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Challenges in the Management of Asthma in Older Adults. CURRENT TREATMENT OPTIONS IN ALLERGY 2023. [DOI: 10.1007/s40521-023-00331-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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Khosa JK, Louie S, Lobo Moreno P, Abramov D, Rogstad DK, Alismail A, Matus MJ, Tan LD. Asthma Care in the Elderly: Practical Guidance and Challenges for Clinical Management - A Framework of 5 "Ps". J Asthma Allergy 2023; 16:33-43. [PMID: 36636705 PMCID: PMC9829983 DOI: 10.2147/jaa.s293081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 12/22/2022] [Indexed: 01/05/2023] Open
Abstract
Uncontrolled asthma in the elderly is a public health issue recognized in developed countries such as the United States and among the European Union, both from patient safety and economic perspectives. Variations in the cutoff, which defines elderly age, contribute to epidemiological study difficulties. Nonetheless, the relevance of elderly asthma from a socioeconomic perspective is inarguable. The projected growth of the enlarging geriatric population in the United States portends an impending national health burden that may or may not be preventable with pharmacologic and non-pharmacologic treatments. Asthma in the elderly might be a consequence of uncontrolled disease that is carried throughout a lifetime. Or elderly asthmatics could suffer from uncontrolled asthma, which overlaps with other ailments common with advancing ages that merit consideration, eg, COPD, heart disease, OSA, diabetes mellitus, and other comorbidities. Because of the heterogeneity of asthma phenotypes and other conditions that could mimic the symptoms of elderly asthma, further cohort studies are needed to elucidate the elderly asthmatic pathophysiology and management. More studies to characterize elderly asthma can help address these patients' unmet need for evidence-based guidelines. We introduce the 5 "Ps" (phenotypes, partnership, pharmacology, practice in acute exacerbations, and problems or barriers for the elderly asthmatics) that establish a framework approach for clinical practice.
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Affiliation(s)
- Jaskiran K Khosa
- Department of Internal Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Samuel Louie
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA
| | - Pamela Lobo Moreno
- Department of Internal Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Dmitry Abramov
- Department of Internal Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Daniel K Rogstad
- Department of Internal Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Abdullah Alismail
- Department of Cardiopulmonary Sciences, Loma Linda University Health, Loma Linda, CA, USA
| | - Michael J Matus
- Department of Internal Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Laren D Tan
- Department of Internal Medicine, Loma Linda University Health, Loma Linda, CA, USA,Correspondence: Laren D Tan, Department of Medicine, Division of Pulmonary, Critical Care, Hyperbaric, Allergy and Sleep Medicine, Loma Linda University Health, 11234 Anderson Street, Suite 6439, Loma Linda, CA, 92354, USA, Tel +1 909-558-8081, Fax +1 909-558-0581, Email
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Muacevic A, Adler JR, Okoli ML, Ahaiwe O, Ogbu SC, Kim ES, Kirby RS. Association of Depression, Poor Mental Health Status and Asthma Control Patterns in US Adults Using a Data-Reductive Latent Class Method. Cureus 2023; 15:e33966. [PMID: 36820113 PMCID: PMC9938719 DOI: 10.7759/cureus.33966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 01/20/2023] Open
Abstract
Objectives To explore the association between depression, poor mental health status, and asthma control patterns among US adults using a latent class analysis (LCA) approach. Methods We used data from 10,337 adults aged 18 years and above from the 2016 Behavioral Risk Factor Surveillance System (BRFSS) Asthma Call-back Survey. Data-reductive LCA was used to derive asthma control patterns in the population using class variables indicative of asthma control. Besides univariate analysis, adjusted and unadjusted logistic regression models were used to examine the association of depression and poor mental health on the derived asthma control patterns. Results About 27.8% of adults aged <55 reported depression, while 27.3% aged ≥55 years were depressed. The latent class prevalence of asthma control patterns was 42.8%, 31.1%, and 26.1%, corresponding to good, fair, and poor asthma control patterns, respectively. In adults aged <55 years, odds of depression (OR=1.52, 95% CI=1.27-1.82) and poor mental health (OR=1.58, 95% CI=1.27-1.96) were higher in the poor asthma control group compared to the good asthma control group. Odds for depression (OR=1.28, 95% CI=1.06-1.53) were also higher in the moderate asthma control group compared to the good asthma control group. Among those aged ≥55 years, depression odds (OR=1.57, 95% CI=1.31-1.87) were higher in only the poor asthma control group. Conclusions These findings may have public health implications. Detecting, screening, and treating depression and mental health disorders may help improve asthma control in people with asthma.
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Attar-Zadeh D, Lewis H, Orlovic M. Health-care Resource Requirements and Potential Financial Consequences of an Environmentally Driven Switch in Respiratory Inhaler Use in England. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2021; 8:46-54. [PMID: 34616856 PMCID: PMC8460426 DOI: 10.36469/001c.26113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/19/2021] [Indexed: 06/13/2023]
Abstract
Background: To reduce greenhouse gas emissions, national initiatives advocate the phasing down of respiratory inhalers that use a fluorinated gas as a propellant (pressurised metered-dose inhalers [pMDI]). Nevertheless, pMDIs continue to be an effective and common choice. Objective: To assess the potential financial impact of patients with asthma or chronic obstructive pulmonary disease (COPD) switching from pMDIs to dry powder inhalers (DPIs) in a representative primary care network (PCN) population of 50 000 and the English National Health Service (NHS). Methods: Epidemiological data were combined with current inhaler use patterns to estimate the resources and costs associated with this transition, varying patient acceptance scenarios. Results: Depending on the approach, resource requirements ranged from £18 000 - £53 000 for a PCN, and from £21 - £60 million for the English NHS. Discussion: Significant funds are needed to successfully manage targeted inhaler transitions, together with counselling and follow-up appointment with an appropriately skilled clinician to assess the patient's inhaler technique and ensure disease control. Conclusions: Targeted transition of inhalers must achieve a balance between environmental impacts, organisational factors, and patient requirements. The resources for managing a switch can be substantial but are necessary to appropriately counsel and support patients, whilst protecting the environment.
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Zuluaga G, Sarmiento I, Pimentel J, Correal C, Andersson N. [Cultivation and use of medicinal plants and association with reporting of childhood asthma: A case-control study in the Bogotá savanna]. Medwave 2021; 21:e8196. [PMID: 34037578 DOI: 10.5867/medwave.2021.04.8196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/13/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction The prevalence of childhood asthma has increased in recent years. The World Health Organization has called for conducting research exploring the role of traditional medicine and medicinal plants in respiratory disease control. Objective To identify the relationship between the prevalence of childhood asthma and traditional care of the respiratory system, including cultivation and use of medicinal plants. Methods We conducted an observational, analytic, case-control study that included children 2 to 14 years old who used official health services in eight municipalities near Bogota between 2014 and 2015. Cases were children diagnosed with asthma. We randomly selected the controls among the remaining patients of the same healthcare facilities. We applied an 18-question survey. The Mantel-Haenszel procedure identified significant associations using 95% confidence intervals. Results We surveyed the caretakers of 97 cases and 279 controls in eight municipalities. Some 23.4% (88/376) and 37.9% (142/375) reported using traditional remedies for fever control and common cold management, respectively. 8.8% (33/376) reported following traditional care during a common cold, 30.4% (114/375) reported growing medicinal plants at home, and 45% (166/369) reported using medicinal plants for health purposes in their household. Multivariate analysis showed that having and using medicinal plants at home is associated with a lower reporting of asthma (odds ratio 0.49; 95% confidence interval: 0.25 to 0.99). Conclusions Cultivating and using medicinal plants at home is associated with a lower reporting of childhood asthma. Researchers should consider the therapeutic, environmental, and cultural properties of medicinal plants to prevent respiratory diseases.
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Affiliation(s)
- Germán Zuluaga
- Grupo de Estudios en Sistemas Tradicionales de Salud, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia. Dirección: Calle 12 # 3A 21, Cota, Cundinamarca, Colombia. . ORCID: 0000-0001-5715-9133
| | - Iván Sarmiento
- Grupo de Estudios en Sistemas Tradicionales de Salud, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia. ORCID: 0000-0003-2871-1464
| | - Juan Pimentel
- Grupo de Estudios en Sistemas Tradicionales de Salud, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia. ORCID: 0000-0002-6842-3064
| | - Camilo Correal
- Universidad de La Sabana, Departamento de Medicina Familiar y Salud Pública, Chía, Colombia. ORCID: 0000-0002-4252-326X
| | - Neil Andersson
- CIET-PRAM, Departamento de Medicina Familiar, Universidad de McGill, Montreal, Quebec, Canadá. ORCID: 0000-0003-1121-6918
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Clinical profile of chronic bronchial asthma patients in Poland: results of the PROKSAL study. Postepy Dermatol Alergol 2021; 37:879-889. [PMID: 33603604 PMCID: PMC7874873 DOI: 10.5114/ada.2020.102102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 04/01/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Asthma is a complex condition characterized by the presence of chronic inflammation in the lower respiratory tract resulting in many disturbing symptoms. The study of the clinical profile of the population with asthma allows us to understand a trend of a specific disease taking into account several indicators and its clinical characteristics. Aim Evaluation of the clinical profile of patients with chronic bronchial asthma in Poland. Material and methods The study included 10400 adult patients, of both sexes, diagnosed with chronic bronchial asthma who started therapy based on inhaled glucocorticosteroids accompanied by salmeterol, and 52 allergists. The examination was performed in a doctor's surgery. Standardized questionnaire interviews were used in order to carry out the procedure. Results The age of the patients ranged from 18 up to 97 years. Most of them suffer from overweight and obesity. 45.3% of the patients smoked cigarettes or declared to be passive smokers. Current asthma control was poor: over 56% of the patients suffered from diurnal symptoms more often than twice a week, almost 55% from nocturnal symptoms, in 72% of the patients' physical activity was limited, whereas 57% required immediate treatment. Most commonly used drugs were inhaled glucocorticosteroids and short acting β2-mimetics. After treatment change, fewer patients suffered from asthma symptoms. Conclusions Adjusting the therapy according to the current guidelines and to the patient's needs helps to improve asthma control.
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GPs should not try to detect mild COPD. NPJ Prim Care Respir Med 2020; 30:20. [PMID: 32393734 PMCID: PMC7214409 DOI: 10.1038/s41533-020-0176-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/07/2020] [Indexed: 11/08/2022] Open
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Kim JH, Lee JH, Ye YM, Lee JH, Park JW, Hur GY, Kim JH, Lee HY, Shin YS, Yang EM, Park HS. Efficacy and Safety of Sublingual Immunotherapy in Elderly Rhinitis Patients Sensitized to House Dust Mites. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2018; 10:675-685. [PMID: 30306749 PMCID: PMC6182194 DOI: 10.4168/aair.2018.10.6.675] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 08/07/2018] [Accepted: 08/07/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE This study aims to determine the efficacy and safety of house dust mite (HDM)-sublingual immunotherapy (SLIT) in elderly patients with AR. METHODS A total of 45 patients aged ≥ 60 years with HDM-induced AR who had ≥ 3 A/H ratio on skin prick test and/or ≥ 0.35 IU/L to both Dermatophagoides farinae and Dermatophagoides pteronyssinus by ImmunoCAP were enrolled in 4 university hospitals. To evaluate additional effects of HDM-SLIT, they were randomized to the SLIT-treated group (n = 30) or control group (n = 15). Rhinoconjunctivitis total symptom score (RTSS), rhinoscopy score, Korean rhinoconjunctivitis quality of life questionnaire, rhinitis control assessment test, asthma control test scores, and adverse reactions, were assessed at the first visit (V1) and after 1 year of treatment (V5); for immunological evaluation, serum levels of HDM-specific immunoglobulin A/IgE/IgG1/IgG4 antibodies and basophil response to HDMs were compared between V1 and V5 in both groups. RESULTS There were no significant differences in demographics, RTSS, skin reactivity to HDMs, or serum total/specific IgE levels to HDMs (P < 0.05, respectively) between the 2 groups. Nasal symptom score and RTSS decreased significantly at year 1 in the 2 groups (P < 0.05). There were no significant differences in percent decrease in nasal symptom score and RTSS at year 1 between the 2 groups (P < 0.05); however, rhinoscopic nasal symptom score decreased significantly in the SLIT-treated group (P < 0.05). Immunological studies showed that serum specific IgA levels (not specific IgE/IgG) and CD203c expression on basophils decreased significantly at V5 in the SLIT-treated group (P = 0.011 and P = 0.001, respectively), not in the control group. The control group required more medications compared to the treatment group, but there were no differences in adverse reactions. CONCLUSIONS It is suggested that HDM-SLIT for 1 year could induce symptom improvement and may induce immunomodulation in elderly rhinitis patients.
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Affiliation(s)
- Ji Hye Kim
- Division of Respiratory, Allergy and Critical Care Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Ji Ho Lee
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Young Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Jae Hyun Lee
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Won Park
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Gyu Young Hur
- Division of Respiratory and Critical Care Medicine, Korea University College of Medicine, Seoul, Korea
| | - Joo Hee Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hallylm University Sacred Heart Hospital, Anyang, Korea
| | - Hyn Young Lee
- Department of Statistics, Clinical Trial Center, Ajou University Medical Center, Suwon, Korea
| | - Yoo Seob Shin
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Eun Mi Yang
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Hae Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.
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Mazloomi E, Ilkhanizadeh B, Zare A, Mohammadzadeh A, Delirezh N, Shahabi S. Evaluation of the efficacy of nicotine in treatment of allergic asthma in BALB/c mice. Int Immunopharmacol 2018; 63:239-245. [PMID: 30114604 DOI: 10.1016/j.intimp.2018.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/22/2018] [Accepted: 08/06/2018] [Indexed: 01/25/2023]
Abstract
Nicotine, an nAChR agonist, shows prominent anti-inflammatory properties, and some studies have illustrated its suppressive effects on inflammation. Here, we have examined whether nicotine as a medicine may have beneficial effects on the treatment of asthma in a mouse model of allergic asthma. BALB/c mice were sensitized with OVA and alum. Two weeks later, the mice received nicotine with concentrations of 1 and 10 mg/kg three times every other day. After 10 days, the mice were challenged with OVA (5%) using an ultrasonic nebulizer and died the next day. Our results showed that the administration of nicotine reduced lung-tissue inflammation, the number of eosinophils in bronchoalveolar fluid, allergen-specific IgE and IL-4 production, while it increased the TGF-β/IL-4 ratio and the number of Treg cells. Our results showed that nicotine applies its suppressive effects in a dose-dependent manner: administration of 10 mg/kg of nicotine showed more suppressive effects than 1 mg/kg. Such data suggested that nicotine might be a good candidate to be used as a medicine in the treatment of allergic asthma by decreasing allergic inflammation severity and potentiating Treg cells proliferation against the allergen.
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Affiliation(s)
- Ebrahim Mazloomi
- Cellular and Molecular Research Center, Cellular and Molecular Medicine institute, Urmia University of Medical Sciences, Urmia, Iran
| | - Behrooz Ilkhanizadeh
- Department of Pathology, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Ahad Zare
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical sciences, Tehran, Iran
| | - Adel Mohammadzadeh
- Departments of Genetics and Immunology, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Nowruz Delirezh
- Department of Cellular and Molecular Biotechnology, Institute of Biotechnology, Urmia University, Urmia, Iran
| | - Shahram Shahabi
- Cellular and Molecular Research Center, Cellular and Molecular Medicine institute, Urmia University of Medical Sciences, Urmia, Iran.
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Heffler E, Madeira LNG, Ferrando M, Puggioni F, Racca F, Malvezzi L, Passalacqua G, Canonica GW. Inhaled Corticosteroids Safety and Adverse Effects in Patients with Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:776-781. [DOI: 10.1016/j.jaip.2018.01.025] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/13/2018] [Accepted: 01/18/2018] [Indexed: 01/06/2023]
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Venturini CL, Macho A, Arunachalam K, de Almeida DAT, Rosa SIG, Pavan E, Balogun SO, Damazo AS, Martins DTDO. Vitexin inhibits inflammation in murine ovalbumin-induced allergic asthma. Biomed Pharmacother 2018; 97:143-151. [DOI: 10.1016/j.biopha.2017.10.073] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 10/13/2017] [Accepted: 10/16/2017] [Indexed: 01/28/2023] Open
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Ridolo E, Rogkakou A, Ventura MT, Martignago I, Incorvaia C, Di Lorenzo G, Passalacqua G. How to fit allergen immunotherapy in the elderly. Clin Mol Allergy 2017; 15:17. [PMID: 29785175 PMCID: PMC5951166 DOI: 10.1186/s12948-017-0075-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/28/2017] [Indexed: 02/08/2023] Open
Abstract
Asthma, allergic rhinitis (AR) and atopic dermatitis are very common in young people, but in the latest decades it was increasingly recognized that also individuals of higher ages, including the population over 65 years, are concerned. Actually, it is now acknowledged the aging does not considerably alter the immune response to allergens. Allergen immunotherapy (AIT) is the only treatment that works on the causes of allergy, but elderly people are commonly excluded from AIT, except the cases of insect sting allergy. A number of recent studies showed that aged individuals also successfully respond to AIT for respiratory allergy. Therefore, there is no reason to exclude elder patients from AIT. Anyhow, clinical conditions that are considered absolute or relative contraindications are quite frequent in this aged population, thus the risk/benefit ratio must be carefully evaluated for each patient, taking into account that the more frequent occurrence of co-morbidities and the consequent need of daily-based multidrug regimen can favor adverse effects. An important issue concern the ability of AIT, and particularly of sublingual immunotherapy, to significantly improve the quality of life, that often is particularly impaired in the elderly, reducing symptoms and drugs consumption.
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Affiliation(s)
- Erminia Ridolo
- 1Medicine and Surgery Department, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Anti Rogkakou
- Allergy and Respiratory Diseases Clinic, DIMI, University of Genoa, IRCCS AOU San Martino-IST, Genoa, Italy
| | | | - Irene Martignago
- 1Medicine and Surgery Department, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | | | - Gabriele Di Lorenzo
- 5Dipartimento BioMedico di Medicina Interna e Specialistica (Di.Bi.M.I.S), Università di Palermo, Palermo, Italy
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases Clinic, DIMI, University of Genoa, IRCCS AOU San Martino-IST, Genoa, Italy
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de Almeida DAT, Rosa SIG, da Cruz TCD, Pavan E, Sabino Damazo A, Soares IM, Ascêncio SD, Macho A, Martins DTDO. Mandevilla longiflora (Desf.) Pichon improves airway inflammation in a murine model of allergic asthma. JOURNAL OF ETHNOPHARMACOLOGY 2017; 200:51-59. [PMID: 28229922 DOI: 10.1016/j.jep.2017.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/08/2017] [Accepted: 02/10/2017] [Indexed: 06/06/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Mandevilla longiflora, popularly known as "velame" in central Brazil, is a subshrub widely distributed in South America. Its xylopodium is used in the form of a decoction or infusion to treat inflammation and other ailments. AIM OF THE STUDY This study aimed to evaluate the anti-inflammatory potential of M. longiflora in an in vivo model of ovalbumin-induced immediate hypersensitivity, identifying its effects on leukocyte infiltration, IgE and LTB4 levels, and Th2 cytokine production. In addition, HPLC fingerprint of the extract was performed. MATERIAL AND METHODS The hydroethanolic extract 70% of M. longiflora (HEMI) was obtained by maceration of the plant xylopodium. Swiss mice were sensitized by i.p. injection OVA-aluminium hydroxide on days 1 and 10. Nine days after the last sensitisation animals were challenged for 6 consecutive days with OVA solution for 20min daily in a closed chamber under continuous flow of aerosol. The animals were treated with HEMl (20, 50 and 200mg/kg p.o.), 2 times per day, and euthanized 24h later. Animals treated with vehicle (2% Tween-20) or dexamethasone were used as negative and positive controls, respectively. The recruitment of inflammatory cells into the pulmonary cavity was evaluated by counting cells present in broncho-alveolar lavage fluid (BALF). Lung tissue was also collected for histopathology and infiltration analysis. Quantification of IL-4, IL-5 and IL-13 from the BALF, and IgE, and LTB4 from plasma, were conducted by immunoassay. RESULTS AND CONCLUSIONS The HEMl attenuated leukocyte migration into the airways, which was evidenced by a decrease in eosinophils, neutrophils and mononuclear cells, both in BALF quantification and by histopathological analysis, as well as decreasing the concentrations of IL-4, IL-5, IL-13, IgE and LTB4. All of these events are typical of air-mucosa inflammatory disease. These findings scientifically evidence for the first time the ethnopharmacological use of M. longiflora to treat chronic inflammatory events, such as asthma, and suggest a potential therapeutic use or complementary therapy for this plant extract.
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Affiliation(s)
- Danielle Ayr Tavares de Almeida
- Department of Basic Sciences in Health, Faculty of Medicine, Federal University of Mato Grosso, Av. Fernando Correa da Costa, n. 2367, Cuiabá, Mato Grosso 78060-900, Brazil
| | - Suellen Iara Guirra Rosa
- Department of Basic Sciences in Health, Faculty of Medicine, Federal University of Mato Grosso, Av. Fernando Correa da Costa, n. 2367, Cuiabá, Mato Grosso 78060-900, Brazil
| | - Thais Campos Dias da Cruz
- Department of Basic Sciences in Health, Faculty of Medicine, Federal University of Mato Grosso, Av. Fernando Correa da Costa, n. 2367, Cuiabá, Mato Grosso 78060-900, Brazil
| | - Eduarda Pavan
- Department of Basic Sciences in Health, Faculty of Medicine, Federal University of Mato Grosso, Av. Fernando Correa da Costa, n. 2367, Cuiabá, Mato Grosso 78060-900, Brazil
| | - Amílcar Sabino Damazo
- Department of Basic Sciences in Health, Faculty of Medicine, Federal University of Mato Grosso, Av. Fernando Correa da Costa, n. 2367, Cuiabá, Mato Grosso 78060-900, Brazil
| | - Ilsamar Mendes Soares
- Research Laboratory of Natural Products (LPPN), Federal University of Tocantins, Av. NS15, Palmas, Tocantins 77020-210, Brazil
| | - Sérgio Donizeti Ascêncio
- Research Laboratory of Natural Products (LPPN), Federal University of Tocantins, Av. NS15, Palmas, Tocantins 77020-210, Brazil
| | - Antonio Macho
- Department of Basic Sciences in Health, Faculty of Medicine, Federal University of Mato Grosso, Av. Fernando Correa da Costa, n. 2367, Cuiabá, Mato Grosso 78060-900, Brazil
| | - Domingos Tabajara de Oliveira Martins
- Department of Basic Sciences in Health, Faculty of Medicine, Federal University of Mato Grosso, Av. Fernando Correa da Costa, n. 2367, Cuiabá, Mato Grosso 78060-900, Brazil.
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Ventura MT, Scichilone N, Paganelli R, Minciullo PL, Patella V, Bonini M, Passalacqua G, Lombardi C, Simioni L, Ridolo E, Del Giacco SR, Gangemi S, Canonica GW. Allergic diseases in the elderly: biological characteristics and main immunological and non-immunological mechanisms. Clin Mol Allergy 2017; 15:2. [PMID: 28174512 PMCID: PMC5290673 DOI: 10.1186/s12948-017-0059-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 01/06/2017] [Indexed: 02/08/2023] Open
Abstract
Life expectancy and the number of elderly people are progressively increasing around the world. Together with other pathologies, allergic diseases also show an increasing incidence in geriatric age. This is partly due to the growing emphasis on a more accurate and careful diagnosis of the molecular mechanisms that do not allow to ignore the real pathogenesis of many symptoms until now unknown, and partly to the fact that the allergic people from 20 years ago represent the elderly population now. Moreover, environmental pollution predisposes to the onset of allergic asthma and dermatitis which are the result of internal pathologies more than the expression of allergic manifestations. At the same time the food contamination permits the onset of allergic diseases related to food allergy. In this review we provide the state of the art on the physiological changes in the elderly responsible for allergic diseases, their biological characteristics and the major immunological and extra immunological mechanisms. Much emphasis is given to the management of several diseases in the elderly, including anaphylactic reactions. Moreover, some new features are discussed, such as management of asthma with the support of physical activity and the use of the AIT as prevention of respiratory diseases and for the purpose of a real and long lasting benefit. The mechanisms of adverse reactions to drugs are also discussed, due to their frequency in this age, especially in polytherapy regimens. Study of the modifications of the immune system is also of great importance, as regards to the distribution of the lymphocytes and also the presence of a chronic inflammatory disease related to the production of cytokines, especially in prevision of all the possible therapies to be adopted to allow an active and healthy aging.
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Affiliation(s)
- Maria Teresa Ventura
- Interdisciplinary Department of Medicine, Unit of Geriatric Immunoallergology, University of Bari Medical School, Bari, Italy
| | | | - Roberto Paganelli
- Laboratory of Immunology and Allergy, Department of Medicine and Sciences of Aging, University of G. d’Annunzio, Chieti, Italy
| | - Paola Lucia Minciullo
- Division and School of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University Hospital of Messina, Messina, Italy
| | - Vincenzo Patella
- Division of Allergy and Clinical Immunology, Department of Medicine, Battipaglia Hospital, Battipaglia, Salerno, Italy
- School of Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Matteo Bonini
- National Heart and Lung Institute (NHLI), Imperial College London & Royal Brompton Hospital, London, UK
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino-IST-University of Genoa, Genoa, Italy
| | - Carlo Lombardi
- Departmental Unit of AllergologyClinical Immunology & Pneumology, Fondazione Poliambulanza Hospital, Brescia, Italy
| | - Livio Simioni
- Department of Medicine, Allergy Service, ULSS 2 Feltre, Belluno, Italy
| | - Erminia Ridolo
- Experimental and Clinical Medicine, University of Parma, Parma, Italy
| | | | - Sebastiano Gangemi
- Division and School of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University Hospital of Messina, Messina, Italy
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15
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Benfante A, Basile M, Battaglia S, Spatafora M, Scichilone N. Use of ICS/LABA (extra-fine and non-extra-fine) in elderly asthmatics. Ther Clin Risk Manag 2016; 12:1553-1562. [PMID: 27789954 PMCID: PMC5072519 DOI: 10.2147/tcrm.s103709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Age represents an exclusion criterion in randomized clinical trials designed to test the efficacy and safety of inhaled drugs in asthma. As a consequence, data on efficacy and safety of inhaled corticosteroid (ICS) and long-acting β2 agonist (LABA) combinations in elderly asthmatics are scanty. Older age is associated with an increased proportion of comorbid conditions; in addition, all organ functions undergo a process of senescence, thus reducing their ability to metabolize the agents. Overall, these age-associated conditions may variably, and often unpredictably, affect the metabolism and excretion of respiratory drugs. However, pharmacological treatment of asthma does not follow specific recommendations in the elderly. In the elderly, the ICS/LABA combinations may carry an increased risk of local indesiderable effects, primarily due to the lack of coordination between activation of the device and inhalation, and systemic adverse events, mainly due to the greater amount of active drug that is available because of the age-associated changes in organ functions as well as drug-to-drug and drug-to-concomitant disease interactions. The extra-fine formulations of ICSs/LABAs, which allow for a more favorable drug deposition in the lungs at a reduced dose, may contribute to overcome this issue. This review revises the efficacy and safety of treatment with ICSs/LABAs, focusing on the main pharmacodynamic and pharmacokinetic properties of the drugs and highlighting the potential risks in the elderly asthmatic population.
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Affiliation(s)
- Alida Benfante
- Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy
| | - Marco Basile
- Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy
| | - Salvatore Battaglia
- Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy
| | - Mario Spatafora
- Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy
| | - Nicola Scichilone
- Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy
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Marcello C, Carlo L. Asthma phenotypes: the intriguing selective intervention with Montelukast. Asthma Res Pract 2016; 2:11. [PMID: 27965779 PMCID: PMC5142440 DOI: 10.1186/s40733-016-0026-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 07/25/2016] [Indexed: 01/19/2023] Open
Abstract
Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation and a variable course associated with various underlying mechanisms that can differ between individuals. Patients with asthma can therefore exhibit different phenotypes, a term used to define the observable characteristics of an organism resulting from the interaction between its genetic makeup and the environment. The heterogeneity of asthma has received a large amount of attention in the last few years in order to better tailor treatment according to the different clinical and biological phenotypes of the disease. Specific asthma phenotypes may require an approach to treatment sometimes different from that recommended by current guidelines, so a personalized approach to asthma pharmacotherapy is recommended. Growing evidence suggests that leukotrienes play an important role in the pathogenesis of bronchial asthma. The mechanisms of action of leukotriene-receptor antagonists theoretically predict a good response in some asthma “phenotypes”.In this article we have performed an analysis of the recent literature (controlled clinical trials and real-life studies) about a possible selective intervention with Montelukast in specific asthma phenotypes.
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Affiliation(s)
| | - Lombardi Carlo
- Departmental Unit of Allergology, Immunology & Pulmonary Diseases, Fondazione Poliambulanza, Via Bissolati, 57, 25124 Brescia, Italy
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González-de-Olano D, Lombardo C, González-Mancebo E. The difficult management of anaphylaxis in the elderly. Curr Opin Allergy Clin Immunol 2016; 16:352-60. [DOI: 10.1097/aci.0000000000000280] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Ridolo E, Caminati M, Martignago I, Melli V, Salvottini C, Rossi O, Dama A, Schiappoli M, Bovo C, Incorvaia C, Senna G. Allergic rhinitis: pharmacotherapy in pregnancy and old age. Expert Rev Clin Pharmacol 2016; 9:1081-9. [PMID: 27177184 DOI: 10.1080/17512433.2016.1189324] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Allergic rhinitis (AR) affects 20-30% of women in reproductive age and may worsen during pregnancy. About 10% of the elderly suffer from AR, and it could be under-diagnosed in these patients. Many drugs are currently available, however AR treatment during pregnancy and old age represents a challenging issue. AREAS COVERED A review of the literature on the topic has been performed. Expert commentary: In pregnancy, drug avoidance should be carefully balanced with the need for AR optimal control. Topical drugs are suggested as a first approach. The safety and tolerability profile of second-generation antihistamines is well supported. If allergen immunotherapy (AIT) is ongoing and well tolerated, there is no reason for stopping it. AIT initiation in pregnancy is not recommended. For elderly patients, no specific concerns have been highlighted regarding topical treatments, except from nasal decongestionants. Second generation antihistamines are generally well tolerated. Old age should not preclude AIT.
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Affiliation(s)
- E Ridolo
- a Clinical and Experimental Medicine , University of Parma , Parma , Italy
| | - M Caminati
- b Allergy Unit and Asthma Center , Verona University Hospital , Verona , Italy
| | - I Martignago
- a Clinical and Experimental Medicine , University of Parma , Parma , Italy
| | - V Melli
- a Clinical and Experimental Medicine , University of Parma , Parma , Italy
| | - C Salvottini
- c Department of Molecular Medicine , University of Pavia , Pavia , Italy
| | - O Rossi
- d Allergy Unit , Azienda Ospedaliera Universitaria Careggi , Firenze , Italy
| | - A Dama
- b Allergy Unit and Asthma Center , Verona University Hospital , Verona , Italy
| | - M Schiappoli
- b Allergy Unit and Asthma Center , Verona University Hospital , Verona , Italy
| | - C Bovo
- e Medical Direction , Verona University Hospital , Verona , Italy
| | - C Incorvaia
- f Allergy/Pulmonary Rehabilitation , ICP Hospital , Milano , Italy
| | - G Senna
- b Allergy Unit and Asthma Center , Verona University Hospital , Verona , Italy
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19
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Lombardi C, Savi E, Costantino MT, Heffler E, Milanese M, Passalacqua G, Canonica GW. Appropriateness in allergic respiratory diseases health care in Italy: definitions and organizational aspects. Clin Mol Allergy 2016; 14:5. [PMID: 27099567 PMCID: PMC4837511 DOI: 10.1186/s12948-016-0042-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 04/11/2016] [Indexed: 01/13/2023] Open
Abstract
In a historical period in which sustainability of the National Health Service is mandatory because of the international economical situation, the limited available resources at national level and the tendency of passing from a “population medicine” model towards the concept of “individualized medicine”, the debate on appropriateness of medical and surgical procedures is of central importance. The choosing wisely campaign, started in United States in 2012 and then spread all over the world, tries to summarize which are the most inappropriate procedures for each medical and surgical speciality; as far as allergic respiratory diseases, the most relevant Italian societies and the American Academy defined the allergological procedures with the highest probability of inappropriateness. In Italy, a recent decree of the Ministry of Health defined a list of more than 200 procedures that will be considered as inappropriate in certain conditions; many of these procedures concern allergology, including allergic respiratory diseases. In this commentary we discuss the above mentioned decree and the concept of appropriateness in the field of allergic respiratory diseases, trying to figure out some practical considerations based on the current health resources available in the field of allergology in Italy.
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Affiliation(s)
- Carlo Lombardi
- Departmental Unit of Allergology-Clinical Immunology and Respiratory Diseases, Fondazione Poliambulanza of Brescia, Via Bissolati, 57, Brescia, Italy
| | - Eleonora Savi
- Departmental Unit of Allergology, AUSL of Piacenza, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Maria Teresa Costantino
- Unit of Allergology, Department of Internal Medicine, Azienda Ospedaliera "Carlo Poma" of Mantua, Mantua, Italy
| | - Enrico Heffler
- Respiratory Medicine and Allergy-Department Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Manlio Milanese
- Unit of Pulmonology, S. Corona Hospital, Pietra Ligure, Savona, Italy
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino-IST-University of Genoa, Genoa, Italy
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Battaglia S, Benfante A, Spatafora M, Scichilone N. Asthma in the elderly: a different disease? Breathe (Sheff) 2016; 12:18-28. [PMID: 27064568 PMCID: PMC4818235 DOI: 10.1183/20734735.002816] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
KEY POINTS Asthma in the elderly can be difficult to identify due to modifications of its clinical features and functional characteristics.Several comorbidities are associated with asthma in the elderly, and this association differs from that observed in younger patients.In clinical practice, physicians should treat comorbidities that are correlated with asthma (i.e. rhinitis or gastro-oesophageal reflux), assess comorbidities that may influence asthma outcomes (i.e. depression or cognitive impairment) and try to prevent comorbidities related to -'drug-associated side-effects (i.e. cataracts, arrhythmias or osteoporosis)."Geriatric asthma" should be the preferred term because it implies the comprehensive and multidimensional approach to the disease in the older populations, whereas "asthma in the elderly" is only descriptive of the occurrence of the disease in this age range. EDUCATIONAL AIMS To present critical issues in performing differential diagnosis of asthma in the elderly.To offer the instrument to implement the management of asthma in the most advanced ages. Asthma is a chronic airway disease that affects all ages, but does this definition also include the elderly? Traditionally, asthma has been considered a disease of younger age, but epidemiological studies and clinical experience support the concept that asthma is as prevalent in older age as it is in the young. With the ever-increasing elderly population worldwide, the detection and proper management of the disease in old age may have a great impact from the public health perspective. Whether asthma in the elderly maintains the same characteristics as in young populations is an interesting matter. The diagnostic process in older individuals with suspected asthma follows the same steps, namely a detailed history supported by clinical examination and laboratory investigations; however, it should be recognised that elderly patients may partially lose reversibility of airway obstruction. The correct interpretation of spirometric curves in the elderly should take into account the physiological changes in the respiratory system. Several factors contribute to delaying the diagnosis of asthma in the elderly, including the age-related impairment in perception of breathlessness. The management of asthma in advanced age is complicated by the comorbidities and polypharmacotherapy, which advocate for a comprehensive approach with a multidimensional assessment. It should be emphasised that older age frequently represents an exclusion criterion for eligibility in clinical trials, and current asthma medications have rarely been tested in elderly asthmatics. Ageing is associated with pharmacokinetic changes of the medications. As a consequence, absorption, distribution, metabolism and excretion of antiasthmatic medications can be variably affected. Similarly, drug-to-drug interactions may reduce the effectiveness of inhaled medications and increase the risk of side-effects. For this reason, we propose the term "geriatric asthma" be preferred to the more generic "asthma in the elderly".
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Affiliation(s)
- Salvatore Battaglia
- Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Alida Benfante
- Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Mario Spatafora
- Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Nicola Scichilone
- Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy; Istituto Euro-Mediterraneo di Scienza e Tecnologia, Palermo, Italy
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22
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Kim MY, Song WJ, Cho SH. Pharmacotherapy in the management of asthma in the elderly: a review of clinical studies. Asia Pac Allergy 2016; 6:3-15. [PMID: 26844215 PMCID: PMC4731478 DOI: 10.5415/apallergy.2016.6.1.3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 01/12/2016] [Indexed: 12/29/2022] Open
Abstract
Asthma in the elderly is a disease with emerging concern. Despite some recent advances in our understanding of epidemiology and pathophysiology, there is a considerable lack of clinical evidence specific to elderly patients. Currently available high quality clinical evidence has been mostly obtained from younger adults, but rarely from elderly patients. Under-representation of elderly patients in previous randomized trials may have been due to being, old age, or having comorbidities. Thus, a question may be raised whether current clinical evidence could be well generalized into elderly patients. Further clinical trials should address clinical issues raised in elderly population. In this review, we aimed to overview the efficacy and safety of pharmacological management, and also to summarize the literature relevant to elderly asthma.
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Affiliation(s)
- Mi-Yeong Kim
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan 47392, Korea
| | - Woo-Jung Song
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul 03080, Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul 03080, Korea
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Heffler E, Landi M, Quadrino S, Incorvaia C, Pizzimenti S, Vernero S, Crimi N, Rolla G, Canonica GW. Choosing wisely in Allergology: a Slow Medicine approach to the discipline promoted by the Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC). Clin Mol Allergy 2015; 13:28. [PMID: 26594132 PMCID: PMC4653937 DOI: 10.1186/s12948-015-0034-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 09/28/2015] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND One of the main problem health care systems are facis is the mis-use and over-use of medical resources (including useless exams, surgical interventions, medical treatments, screening procedures…) which may lead to high health care related costs without increased patients' benefit and possible harm to the patients themselves. The "Choosing wisely" campaign, in Italy denominated "Doing more does not mean doing better", tries to educate doctors and citizens at a correct use of medical resources. METHODS the Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC) adhered to the "Doing more does not mean doing better" campaing and made a list of the 5 allergological procedures with the highest evidence of inappropriateness. RESULTS the 5 recommendations were: "Do not perform allergy tests for drugs (including anhestetics) and/or foods when there are neither clinical history nor symptoms suggestive of hypersensitivity reactions"; "Do not perform the so-called "food intolerance tests" (apart from those which are validated for suspect celiac disease or lactose enzymatic intolerance)"; "Do not perform serological allergy tests (i.e.: total IgE, specific IgE, ISAC) as first-line tests or as "screening" assays"; "Do not treat patients sensitized to allergens or aptens if there is not a clear correlation between exposure to that specific allergen/apten and symptoms suggestive of allergic reaction"; "Do not diagnose asthma without having performed lung function tests". CONCLUSIONS An important role scientific societies should play is to advise on correct diagnostic and therapeutical pathways. For this reason SIAAIC decided to adhere to the Slow Medicine Italy campaign "Doing more does not mean doing better" with the aim of warning the scientific community and the citizens/patients about some allergological procedures, which, when performed in the wrong clinical setting, may be not only useless, but unnecessarily expensive and even harmful for patients' health.
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Affiliation(s)
- Enrico Heffler
- />Department of Clinical and Experimental Medicine, Respiratory Medicine and Allergy, University of Catania, Catania, Italy
| | | | - Silvana Quadrino
- />“Change” Institute, Turin, Italy
- />“Slow Medicine Italy”, Turin, Italy
| | | | - Stefano Pizzimenti
- />ASL-TO3, Allergy Outpatients’ Clinic, “Edoardo Agnelli” Hospital, Pinerolo, TO Italy
| | | | - Nunzio Crimi
- />Department of Clinical and Experimental Medicine, Respiratory Medicine and Allergy, University of Catania, Catania, Italy
| | - Giovanni Rolla
- />Department of Medical Sciences, Allergy and Clinical Immunology, University of Torino, Turin, Italy
| | - Giorgio Walter Canonica
- />Allergy and Respiratory Diseases Clinic, DIMI-Department of Internal Medicine, IRCCS AOU S.Martino-IST, Genoa, Italy
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