The clinical burden of allergic rhinitis in five Middle Eastern countries: results of the SNAPSHOT program

Efficient experimental method for purifying allergens from aqueous extracts

Studying the molecular and immunological basis of allergic diseases often requires purified native allergens. The methodologies for protein purification are usually difficult and may not be completely successful. The objective of this work was to describe a methodology to purify allergens from their natural source, while maintaining their native form. The purification strategy consists of a three-step protocol and was used for purifying five specific allergens, Ole e 1, Amb a 1, Alt a 1, Bet v 1 and Cup a 1. Total proteins were extracted in PBS (pH 7.2). Then, the target allergens were pre-purified and enriched by salting-out using increasing concentrations of ammonium sulfate. The allergens were further purified by anion exchange chromatography. Purification of Amb a 1 required an extra step of cation exchange chromatography. The detection of the allergens in the fractions obtained were screened by SDS-PAGE, and Western blot when needed. Further characterization of purified Amb a 1 was performed by mass spectrometry. Ole e 1, Alt a 1, Bet v 1 and Cup a 1 were obtained at > 90 % purity. Amb a 1 was obtained at > 85 % purity. Overall, we propose an easy-to-perform purification approach that allows obtaining highly pure allergens. Since it does not involve neither chaotropic nor organic reagents, we anticipate that the structural and biological functions of the purified molecule remain intact. This method provides a basis for native allergen purification that can be tailored according to specific needs.

Management of Allergic Rhinitis in the United Arab Emirates: Expert Consensus Recommendations on Allergen Immunotherapy

Allergic rhinitis (AR) is a chronic inflammatory condition of the upper airways caused by a type I hypersensitivity reaction triggered by environmental allergens. AR is associated with significant morbidity and affects patients' quality of life, emotional well-being, productivity, and cognitive functioning. As AR prevalence and morbidity have increased significantly worldwide, similar observations have been noted in the United Arab Emirates (UAE) with AR becoming a potential public health issue. Management of AR in the UAE is mainly provided by non-allergy specialists relying on first-line treatments such as intranasal steroids and antihistamines, with often suboptimal and short-term efficacy. Allergen Immunotherapy (AIT) is the only currently available disease-modifying treatment option in the form of either subcutaneous or sublingual allergen immunotherapy that has been proven to have long-term benefits. This article aims to provide recommendations regarding the use of AIT for managing AR in the UAE, considering both the current landscape in the Emirati healthcare system and local experience.

Patients' values and preferences for health states in allergic rhinitis-An artificial intelligence supported systematic review

BACKGROUND

Allergic rhinitis (AR) impacts patients' physical and emotional well-being. Assessing patients' values and preferences (V&P) related to AR is an essential part of patient-centered care and of the guideline development process. We aimed to systematically summarize the information about patients' V&P on AR and its symptoms and impact on daily life.

METHODS

We conducted systematic review in a MEDLINE, Embase, PsychInfo, and CINAHL databases. We included studies which quantitatively assessed patients' V&P for specific outcomes in AR by assessing utilities, applying discrete choice approaches, or rating and ranking outcomes. We grouped outcomes as AR symptoms, functional status, and care-related patient experience. Study selection and data extraction were supported by the Laser AI tool. We rated the certainty of evidence (CoE) using the GRADE approach.

RESULTS

Thirty-six studies (41 records) were included: nine utility studies, seven direct-choice studies and 21 studies of rating or ranking outcomes. Utilities were lower with increased AR severity and with the concomitant presence of asthma, but not with whether AR was seasonal or perennial (CoE = low-high). Patients rated AR symptom-related outcomes as more important than those related to care-related patient experience and functional status (CoE = very low-moderate). Nasal symptoms (mainly nasal congestion) followed by breathing disorders, general and ocular symptoms were rated as the symptoms with the highest impact.

CONCLUSIONS

This systematic review provides a comprehensive overview of V&P of patients with AR. Patients generally considered nasal symptoms as the most important. Future studies with standardized methods are needed to provide more information on V&P in AR.

Clinical Practice Guideline: Immunotherapy for Inhalant Allergy

OBJECTIVE

Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care.

PURPOSE

The purpose of this clinical practice guideline (CPG) is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce the risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The GDG made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitizations, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions (LRs) to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The GDG offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.

Executive Summary of Clinical Practice Guideline on Immunotherapy for Inhalant Allergy

OBJECTIVE

Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care.

PURPOSE

The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The guideline development group made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The guideline development group made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitization, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The guideline development group offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.

The Impact of Cytokines on Health-Related Quality of Life in Adolescents with Allergic Rhinitis

BACKGROUND

Frequent episodes of nasal symptoms are the usual clinical manifestations (CM) of allergic rhinitis (AR) and have a significant negative impact on health-related quality of life (HRQoL) in adolescents. The purpose of this cross-sectional study was to test the hypothesis that cytokines in nasal mucus may be associated with HRQoL in adolescents with AR.

METHODS

European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L), "The Adolescent Rhinoconjunctivitis Quality of Life Questionnaire" (AdolRQLQ) and the Total 4 Symptom Score (T4SS) scoring system were administered to 113 adolescents with AR, nonallergic rhinitis (NAR) and to healthy control subjects. Nasal secretions were sampled and tested for 13 cytokines using a multiplex flow cytometric bead assay.

RESULTS

The AR group had significantly lower EQ-5D-3L (0.661 ± 0.267 vs. 0.943 ± 0.088; p < 0.001) and higher AdolRQLQ total scores (2.76 ± 1.01 vs. 1.02 ± 0.10; p < 0.001) compared to the control group. The AR group had higher concentrations of IL-1β (p = 0.002), IL-6 (p = 0.031), IL-8 (p < 0.001), IL17-A (p = 0.013) and IL-18 (p = 0.014) compared to the control group, and IL-1β, IL-6, IL17-A and IL-18 were significantly (p < 0.050) increased with disease progression. Cytokines IL-1β, IL-6, as well as severe CM, were identified as significant predictors of lower HRQoL in adolescents with AR.

CONCLUSIONS

This study identified IL-1β, IL-6, as well as severe CM, as predictors of lower HRQoL in adolescents with AR. However, these results should only serve as a starting point for additional confirmation research.

Airways Type-2 Related Disorders: Multiorgan, Systemic or Syndemic Disease?

Chronic rhinosinusitis (CRS) has recently undergone a significant paradigm shift, moving from a phenotypical classification towards an "endotype-based" definition that places more emphasis on clinical and therapeutic aspects. Similar to other airway diseases, like asthma, most cases of CRS in developed countries exhibit a dysregulated type-2 immune response and related cytokines. Consequently, the traditional distinction between upper and lower airways has been replaced by a "united airway" perspective. Additionally, type-2 related disorders extend beyond respiratory boundaries, encompassing conditions beyond the airways, such as atopic dermatitis. This necessitates a multidisciplinary approach. Moreover, consideration of possible systemic implications is crucial, particularly in relation to sleep-related breathing diseases like Obstructive Sleep Apnoea Syndrome (OSAS) and the alteration of systemic inflammatory mediators such as nitric oxide. The trends in epidemiological, economic, and social burden are progressively increasing worldwide, indicating syndemic characteristics. In light of these insights, this narrative review aims to present the latest evidence on respiratory type-2 related disorders, with a specific focus on CRS while promoting a comprehensive perspective on the "united airways". It also introduces a novel concept: viewing these conditions as a multiorgan, systemic, and syndemic disease.

Determinants of uncontrolled allergic rhinitis in Kinshasa hospitals

Objective

To identify the determinants of uncontrolled allergic rhinitis (UCAR) in a hospital setting in Kinshasa, Democratic Republic of Congo.

Methods

Hospital-based cross-sectional study of 153 patients with allergic rhinitis (AR). The diagnosis of AR was based on clinical grounds according to the Allergic Rhinitis and its Impact on Asthma (ARIA) criteria. Categorization into controlled AR (CAR) and UCAR was based on the visual analog scale (VAS with cut off point of 5). Binary logistic regression was used to identify factors associated with UCAR.

Results

Patients with UCAR (60.1%) proportionally outnumbered those with CAR (39.9%). There were significantly more patients younger than 30 years of age among patients with UCAR. Factors significantly associated with UCAR were age below 30 years (OR = 3.31; 95% CI: 1.49-7.36; p = 0.003), low serum vitamin D level (OR = 3.86; 95% CI: 1.72-8.68; p = 0.001), persistent form (OR = 3.11; 95% CI: 1.39-6.98; p = 0.006) and moderate to severe form of AR (OR = 4.31; 95% CI: 1.77-10.49; p = 0.001).

Conclusions

Factors associated with UCAR in this study population were younger age less than 30 years, low vitamin D level, and persistent as well as moderate to severe AR. Further studies are needed to elucidate the underlying mechanisms favoring the occurrence of these factors.

Combined Korean medicine therapies in children with allergic rhinitis: A multi-center, observational explanatory registry trial: A study protocol

INTRODUCTION

Allergic rhinitis (AR) is the third most prevalent disease in early and middle adolescence in South Korea and one of the most common allergic diseases worldwide. Due to the ineffectiveness and frequent side effects of conventional medications for AR (such as antihistamines, corticosteroids) complementary and alternative medical (CAM) therapies have been in the spotlight. Although previous clinical trials conducted on AR with CAM showed efficacy and safety, these research results have limitations in that they did not estimate the effectiveness of combining multiple interventions. In this respect, this study aims to investigate the efficacy and safety of combined Korean medicine therapy by establishing an observational registry study at 13 Korean medical clinics that specialize in treating pediatric rhinitis.

METHODS

This is a prospective, observational, registry study of adolescent patients with AR. After screening, eligible subjects will be allocated to the registry. The patients will undergo a 4-week treatment and a 4-week post-treatment follow-up. The primary outcome will be the change in the average total nasal symptom score evaluated from baseline to the end of treatment. The secondary outcomes will include the numerical range scale, quality of life questionnaire in Korean children with AR, and the Pediatric Allergic Disease Quality of Life Questionnaire. KiFDA 3.0 will be measured for explanatory application on adolescents. Medical cost data and characteristics of patients such as weight, height, and sex will be collected by researchers.

DISCUSSION

This is the first multi-center observational registry study to compare combined Korean medicine treatment for AR. The results of this study will shed light on the effectiveness and safety of Korean medicine treatments for the treatment of patients with AR.

TRIAL REGISTRATION

KCT0006625 (2021.09.30)/IRB approval: Kyung-hee University Institutional Review Board (approval number: KHSIRB-21-358-1 [NA]).Trial Status: Protocol version 1.2(2021.09.16).

Composition of nasal bacterial community and its seasonal variation in health care workers stationed in a clinical research laboratory

The microorganisms at the workplace contribute towards a large portion of the biodiversity a person encounters in his or her life. Health care professionals are often at risk due to their frontline nature of work. Competition and cooperation between nasal bacterial communities of individuals working in a health care setting have been shown to mediate pathogenic microbes. Therefore, we investigated the nasal bacterial community of 47 healthy individuals working in a clinical research laboratory in Kuwait. The taxonomic profiling and core microbiome analysis identified three pre-dominant genera as Corynebacterium (15.0%), Staphylococcus (10.3%) and, Moraxella (10.0%). All the bacterial genera exhibited seasonal variations in summer, winter, autumn and spring. SparCC correlation network analysis revealed positive and negative correlations among the classified genera. A rich set of 16 genera (q < 0.05) were significantly differentially abundant (LEfSe) across the four seasons. The highest species counts, richness and evenness (P < 0.005) were recorded in autumn. Community structure profiling indicated that the entire bacterial population followed a seasonal distribution (R2-0.371; P < 0.001). Other demographic factors such as age, gender and, ethnicity contributed minimally towards community clustering in a closed indoor laboratory setting. Intra-personal diversity also witnessed rich species variety (maximum 6.8 folds). Seasonal changes in the indoor working place in conjunction with the outdoor atmosphere seems to be important for the variations in the nasal bacterial communities of professionals working in a health care setting.

ARIA 2019 Care Pathways for Allergic Rhinitis in the Kuwait Health Care System

A worldwide increase in prevalence of allergic diseases has led to adaptations in national and international health care systems. ARIA (Allergic Rhinitis and Its Impact on Asthma) initiative develops internationally applicable guidelines for allergic respiratory diseases. In collaboration with international initiatives, ARIA offers updates of real-life integrated care pathways (ICPs) for digitally assisted, integrated, and individualized treatment of allergic rhinitis (AR). This article presents certain aspects of the health care system in Kuwait with reference to the management of AR and the objective of introducing ICPs and adopting the latest ARIA recommendations. Guidelines for ICPs include aspects of patients and health care providers and cover key areas of management of AR. This model of guidelines supports real-life health care better than traditional models. ARIA recommendations will be locally integrated in the health care system with the aim of improving both pharmacotherapy and allergy immunotherapy.

The Association Between Serum 25-Hydroxyvitamin D Levels and Patients With Allergic Rhinitis

Introduction Many studies have suggested a link between vitamin D deficiency and the development of other atopic diseases like allergic rhinitis (AR). AR can lead to sleep disturbance, fatigue, depressed mood, and compromised cognitive function, which can impair the quality of life and productivity in many people. Objective We aimed to determine the association between vitamin D levels and AR and the effect of vitamin D on atopy markers. Methods All patients with AR who were diagnosed, treated, and followed up at the King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia from January 2012 to January 2020 were included in the study. Our exclusion criteria were as follows: pediatric patients, patients with insufficient follow-up data, patients with no atopy markers, patients with comorbid conditions affecting their serum vitamin D levels, and patients with a history of taking medications that affect serum vitamin D levels. Results Fifty-five adult patients with AR were included in the study. Patients with vitamin D deficiency were more likely to have uncontrolled AR. Regarding the effect of vitamin D deficiency on atopy markers, there was no statistically significant relationship between vitamin D deficiency and serum immunoglobulin E (IgE) levels. However, serum eosinophil levels were significantly higher in patients with vitamin D deficiency. Conclusion Our results showed that vitamin D deficiency is strongly associated with uncontrolled AR; there was a statistically significant relationship between vitamin D deficiency and eosinophil levels, but no significant relationship between vitamin D deficiency and serum IgE was found.

Budesonide vs Saline Nasal Irrigation in Allergic Rhinitis: A Randomized Placebo-Controlled Trial

Objectives

Budesonide nasal irrigation is currently widely used in the treatment of chronic sinusitis typically following endoscopic sinus surgery to improve inflammatory control. Its application in treatment of allergic rhinitis has not been previously studied. This study assesses the subjective and clinical response to budesonide buffered hypertonic saline nasal irrigation and hypertonic saline nasal irrigation in patients with allergic rhinitis.

Study Design

This is a prospective, single-center, double-blind, randomized placebo-controlled trial.

Setting

Tertiary care hospital.

Subjects and Methods

Fifty-two patients diagnosed with allergic rhinitis were randomized into 2 groups to receive either buffered hypertonic saline nasal irrigation with a placebo respule or buffered hypertonic saline nasal irrigation with a budesonide respule. Patients were assessed at baseline and 4 weeks subjectively using the Sino-Nasal Outcome Test–22 (SNOT-22) questionnaire and visual analog scale (VAS). Clinical assessment was done using the modified Lund-Kennedy score.

Results

The average SNOT-22, VAS, and modified Lund-Kennedy scores improved in both groups ( P < .001). The budesonide irrigation group was found to have significantly better improvement than the saline nasal irrigation group with the SNOT-22 scores ( P = .012) and VAS scores ( P = .007). However, the difference in the clinical response between the 2 groups was not significant ( P = .268).

Conclusion

This study adds evidence to the use of saline nasal irrigation in allergic rhinitis but also demonstrates efficacy of the addition of budesonide to irrigations. Budesonide nasal irrigation thus appears to be a viable treatment option for allergic rhinitis.