and regulating the proportions of lymphocytes to maintain immune balance. Proteomics analysis showed that the cell adhesion factors and focal adhesion pathway might be potential mechanism of BYTQ against AR. The levels of E-selectin, vascular endothelial cell adhesion molecule-1 (VCAM-1), and intercellular adhesion molecule-1 (ICAM-1) proteins in the nasal mucosal tissue were significantly downregulated in the BYTQ-H group compared to the AR group. Integrating network pharmacology and proteomics analysis identified that SRC, PIK3R1, HSP90AA1, GRB2, AKT1, MAPK3, MAPK1, TP53, PIK3CA, and STAT3 may be potential protein targets for BYTQ to treat AR. Molecular docking analysis indicated that the active compounds of BYTQ could bind tightly to these key targets. In addition, BYTQ could inhibit OVA-induced phosphorylation levels of PI3K, AKT1, STAT3 and ERK1/2. The CETSA data suggested that BYTQ could improve the heat stability of PI3K, AKT1, STAT3 and ERK1/2.

CONCLUSIONS

BYTQ suppresses E-selectin and VCAM-1 and ICAM1 expression by regulating PI3K/AKT and STAT3/MAPK signaling pathways, thus alleviating inflammation in AR mice. BYTQ is the aggressive treatment for AR.

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.

Prevention Is Better than Cure: Impact of Allergen Immunotherapy on the Progression of Airway Disease

Allergen immunotherapy is highly effective for seasonal pollinosis. Three years of treatment results in long-term efficacy. This disease modification is accompanied by downregulation of allergen-specific Th2 responses and the induction of persistent specific IgG- and IgA-associated IgE-blocking activity. In children with seasonal rhinitis, both subcutaneous and sublingual pollen immunotherapy have been shown to reduce the development of asthma symptoms and asthma medication requirements. House dust mite tablet allergen immunotherapy has been shown to be effective for perennial mite-driven rhinitis in adults and children and may suppress asthma exacerbations, whereas its long-term efficacy has yet to be explored. The success of primary prevention of peanut allergy in childhood by introduction of peanut into the diet during infancy provides a strong rationale to explore whether primary prevention of inhalant allergies and asthma may also be possible. House dust mite allergy is a major risk factor for developing asthma. Preliminary data in at-risk children suggest that sublingual house dust mite immunotherapy initiated during infancy could reduce the onset of multiple allergen sensitizations and prevent the development of asthma at age 6 years. This possibility should now be explored in an adequately powered, prospectively randomized controlled trial.

Increase in the prevalence of follicular regulatory T cells correlates with clinical efficacy of sublingual immunotherapy with house dust mites

BACKGROUND

Allergic rhinitis (AR) impairs quality of life and affects nearly 40% of the Japanese population. Sublingual immunotherapy (SLIT) is the disease-modifying treatment for AR, but requires the selection of a biomarker associate with clinical efficacy in patients with AR who are treated with SLIT. The present study sought to examine objective biomarkers used for assessing the clinical efficacy of SLIT.

METHODS

The authors examined the effects of 1 year of SLIT treatment with house dust mites (HDMs) using peripheral blood mononuclear cells (PBMCs) and serum from patients with AR. The prevalences of follicular regulatory T (Tfr), type 2 follicular helper T (Tfh2), type 2 helper T (Th2), conventional regulatory T (Treg), and type 1 regulatory T (Tr1) cells were examined by flow cytometry. Serum concentrations of HDM-specific IgA, IgE, and IgG4 antibodies, and HDM-induced production of interleukin (IL) 5 and IL-10 from cultured PBMCs were evaluated by enzyme-linked immunosorbent assay.

RESULTS

Following 1 year of SLIT, the prevalences of Tfr, conventional Treg, and Tr1 cells were significantly increased, whereas that of Th2 cells and Tfh2 cells were significantly decreased; the serum concentration of HDM-specific IgG4 was significantly increased; and HDM-induced production of IL-5 from PBMCs was significantly decreased, while that of IL-10 was significantly increased. The increase in the prevalence of Tfr cells after SLIT correlated positively with the improvement of clinical symptom scores.

CONCLUSION

An increase in Tfr cells may play an important role in SLIT, and may be a useful indicator for the clinical efficacy of SLIT.

In Silico Design of a New Epitope-Based Vaccine against Grass Group 1 Allergens

Allergic diseases are a global public health problem that affects up to 30% of the population in industrialized societies. More than 40% of allergic patients suffer from grass pollen allergy. Grass pollen allergens of group 1 and group 5 are the major allergens, since they induce allergic reactions in patients at high rates. In this study, we used immunoinformatic approaches to design an effective epitope-based vaccine against the grass group 1 allergens. After the alignment of all known pollen T-cell and B-cell epitopes from pollen allergens available in the public databases, the epitope GTKSEVEDVIPEGWKADTSY was identified as the most suitable for further analyses. The target sequence was subjected to immunoinformatics analyses to predict antigenic T-cell and B-cell epitopes. Population coverage analysis was performed for CD8+ and CD4+ T-cell epitopes. The selected T-cell epitopes (VEDVIPEGW and TKSEVEDVIPEGWKA) covered 78.87% and 98.20% of the global population and 84.57% and 99.86% of the population of Europe. Selected CD8+, CD4+ T-cell and B-cell epitopes have been validated by molecular docking analysis. CD8+ and CD4+ T-cell epitopes showed a very strong binding affinity to major histocompatibility complex (MHC) class I (MHC I) molecules and MHC class II (MHC II) molecules with global energy scores of -72.1 kcal/mol and -89.59 kcal/mol, respectively. The human IgE-Fc (PDB ID 4J4P) showed a lower affinity with B-cell epitope (ΔG = -34.4 kcal/mol), while the Phl p 2-specific human IgE Fab (PDB ID 2VXQ) had the lowest binding with the B-cell epitope (ΔG = -29.9 kcal/mol). Our immunoinformatics results demonstrated that the peptide GTKSEVEDVIPEGWKADTSY could stimulate the immune system and we performed ex vivo tests showed that the investigated epitope activates T cells isolated from patients with grass pollen allergy, but it is not recognized by IgE antibodies specific for grass pollen allergens. This confirms the importance of such studies to establish universal epitopes to serve as a basis for developing an effective vaccine against a particular group of allergens. Further in vivo studies are needed to validate the effectiveness of such a vaccine against grass pollen allergens.

Standardization of clinical outcomes used in allergen immunotherapy in allergic asthma: An EAACI position paper

INTRODUCTION

In allergic asthma patients, one of the more common phenotypes might benefit from allergen immunotherapy (AIT) as add-on intervention to pharmacological treatment. AIT is a treatment with disease-modifying modalities, the evidence for efficacy is based on controlled clinical trials following standardized endpoint measures. However, so far there is a lack of a consensus for asthma endpoints in AIT trials. The aim of a task force (TF) of the European Academy of Allergy and Clinical Immunology (EAACI) is evaluating several outcome measures for AIT in allergic asthma.

METHODS

The following domains of outcome measures in asthmatic patients have been evaluated for this position paper (PP): (i) exacerbation rate, (ii) lung function, (iii) ICS withdrawal, (iv) symptoms and rescue medication use, (v) questionnaires (PROMS), (vi) bronchial/nasal provocation, (vii) allergen exposure chambers (AEC) and (viii) biomarkers.

RESULTS

Exacerbation rate can be used as a reliable objective primary outcome; however, there is limited evidence due to different definitions of exacerbation. The time after ICS withdrawal to first exacerbation is considered a primary outcome measure. Besides, the advantages and disadvantages and clinical implications of further domains of asthma endpoints in AIT trials are elaborated in this PP.

CONCLUSION

This EAACI-PP aims to highlight important aspects of current asthma measures by critically evaluating their applicability for controlled trials of AIT.

Modification of allergen subcutaneous immunotherapy safety precautions and systemic allergic reaction rate reduction

Background: Despite their life-threatening potential, medical team mistakes during subcutaneous immunotherapy are rarely discussed. Real data are missing, and a survey study estimated that dosing errors are responsible for 25% of systemic reactions during immunotherapy. To minimize errors, we modified our safety precautions and compared the rates of systemic allergic reactions before and after the change. Methods: Our retrospective comparative cohort study compared systemic allergic reaction rates during 2012-2015 and 2016-2019, after a second check of the injected allergen/s by another nurse/physician was added to the treatment protocol. Results: The rate of systemic allergic reaction per injection was reduced from 0.93 to 0.71%; p = 0.023. Conclusion: A second check prior to injection is beneficial and can reduce the allergic reaction rate during immunotherapy.

A high-dose, depigmented polymerized birch pollen extract for subcutaneous allergen immunotherapy has a favourable efficacy/safety ratio

BACKGROUND

Subcutaneous allergen immunotherapy (SCIT) with depigmented, polymerized (DPP) birch pollen extract has been marketed at doses of up to 1000 DPP units/mL since 2001. We sought to determine the dose-dependent efficacy of a DPP birch pollen extract formulation in patients suffering from birch-pollen-induced allergic rhinitis or rhinoconjunctivitis with or without intermittent asthma.

METHODS

A titrated conjunctival provocation test (CPT) was applied as a surrogate marker. This Phase II randomized, double-blind, parallel-group, dose-ranging clinical trial was performed at 39 centres in Germany, Lithuania and Poland. After randomization to four dose-level groups (100, 1000, 5000 and 10,000 DPP units/mL) and up-dosing, participants received maintenance SCIT with five monthly subcutaneous injections. The primary endpoint was the proportion of patients in whom a higher concentration of birch pollen (vs. baseline) was needed to elicit a positive CPT.

RESULTS

Three hundred forty-three patients were included (mean (range) age: 42.6 (19-70)). The highest CPT responder rates were seen in the higher dose-level groups. In the intention-to-treat analysis, the difference between the 100 and 10,000 groups was statistically significant (p = 0.0118). Although the proportion of patients with ≥1 treatment-emergent adverse events increased with the dose, almost all these events were mild (65.6%) or moderate (18.5%).

CONCLUSION

Judging by the results of a CPT, the efficacy/safety ratio in SCIT appears to be favourable for a high-dose-level preparation of a DPP birch pollen extract.

Allergic rhinitis: Review of the diagnosis and management: South African Allergic Rhinitis Working Group

BACKGROUND

 Allergic rhinitis (AR) has a significant impact on the community as a whole with regard to quality of life and its relationship to allergic multi-morbidities. Appropriate diagnosis, treatment and review of the efficacy of interventions can ameliorate these effects. Yet, the importance of AR is often overlooked, and appropriate therapy is neglected. The availability of effective medications and knowledge as to management are often lacking in both public and private health systems.

METHODS

 This review is based on a comprehensive literature search and detailed discussions by the South African Allergic Rhinitis Working Group (SAARWG).

RESULTS

 The working group provided up-to-date recommendations on the epidemiology, pathology, diagnosis and management of AR, appropriate to the South African setting.

CONCLUSION

 Allergic rhinitis causes significant, often unappreciated, morbidity. It is a complex disease related to an inflammatory response to environmental allergens. Therapy involves education, evaluation of allergen sensitisation, pharmacological treatment, allergen immunotherapy (AIT) and evaluation of the success of interventions. Regular use of saline; the important role of intranasal corticosteroids, including those combined with topical antihistamines and reduction in the use of systemic steroids are key. Practitioners should have a thorough knowledge of associated morbidities and the need for specialist referral.Contribution: This review summarises the latest developments in the diagnosis and management of AR such that it is a resource that allows easy access for family practitioners and specialists alike.

Prevelance of Common Aeroallergens in Allergic Rhinitis and its Correlation with Bronchial Asthma: A Study on 798 Patients by Skin Prick Test

Allergic rhinitis affects 30% of the Indian population (Dey et al. in Int Arch Allergy Immunol 178:60-65, 2019). Patients can be sensitive to single or multiple allergens. Polysensitization is more common (Bousquet et al. in Ann Epidemiol 20:797-803, 2010; Arbes et al. in J Allergy Clin Immunol 116:377-383, 2005). Sensitization to multiple allergens may have a role in the severity and the association of Asthma in such patients. A total of 798 patients with allergic rhinitis (SFAR ≥ 7) were included. Disease severity and associated symptoms were evaluated using questionnaire. Each patient underwent a Skin prick test with an allergen panel of 35 allergens each (Annesi-Maesano et al. in Allergy 57:107-114, 2002) and the results were evaluated to study the association of asthma and severity of Allergic rhinitis. Data consisting of 389 (48.7%) males and 409 (51.3%) females were assessed. A total of 82.2% of the study population of symptomatic patients were sensitized to at least one of the allergens. Seventy patients (8.78%) had associated asthma. Forty-four patients were polysensitized and fifteen were mono sensitized. Among polysensitized patients, 36 patients had sensitization to at least 6 different allergens. Dermatophagoides pteronyssinus was the most common allergen among asthma patients. This study provides a thorough knowledge of locally prevalent aeroallergens which is essential for the prompt diagnosis and treatment of allergic patients. Skin prick test can be a non-invasive vital tool in analyzing patterns of allergen exposure, the prevalence of allergen, sensitizing potential of different allergens in that specific geographic area.

Sleep Disturbance in Chronic Rhinitis: Evaluation of Nasal Symptoms, Sleep Disorder Questionnaires, and Sleep Architecture in Allergic and Non-allergic Rhinitis in Dr. Cipto Mangunkusumo Hospital

Chronic rhinitis is often associated with sleep disturbance and daytime sleepiness. Disturbance in sleep impairs numerous metabolic processes and brain function. However, there is a paucity of data regarding the evaluation of nasal symptoms and sleep disturbance in chronic rhinitis, either allergic or non-allergic group. To evaluate the characteristic of sleep disturbance in allergic and non-allergic rhinitis in Dr. Cipto Mangunkusumo Hospital Jakarta, a cross sectional analytic descriptive study was performed. All recruited subjects were evaluated for total nasal symptom scores (TNSS) and nasal obstruction symptoms evaluation scores (NOSE). Sleep disorder was assessed using Epworth Sleepiness Scale (ESS), Pittsburg Sleep Quality Index (PSQI) questionnaires, and polysomnography (PSG). A total of 22 chronic rhinitis patients, with 11 allergic and 11 non-allergic rhinitis were evaluated. Most subjects with allergic rhinitis experienced daytime sleepiness and poor quality of sleep as well as non-allergic rhinitis, without significant differences in TNSS, NOSE, ESS, and PSQI scores. There was impairment in sleep architecture from PSG parameters in both groups, but the difference was not significant. However, RDI-REM (17.7 ± 14.5 vs. 14.7 ± 18.5) and RERA (2.2 ± 2.1 vs. 1.6 ± 1.7) parameters have a tendency to be higher in the allergic rhinitis compared to non-allergic rhinitis group. Sleep disturbance existed in chronic rhinitis, presented by excessive daytime sleepiness and impairment in sleep architecture, yet no significant difference shown in the severity of TNSS, NOSE, ESS, PSQI scores, and sleep architecture parameters between the allergic and non-allergic rhinitis.

Impact of the Allergic Therapeutic Adherence in Children with Allergic Rhinitis and ADHD: A Pilot Study

BACKGROUND

Allergic rhinitis (AR) is the most common chronic allergic disease in children. Several studies have shown an association between attention deficit hyperactivity disorder (ADHD) and allergies, especially AR. Patients with ADHD usually have poor therapeutic adherence, and untreated AR symptoms may worsen the quality of life of patients.

METHODS

The aim of our study was to analyse therapeutic adherence in patients with ADHD and AR and estimate the impact of the adherence on ADHD symptoms. Total Nasal Symptoms Score (TNSS), Paediatric or Adolescent Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ 6-12 years; ARQLQ 13-17 years), Swanson, Nolan, and Pelham version IV scale (SNAP-IV), and Medication Assessment Questionnaire (MGL MAQ) were recorded.

RESULTS

In the AR-ADHD group, a positive correlation between TNSS and SNAP-IV subscales was found: worse AR symptoms were related to a negative effect on ADHD scores. AR-ADHD patients with better ADHD therapeutic adherence showed higher AR symptoms and higher oppositional defiant disorder scores in the SNAP-IV questionnaire.

CONCLUSIONS

Our results suggest that better adherence to AR therapy (oral antihistamines and/or intranasal corticosteroids, INCS) is associated with a reduction in inattention symptoms in children with ADHD. This data could prove to be fundamental for the psychic outcome of these patients.

The Trend of the Burden of Allergic Rhinitis Pre- and Post-COVID-19 Pandemic in the Urban Population of Perak, Malaysia

Aims

This study aims to determine the trend of allergic rhinitis (AR) prevalence in a tertiary hospital between 2017 and 2022, and to compare its prevalence pre- and post-COVID-19 pandemic.

Methods

This was a cross-sectional study involving the extraction of all Malaysian patients' medical records who were diagnosed with AR and attended the otorhinolaryngology outpatient clinic of a government-funded tertiary hospital in Malaysia between 2017 and 2022.

Results

3,744 cases out of the 57,968 first-encounter outpatient visits to the otorhinolaryngology clinic were extracted for analysis. Overall, the prevalence of AR cases ranged from 1.83 to 9.23% between 2017 and 2022. There was a significant drop of 21.38 to 70.22% between the pre- and post-COVID-19 pandemic (p < 0.001). Males (0.34 to 1.60%) were more prevalent in the 6 to 18 year old than females (0.09 to 1.23%). The trend shifted with age, whereby females (0.50 to 2.45%) experienced a higher prevalence than males (0.21 to 1.77%) as they aged from 19 to 59. The Malay (1.01 to 4.59%) demonstrated a two-time higher prevalence than the Chinese (0.30 to 2.01%) and Indian (0.40 to 2.14%) ethnicities. After stratifying by gender and ethnicity, Indian women (0.17 to 1.09%) had a higher rate of AR than their Chinese counterparts (0.12 to 0.99%) across all years.

Conclusion

The AR prevalence consistently ranged from 8.14 to 9.23% pre-pandemic. A remarkable drop was observed post-pandemic, ranging from 1.83 to 6.40%. A gender shift from male to female predominance as age progressed. The Malay had the highest prevalence of AR.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Epidemiology of adult patients with atopic dermatitis in AWARE 1: A second international survey

Background

There are gaps in our understanding of the epidemiology of atopic dermatitis (AD) in adults.

Objective

To evaluate the prevalence and severity of AD in adults from countries/regions within Asia, Eurasia, Latin America, Middle East, and Russia.

Methods

This international, web-based survey was performed in Argentina, Brazil, China, Colombia, Egypt, Hong Kong, Israel, Malaysia, Mexico, Russia, Kingdom of Saudi Arabia (KSA), Singapore, Taiwan, Thailand, Turkey, and United Arab Emirates. Questionnaires were sent to adult members of online respondent panels for determination of AD and assessment of severity. A diagnosis of AD required respondents to meet the modified United Kingdom (UK) Working Party criteria and to self-report they had a physician diagnosis of AD. Severity of AD was determined using Patient-Oriented Scoring of Atopic Dermatitis (PO-SCORAD), Patient-Oriented Eczema Measure (POEM), and Patient Global Assessment (PGA).

Results

Among respondents by country/region the prevalence of AD ranged from 3.4% in Israel to 33.7% in Thailand. The prevalence was generally higher in females versus males. Severity varied by scale, although regardless of scale the proportion of respondents with mild and moderate disease was higher than severe disease. PGA consistently resulted in the lowest proportion of severe AD (range 2.4% China - 10.8% Turkey) relative to PO-SCORAD (range 13.4% China - 41.6% KSA) and POEM (range 5.1% China - 16.6% Israel).

Conclusions

This survey highlights the importance of AD in adults, with high prevalence and high morbidity among respondents and emphasizes that AD is not just a disease of childhood-there is disease persistence and chronicity in adults.

Prevalence and risk factors of allergic rhinitis among Chinese adults: A nationwide representative cross-sectional study

Background

The prevalence of allergic rhinitis (AR) has been increasing steadily worldwide, especially in countries with increasing industrialization such as China. However, available evidence regarding AR prevalence among Chinese adults is scarce and limited to regional data collected in earlier years. We therefore aimed to provide a more recent and robust estimate of AR prevalence using a nationwide representative cross-sectional study in China.

Methods

Data of 184 326 participants aged 18 years or older were obtained from the China Chronic Disease and Risk Factor Surveillance conducted in 2018-2019. AR was determined by self-reported sneezing, nasal itching, obstruction, or rhinorrhea symptoms for at least 1 h in the absence of a cold or flu within the last 12 months. Multivariable logistic model was used to examine the risk factors of AR, and a possible non-linear relationship was further tested by restricted cubic spline. Potential additive interactions of risk factors with sex, residence, and geographic region were assessed by relative excess risk due to interaction (RERI).

Results

The weighted prevalence of AR was 8.1% (95% confidence interval [CI], 7.4%-8.7%), of whom 23.7% (95% CI, 21.3%-26.0%) were aware of their diagnosis. Increased odds of AR were associated with younger age, men, living in urban area or north region, more education, smoking, underweight, and higher income. Despite the nonsignificant linear trend, the spline regression demonstrated a non-linear association between AR and sleep duration, with higher odds at both ends. Additionally, the observed associations were generally stronger among men and people living in urban area and north region, with significant RERI ranging from 0.07 (95% CI, 0.00-0.14) to 0.40 (95% CI, 0.12-0.67).

Conclusions

AR is prevalent in China and the associated factors and interactions are helpful to design targeted preventive strategies towards certain subpopulations. The low awareness of AR calls for a national effort on AR screening.

Specific local nasal immunotherapy: Single center experience on 324 patients

OBJECTIVE

To evaluate the efficacy and safety of specific local nasal immunotherapy (LNIT) in patients with allergic rhinitis.

MATERIALS AND METHODS

A retrospective single-center study of 324 patients with allergic rhinitis (191 allergic to mites, 133 allergic to Grarninaceae or Parietaria pollen) treated with specific LNIT was carried out. As control group, 158 patients without allergic rhinitis were enrolled. All patients were evaluated before and after 32 weeks of treatment by subjective analysis of their self-reported symptoms and by objective analysis of nasal provocation test, nasal resistance by anterior rhinomanometry, and mucociliary clearance time.

RESULTS

Clinical efficacy of LNIT for allergy to mites and pollens was confirmed by the differences in the symptoms score between the active group and the placebo group. The nasal provocation test and the rhinomanometric analysis confirm the result with a difference statistically significant. No differnces in mucociliary clearance time were found.

CONCLUSIONS

Specific LNIT is a valide alternative to subcutaneous and sublingual administration. It is effective, safe, well tolerated by the patient, it can be done at home with fewer systemic reactions.

Increasing capacity in acute day care settings: patients' experiences of a pop-up day care unit

The COVID-19 pandemic had considerable impact on paediatric ambulatory care. A pop-up paediatric day care unit for children with allergic and inflammatory bowel diseases was delivered from Nightingale Hospital Bristol (NHB) which was set up to treat patients during the pandemic.

METHODOLOGY

The unit operated fortnightly between December 2020 and March 2021. Family feedback on the service was collated via an online survey.

RESULTS

72 respondents found NHB acceptable; 70 (97%) would be happy to return; 63 (90.3%) preferred the NHB to attending Bristol Royal Hospital for Children or had no preference for their appointments. Positive comments focused on service organisation and clinical environment. Families valued the availability of the close, free parking. The minimal negative comments related to travel directions, lack of catering facilities and the small number of toilets.

CONCLUSION

The pop-up service model was highly acceptable to families. This highlights the need for appropriate hospital services to explore similar initiatives beyond traditional healthcare settings in order to ensure that the provision of equitable health care is in line with the NHS Long Term Plan.

Quality of life in allergic rhinitis patients treated with intralymphatic immunotherapy (ILIT): A 19-year follow-up

Background

In 2002-2005, we conducted a phase I/II clinical trial where a new allergy immunotherapy (AIT) route was introduced: intralymphatic immunotherapy (ILIT). Ultrasound guidance allowed injection of allergen directly into inguinal lymph nodes. Grass pollen-allergic patients received 3 injections with 1-month intervals. The short ILIT was more patient-friendly, required lower dosing, and was comparable with SCIT regarding short-term efficacy, which was used as a reference.

Objective

Nineteen years after ILIT, the same patients were followed up to assess the long-term effect on quality of life and efficacy of the treatment.

Methods

Patients who received ILIT and SCIT in 2002-2005 and an additional group of patients, who completed SCIT in 2015-2018, were recruited. All participants received a trial-specific in-house questionnaire and a standardized Rhinoconjunctivitis Quality of Life Questionnaire. Data were recorded off- (February 2021) and on- (May-June 2021) season. Descriptive statistics were applied.

Results

Of 58 and 54 patients who originally received ILIT or SCIT, 25 (43%) and 29 (54%) patients, respectively, returned the questionnaires for analysis. Four (16%) and 3 (11%) of the ILIT and SCIT patients, respectively, developed complete protection against grass pollen-mediated rhinitis, whereas another 15 (60%) and 20 (69%) expressed satisfaction with the received AIT. In both groups, any persistent symptoms were reported as mild. Medication usage in the ILIT and SCIT groups was comparable. Nineteen (76%) and 23 (79%) patients, respectively, expressed satisfaction with their AIT.

Conclusions

Grass pollen ILIT leads to long-term significant improvement in rhinitis-associated quality of life 19 years after treatment, and the ILIT quality-of-life effect was not inferior to that of SCIT.

Lack of Harmonized Adherence Criteria in Allergen Immunotherapy Prevents Comparison of Dosing and Application Strategies: A Scoping Review

Allergen immunotherapy (AIT) involves the application of increasing doses of allergen extract (as oral, sublingual, or subcutaneous immunotherapy) until immunologic tolerance is reached. Successful AIT relies on the consistent administration of allergen extract; therefore, adherence to these treatments is vital for compelling long-term results. Our review discusses the current terminology from adherence research in general, summarizes 25 current studies on adherence research in AIT in a scoping literature review, and delineates recommendations for tools and parameters for adherence research, aiming to improve outcomes in AIT. Almost every adherence study in AIT published to date used different tools, parameters, and data sources for measuring adherence and persistence rates. Unfortunately, an easily accessible, objective parameter or biomarker for monitoring treatment adherence and success has not yet been established for AIT. This situation calls for the development of an international core outcomes set for AIT that defines what is exactly meant by AIT adherence and how AIT adherence should be consistently measured. Therefore, we exemplarily present results and conclusions from adherence research in chronic diseases other than allergology. We aim to facilitate the development of advanced methods, considering the challenging disease specificities of these parameters in a routine care setting of AIT.

How an Immune-Factor-Based Formulation of Micro-Immunotherapy Could Interfere with the Physiological Processes Involved in the Atopic March

Allergic diseases consist of improper inflammatory reactions to antigens and are currently an important healthcare concern, especially considering their increasing worldwide development in recent decades. The "atopic march" defines the paradigm of allergic diseases occurring in chronological order and displaying specific spatial manifestations, as they usually start as atopic dermatitis (AD) and food allergies during infancy and progressively evolve into allergic asthma (AA) and allergic rhinitis (AR) or rhino-conjunctivitis in childhood. Many immune cell subtypes and inflammatory factors are involved in these hypersensitivity reactions. In particular, the T helpers 2 (Th2) subset, through its cytokine signatures made of interleukins (ILs), such as IL-4, IL-5, IL-10, and IL-13, as well as mast cells and their related histamine pathways, contribute greatly to the perpetuation and evolution of the atopic march. By providing low doses (LD) and ultra-low doses (ULD) of ILs and immune factors to the body, micro-immunotherapy (MI) constitutes an interesting therapeutic strategy for the management of the atopic march and its symptoms. One of the aims of this review is to shed light on the current concept of the atopic march and the underlying immune reactions occurring during the IgE-mediated responses. Moreover, the different classes of traditional and innovative treatments employed in allergic diseases will also be discussed, with a special emphasis on the potential benefits of the MI medicine 2LALERG^® formulation in this context.

Cross-sectional study to describe allergic rhinitis flare-ups and associated airways phenotype in house dust mite sensitization

OBJECTIVES

To quantify and describe flare-ups of house dust mite allergic rhinitis (HDM-AR) which had occurred during the last 12 months in a population of adults and children candidate for Allergen ImmunoTherapy (AIT). Next, to identify associated clinical features.

MATERIALS AND METHODS

This was an observational, multicenter, cross-sectional study that included patients aged ≥ 5 years with HDM-AR eligible for AIT and without prior AIT for at least 12 months. Flare-ups were all period with impairment of quality of life (QoL) and requiring a change in their usual treatment. Data were collected using medical records and patient questionnaires. Variables associated with the occurrence of ≥ 2 AR flare-ups were identified.

RESULTS

1,701 patients were included (average age: 23 years, 51.5% males, 30.4% children, 17.7% adolescents and 51.9% adults). Severe and persistent AR affected 70.9% of them and 53.7% showed polysensitization. Asthma was associated with AR in 34.4% and was well-controlled in 58.5%. The occurrence of at least one AR flare-up in the year was reported by 77.7%, with an annual rate in the whole population of 2.6 ± 3.9 and a duration of 14.1 ± 17.1 days. Deeply or moderately AR-related degraded QoL was experienced by 39.5% and 64.6%, respectively. The occurrence of ≥ 2 AR flare-ups was reported by 54.5% and was associated with polysensitization, AR intermittence and severity.

CONCLUSION

AR flare-ups are frequent and impair QoL in HDM-allergic patients, suggesting that it could be considered as therapeutic targets.

Associative factors for atopic dermatitis and other atopic diseases in middle-aged adults: A population-based birth cohort study among 5373 subjects

Background and aims

The study aimed to examine parental, longitudinal and current associative factors for atopic dermatitis (AD) and to compare those to other atopic diseases in 46-year-old adults.

Methods

Questionnaire data from the Northern Finland Birth Cohort 1966 study were used. To analyze allergic sensitization, skin prick tests (n = 5373) were performed for birch, timothy, cat, and house dust mite at age 46.

Results

Maternal (odds ratio [OR] 1.81; 95% confidence interval [CI] 1.25-2.59) and paternal allergy (OR 2.54; CI 1.76-3.64), sensitization to any of the four tested aeroallergens (OR 1.56; CI 1.04-2.30) as well as polysensitization (OR 3.04; CI 2.10-4.37) were associated with current AD. Living on a farm in infancy was negatively associated with allergic rhinitis, allergic conjunctivitis, and atopic multimorbidity. Current AD (OR 2.65; CI 1.44-4.60) and all atopic diseases associated with indoor air related symptoms. Current AD associated with other atopic diseases, most strongly with allergic rhinitis (OR 4.92; CI 3.92-6.22).

Conclusion

Current AD in a 46-year-old general population occurred frequently with allergic rhinitis, allergic conjunctivitis, and asthma in the Northern Finland Birth Cohort study 1966. Parental allergy and sensitization to common aeroallergens were found as shared associative factors for AD, allergic rhinitis, allergic conjunctivitis, and asthma. AD and other atopic diseases associated with symptoms related to poor indoor air quality. In daily practice, it is important to take these comorbidities into consideration when treating patients with AD.

The Prevalence, Clinical Picture, and Triggers of Allergic Rhinitis in Saudi Population: A Systematic Review and Meta-Analysis

Objective

To summarize the current evidence regarding the prevalence of Allergic rhinitis (AR) and its symptoms, triggers, and impact on the quality of life of the Saudi population.

Methods

A Computerized Search in MEDLINE via PubMed, MEDLINE Core database, Scopus, and Web of Science was conducted using relevant keywords. A two-stage screening process, data extraction, and quality assessment were conducted by four independent reviewers. Comprehensive Meta-analysis was used for all statistical analyses (CMA; USA: version 3.3.070).

Results

Sixteen articles (n= 31,990 patients) were included. The overall estimated prevalence of AR was 21.2%, 95% CI (12.8-33.1%). Males had a higher prevalence of AR than females (31.7% vs 27.1%), although the difference was not significant (OR=1.24, 95% CI: 0.78-1.953; p=0.356). Children and adolescents exhibited a lower prevalence of AR than adults (13.7% vs 31.1%). Urban AR prevalence was much greater than rural (38.4% vs 13.0%). Asthma, atopic dermatitis, and eczema are all associated with AR. The most common signs and symptoms of AR were headache 33.9%, watery discharge 28.6%, sneezing 24.6%, itchy nose, runny nose 22.2%, nasal obstruction or congestion 22.0%, loss of smell 21.9%, and wheezing 17.2%. The most prevalent triggers of AR were perfume 36.8%, dust 27.3%, air conditioning 23.4%, weather or temperature changes 17.8%, air pollution 14.5%, drugs or chemicals 13.8%, tobacco 10.8%, atopy 10.3%, and insects 10.2%.

Conclusion

The overall prevalence of AR in Saudi Arabia is 21.2%. The prevalence of AR was comparable in both males and females. However, it was higher in adults than in children and adolescents, and in urban areas than rural areas. Asthma, atopic dermatitis, and eczema co-occurrence with AR are common. AR has a negative impact on the quality of life of the patients in the form of interference with daily activities, sleep problems, difficulty of breath, and school absenteeism.

Homeopathy for seasonal allergic rhinitis: rationale, design and methods of the three-armed randomized controlled HOMEOSAR trial

BACKGROUND

Patients with seasonal allergic rhinitis (SAR) frequently use homeopathic therapy. Although there is some evidence that homeopathy may be effective in treating symptoms of SAR, there is a lack of high-quality clinical trials. Therefore, the aim of the homeopathy for SAR (HOMEOSAR) trial is to determine the efficacy of individualized or standardized homeopathic drug treatment compared to placebo regarding rhinitis-related quality of life in patients with SAR.

METHODS

This randomized, placebo-controlled, double-blind, three-armed intervention study will be conducted at two university hospital outpatient clinics for complementary and integrative medicine in Berlin and in 12 office-based practices specializing in homeopathic treatment in Germany. A total of 270 patients with clinical symptoms of SAR and positive allergy test to birch and grass pollen will receive homeopathic anamnesis and subsequently be randomized into (a) standardized homeopathic drug treatment with Galphimia Glauca (potency D6), (b) individualized homeopathic drug treatment (D6), or (c) placebo. All three groups can receive on-demand rescue medication as needed. Treatment will consist of two consultations and daily intake of the study medication for 4 weeks during the pollen season. The primary outcome is the mean overall score of the Rhinitis Quality of Life Questionnaire (RQLQ) in weeks 3 and 4, analyzed using analysis of covariance (adjusted for baseline RQLQ overall score and study center). A closed testing procedure will be used to control the overall type I error comparing the 3 treatment groups. Secondary outcomes include the overall RQLQ and its seven domain scores, responder status (decrease in RQLQ overall score of at least 0.5 points compared to the baseline value), use of rescue medication, intensity of total and individual SAR symptoms based on visual analog scale, generic health-related quality of life, safety, utilization of health care resources and associated costs. In addition, a qualitative data analysis is planned.

CONCLUSION

The results of our study will contribute to clarifying the possible therapeutic effects of homeopathic drug treatment for patients with SAR.

TRIAL REGISTRATION

This study has been registered in the German Clinical Trial Registry with trial ID DRKS00018081 on June 09, 2020.

Channa striatus in inflammatory conditions: A systematic review

Channa striatus (CS), or snakehead murrel, is an obligate air-breathing freshwater fish. Besides its wound healing properties, CS has also been reported to exhibit anti-inflammatory effects in multiple studies. While there are anti-inflammatory medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), their long-term use is associated with an increased risk of peptic ulcers, acute renal failure, stroke, and myocardial infarction. Thus, it is essential to look at natural methods such as CS extract. While there is an abundant number of investigative studies on the inflammatory properties of CS, the quality of these studies has not been evaluated effectively. Thus, this review aims to summarise, evaluate, and critically appraise currently available literature regarding the anti-inflammatory properties of CS extract. This is done by performing a search using four databases, namely Google Scholar, Embase via Elsevier, Scopus, and Web of Science, with the following terms: Channa striatus AND inflammation. From our review, CS has been experimentally shown to positively affect inflammatory conditions such as gastric ulcers, dermatitis, osteoarthritis, and allergic rhinitis. Beneficial effects were also found on inflammation in the presence of tuberculosis and in situations that involve inflammation, such as wound healing. While CS clearly has potential for treating inflammatory conditions, much work needs to be done on identifying and isolating the active constituents before exact mechanisms of action can be worked out to develop future anti-inflammatory medications.

Observation on the efficacy of sublingual immunotherapy with dust mite allergen for perennial allergic rhinitis and the mechanism of action on ILCs with ILC1s and ILC2s and ILC3s

BACKGROUND

Allergic rhinitis (AR) is considered to be 1 of the most difficult diseases to treat globally. It has a serious impact on the quality of life and social economy of patients and has become an important global health problem. Several drugs have been recommended to treat AR, but their effectiveness and mechanism of action in these patients remain unclear. The purpose of this study will be to compare the efficacy and mechanism of action of 2 drugs for the treatment of AR (moderate to severe): a Dermatophagoides Farinae Drops Sublingual Immunotherapy and a Momethasone Furoate nasal spray as an adjunct to the treatment of subjects with AR.

METHODS

A randomized, prospective, double-blind (patient and evaluator) clinical trial. The participants (n = 60) will be randomly distributed into 2 groups. The experimental group will receive a sublingual Immunotherapy for 3 months. The control group will receive the mometasone furoate nasal spray for 3 months. Before treatment, 1 month and 3 months after treatment, total nasal symptom score scale, Visual analogue Scale and Quality of Life questionnaire of rhinoconjunctivitis will be measured and Changes of the serums of IgE, interferon-γ, IL-4, IL-17, tumor necrosis factor-α, IL-5, IL-9, IL-13, IL-25, IL-33, vascular endothelial growth factor, TSLP and IL-22 in both groups. The measurements will be performed by the same researcher who was unaware of the participants' subgroup.

DISCUSSION

We believe that the treatment of perennial AR with sublingual Immunotherapy and nasal hormones will be more effective in these patients. Furthermore, the sublingual Immunotherapy mainly acts mostly on the cellular immunity, while nasal hormones mainly act on local inflammatory responses. We expect to clarify which treatments are more effective and how they work in improving perennial AR.

A Clinical Study to Evaluate the Role of Vitamin D3 in Allergic Rhinitis

Allergic rhinitis is a common and chronic immunoglobulin E-mediated inflammation of nasal mucosa induced after allergen exposure. Allergic rhinitis is a global health problem that causes major illness and affects patient's social life, sleep, school and work performance. Various studies have implicated the association between low serum vitamin D levels and allergic diseases. Active form of Vitamin D3 has been shown to have immunoregulatory effect on both innate and adaptive immunity, which can significantly affect the outcome of allergic responses in allergic rhinitis. The study aims to evaluate effectiveness of Oral Vitamin D3 supplementation as an adjunct to standard therapy, in the management of allergic rhinitis. The present study is a prospective study in which 80 subjects were recruited and were randomly divided into two groups. The study group received oral vitamin D3 (60,000 IU) along with intranasal steroid spray while control group received only intranasal steroid spray for 4 weeks. The response in both the groups was compared by evaluating total nasal symptom score (TNSS). Subjects of allergic rhinitis showed deficiency in vitamin D indicated by mean serum vitamin D levels of 15 ± 2.42 ng/ml in the study group and 14.72 ± 2.64 ng/ml in the control group. The pre treatment mean TNSS score was 10.45 ± 3.1 in the study group and 11.43 ± 2.35 in the control group. The post treatment mean TNSS score was 2.1 ± 0.21 in the study group and 3.85 ± 0.76 in the control group. A significant reduction in symptoms score was observed after 4 weeks of oral vitamin D3 supplementation. The difference between two groups was found to be statistically significant (p value < 0.05).

The management of allergic rhinitis by pharmacists in public services: a proposed PhaRmacISt-led Education Model (AR-PRISE)

Allergic rhinitis has been identified as a major respiratory disease that places a significant burden on patients and the healthcare system. Nevertheless, the management of allergic rhinitis is challenging for both patients and practitioners. Pharmacists have been recognised as strategic in providing advice for allergic avoidance, disease information, and pharmacological care for allergic rhinitis management. This role has been underutilised in the public health service sector in Malaysia due to variation in practice, regulation, and health system structures when compared to the international guidelines. This article proposed a PhaRmacISt-led Education Model (AR-PRISE) that includes explicit patient education materials and an algorithm for structured counselling by pharmacists in the management of patients with allergic rhinitis.

Allergen immunotherapy: past, present and future

Allergen immunotherapy is a form of therapeutic vaccination for established IgE-mediated hypersensitivity to common allergen sources such as pollens, house dust mites and the venom of stinging insects. The classical protocol, introduced in 1911, involves repeated subcutaneous injection of increasing amounts of allergen extract, followed by maintenance injections over a period of 3 years, achieving a form of allergen-specific tolerance that provides clinical benefit for years after its discontinuation. More recently, administration through the sublingual route has emerged as an effective, safe alternative. Oral immunotherapy for peanut allergy induces effective ‘desensitization’ but not long-term tolerance. Research and clinical trials over the past few decades have elucidated the mechanisms underlying immunotherapy-induced tolerance, involving a reduction of allergen-specific T helper 2 (T_H2) cells, an induction of regulatory T and B cells, and production of IgG and IgA ‘blocking’ antibodies. To better harness these mechanisms, novel strategies are being explored to achieve safer, effective, more convenient regimens and more durable long-term tolerance; these include alternative routes for current immunotherapy approaches, novel adjuvants, use of recombinant allergens (including hypoallergenic variants) and combination of allergens with immune modifiers or monoclonal antibodies targeting the T_H2 cell pathway.

Durham and Shamji review the history and future of allergen immunotherapy for established IgE-mediated hypersensitivity to common allergens. They describe the mechanisms of immunotherapy-induced tolerance and the new strategies being explored to achieve safer, more effective, long-term tolerance.

Subcutaneous birch pollen allergen immunotherapy with a depigmented polymerized extract shows only sustained and long-term efficacy in a subgroup of monosensitized adults and adolescents with allergic rhinitis

Background

Allergen immunotherapy (AIT) is an approved treatment for seasonal respiratory allergic diseases. A depigmented polymerized birch pollen extract for subcutaneous allergen immunotherapy (SCIT) has been demonstrated to be efficacious and safe in patients allergic to birch pollen and its homologous group.

Objective

To determine whether SCIT with a birch pollen formulation (5000 depigmented polymerized (DPP) units/mL) shows sustained and long‐term efficacy in adults and adolescents with birch‐pollen induced allergic rhinitis with or without intermittent asthma.

Methods

A multicentre (n = 66), double‐blind, placebo‐controlled Phase III clinical trial was performed in the Czech Republic, Finland, Germany, Latvia, Lithuania, Poland and Russia. Participants were randomized 2:1 to active treatment (birch 5000 DPP/ml) or placebo for three years of SCIT and followed up for two treatment‐free years. The primary efficacy endpoint was the EAACI's combined symptom and medication score for rhinoconjunctivitis (CSMS_EAACI).

Results

A total of 973 participants were screened and 649 were randomized (active treatment: n = 434; placebo: n = 215). The intention‐to‐treat analysis of the CSMS_EAACI in the overall study population did not demonstrate statistically significant differences in years 1, 2 and 3. In a post‐hoc analysis, among the subgroup of patients monosensitized to birch pollen allergen only (n = 200), we observed a statistically significant difference (active treatment vs. placebo) in the CSMS_EAACI in year 2, 3 and 5. The AIT's safety profile was good.

Conclusions

SCIT with a depigmented polymerized birch pollen extract was safe. Sustained and long‐term efficacy in years 2, 3 and 5 in monosensitized patients, but not in polysensitized patients was demonstrated.

(EudraCT 2012‐000414‐11)

Correlation of the combined symptom and medication score with quality of life, symptom severity and symptom control in allergic rhinoconjunctivitis

Background

The European Academy of Allergy and Clinical Immunology recommended the Combined Symptom and Medication Score (CSMS) as primary endpoint in clinical trials on allergen‐specific immunotherapy (AIT) in allergic rhinoconjunctivitis. Here, the correlation between the CSMS and the validated standardised Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ(S)), Rhinitis Control Assessment Test (RCAT) and Visual Analogue Scale (VAS) was analysed.

Methods

Two prospective, multicentre, non‐interventional studies on tree pollen, grass pollen and house dust mite allergic patients were performed. The first study comprised 167 patients receiving AIT (AIT population), and the second included 56 patients treated with symptomatic medication only (control population). For up to two seasons (pollen)/exposure periods (house dust mites), participants documented their symptoms and medication intake in a CSMS diary, including VAS. In addition, the standardised RQLQ(S) and the RCAT were completed during study visits.

Results

Comparison between CSMS and RQLQ(S) revealed a positive correlation in the AIT population (r = 0.426) and in the control population (r = 0.569). For CSMS and RCAT, a negative correlation with r = −0.409 (AIT) and r = −0.547 (control) was shown. Positive correlation between CSMS and VAS was also demonstrated with r = 0.585 (AIT) and r = 0.563 (control).

Conclusion

These results support the assumption that the CSMS correlates with quality of life, symptom severity and symptom control on the one hand, while the moderate strength of correlations on the other hand mirrors distinctions of the CSMS compared to the assessments used here.

EAST in Children with Allergic rhinitis: Experience from Indian Tertiary Centre

Allergic rhinitis (AR) is recognized as a growing global health disease with considerable importance among children and adolescents. This study aims to study the clinical and sensitization profile of children with allergic rhinitis using EAST. All children presenting to pediatric ENT outpatient with a clinical diagnosis of AR were prospectively recruited. Detailed demographic and clinical history including self-reported allergens, predominant symptoms and associated comorbid conditions were obtained. Severity of symptoms was graded on a visual analogue scale. Specific Ig E antibodies to 20 inhalant allergens was measured using EAST (EUROIMMUN, Germany).The pattern of sensitization was analyzed with respect to age, symptoms, associated comorbid conditions and urbanization. We recruited 328 children with a clinical diagnosis of AR (Mean age 10.3 year, IQR 8-13 years) Nasal block was the predominant symptom across all age groups, sneezing became more troublesome during adolescence. In 191 children sera were tested for allergen specific IgE, 119 (62.3%) showed positive sensitization. The most common sensitization noted was for cockroach, followed by dust mite and pollens. Majority had polysensitization (73%). Those who were predominantly sneezers were more likely to be sensitized with indoor allergens (p < 0.05). Among the comorbid conditions, asthma and atopic dermatitis accounted for maximum non ENT physician visits. The pattern of sensitization did not vary with age, urbanization or comorbid condition. This study highlights the clinical and sensitization profile of children with AR in South East India. Various peculiarities of this community has been presented which needs further attention.

Effects of early life exposure to home environmental factors on childhood allergic rhinitis: Modifications by outdoor air pollution and temperature

BACKGROUND

There is growing evidence that allergic rhinitis (AR) is associated with indoor environmental factors, but their role in childhood AR during early life remains unclear.

OBJECTIVE

To investigate the association of preconceptional, prenatal, early postnatal, and current exposure to home environmental factors with childhood AR, and to further explore whether this association can be interacted by outdoor air pollution and temperature.

METHODS

A retrospective cohort study of 8689 preschool children was conducted during 2019-2020 in Changsha, China. A standard questionnaire was used to collect data on each family's health outcomes and home environments. We considered home environmental exposures during one year before conception, pregnancy, first year of life, and past year. Associations of indoor air pollution and allergens with AR were assessed by multiple logistic regression models.

RESULTS

Pre-birth exposure to indoor air pollution emitted by new furniture or redecoration and dampness related allergen derived from mold/damp stains and mold/damp clothes or bedding during 1 year before conception and pregnancy was significantly associated with increased AR, with adjusted ORs (95% CI) ranging from 1.35 (1.05-1.75) to 1.87 (1.55-2.27). Childhood AR was also significantly related with post-birth exposure to dampness related indoor allergen including mold/damp stains and mold/damp clothes or bedding in first year and past year and pollen allergen including total and nonflowing plants in past year, with a range of ORs (95% CI) from 1.20 (1.01-1.42) to 1.79 (1.42-2.27). We identified that pre-birth, particularly in utero exposure to both indoor air pollution from renovation and dampness related allergens, played a key role in AR development compared to post-birth exposures, and accumulative effect was observed with the highest risk of AR. High exposure to traffic-related air pollution (TRAP) including outdoor PM_2.5, NO₂, CO, and O₃, as well as living near traffic road not only significantly increased adverse effect of home environmental factors but also decreased protective effect of household dogs on childhood AR. Early life exposure to low temperature in pregnancy and high temperature in first year significantly increased AR risk of home environmental exposure. Sensitivity analysis indicated that some sub-groups were more susceptible to AR risk of home environmental exposure.

CONCLUSION

Our study suggests that pre-birth exposure to home environmental factors played an important role in AR development and this effect can be interacted by TRAP and temperature, which supports a hypothesis of "(pre)fetal origin of childhood AR".

Health and economic impact of subcutaneous allergen immunotherapy in patients with pollen-induced allergic rhinoconjunctivitis: real-word evidence from the Czech Republic

Background: The prevalence of allergic rhinoconjunctivitis (AR) has been increasing over the years, and allergen immunotherapy (AIT) remains the only disease-modifying treatment. However, cost-effectiveness data remain scarce. Methods: In this single-arm, noninterventional, prospective, multicenter study, we describe the effectiveness, safety and costs of subcutaneous AIT for pollen-induced allergic rhinoconjunctivitis. Results: Of 471 new AIT users, 317 completed three courses of treatment, and symptoms improved in 96%; no serious adverse reactions were reported. The cost of symptomatic medication decreased by 49% and the cost of unscheduled specialist visits decreased by 73%. Except for AIT administration, total healthcare costs decreased by 54% compared with the baseline pollen season without AIT. Conclusion: In clinical practice, subcutaneous AIT is an effective treatment generating savings on symptomatic medication and unscheduled consultations.