Updated grading system for systemic allergic reactions: Joint Statement of the World Allergy Organization Anaphylaxis Committee and Allergen Immunotherapy Committee

There is a lack of consensus over the description and severity assignment of allergic adverse reactions to immunotherapy, although there seems to be a consensus at least in terms of using the World Allergy Organization (WAO) grading systems to describe local adverse events for Sublingual Immunotherapy (SLIT) and Systemic Allergic Reactions (SARs) to Subcutaneous Immunotherapy (SCIT) amongst the major national/regional allergy societies. In this manuscript, we propose a modification of the previous WAO Grading system for SARs, which aligns with the newly-proposed Consortium for Food Allergy Research (CoFAR) Grading Scale for Systemic Allergic Reactions in Food Allergy (version 3.0). We hope this can facilitate a unified grading system appropriate to SARs due to allergen immunotherapy, independent of allergen and route of administration, and across clinical and research practice.

Open-inhaler versus single-inhaler triple therapy (long-acting muscarinic antagonist, inhaled corticosteroid, and long-acting β2-agonist) in asthma patients: a narrative review

OBJECTIVE

To review the evidence for the use of open-inhaler (inhaled corticosteroid [ICS] plus long-acting β2-agonist [LABA] with separate add-on long-acting muscarinic antagonist [LAMA]) versus single-inhaler triple therapy (ICS/LABA/LAMA combination) and the merits of add-on LAMA to ICS/LABA in patients with uncontrolled asthma.

DATA SOURCES

Original research articles were identified from PubMed using the search term "triple therapy asthma." Information was also retrieved from the ClinicalTrials.gov website.

STUDY SELECTIONS

Articles detailing the use of add-on LAMA to ICS plus LABA (open-inhaler triple therapy), and closed triple therapy compared with ICS plus LABA dual therapy, addressing patient symptoms, exacerbations, and health-related quality of life.

RESULTS

Open-inhaler triple therapy was associated with a significantly reduced incidence of hospitalizations and emergency department visits and a decrease in ICS dose, oral corticosteroids use, and antibiotics use. Exacerbations and acute respiratory events were also reduced. Single-inhaler triple therapy showed a greater improvement in lung function, asthma control, and health status and was noninferior to open-inhaler triple therapy for Asthma Quality of Life Questionnaire scores. Single-inhaler triple therapy may also lead to improved therapy adherence.

CONCLUSION

Add-on LAMA to ICS plus LABA (open- or single-inhaler triple therapy) improves the response in patients who remain symptomatic and provides a reasonable alternative to ICS dose escalation in treatment-refractory patients.

Provision of Food Allergy Care in the United Kingdom and United States: Current Issues and Future Directions

Food allergy (FA) is a growing issue worldwide. The United Kingdom and United States are high-income, industrialized countries with reported increases in FA prevalence over the past few decades. This review compares delivery of FA care in the United Kingdom and United States and each country's response to the heightened demand and disparities for FA services. In the United Kingdom, allergy specialists are scarce and general practitioners (GPs) provide most allergy care. Whereas the United States has more allergists per capita than the United Kingdom, there is still a shortage of allergy services owing to the greater reliance on specialist care for FA in America and wide geographic variation in access to allergist services. Currently, generalists in these countries lack the specialty training and equipment to diagnose and manage FA optimally. Moving forward, the United Kingdom aims to enhance training for GPs so they may provide better quality frontline allergy care. In addition, the United Kingdom is implementing a new tier of semi-specialized GPs and increasing cross-center collaboration through clinical networks. The United Kingdom and United States aim to increase the number of FA specialists, which is critical at a time of rapidly expanding management options for allergic and immunologic diseases requiring clinical expertise and shared decision-making to select appropriate therapies. While these countries aim to grow their supply of quality FA services actively, further efforts to build clinical networks and perhaps recruit international medical graduates and expand telehealth services are necessary to reduce disparities in access to care. For the United Kingdom in particular, increasing quality services will require additional support from the leadership of the centralized National Health Service, which remains challenging.

Yardstick for managing cough. Part 2: in children

Nationwide statistics in the United States and Australia reveal that cough of undifferentiated duration is the most common complaint for which patients of all ages seek medical care in the ambulatory setting. Management of chronic cough is one of the most common reasons for new patient visits to respiratory specialists. Because symptomatic cough is such a common problem and so much has been learned about how to diagnose and treat cough of all durations but especially chronic cough, this 2-part yardstick has been written to review in a practical way the evidence-based guidelines most of which have been developed from high-quality systematic reviews on how best to manage cough of all durations in adults, adolescents, and children. Chronic cough in children is often benign and self-limiting. Using established and validated protocols and specific pointers (clues in history, findings on examination) can aid the clinician in identifying causes when present and improve outcomes. In this manuscript, part 2 of the 2-part series, we provide evidence-based, expert opinion recommendations on the management of chronic cough in the pediatric patient (<14 years of age).

Prevalence and Burden of Chronic Cough in the United States

BACKGROUND

Chronic cough is a common complaint but there are little population-based data on its burden in the United States.

OBJECTIVE

To determine the prevalence of chronic cough and its burden on individuals and the health care system.

METHODS

This was a survey of respondents who completed the 2018 National Health and Wellness Survey and questions about sleep and health care resource use. Chronic cough was defined as having a daily cough for 8 or more weeks. Respondents without chronic cough were selected through propensity score matching. Chronic cough prevalence was estimated using poststratification sampling weights calculated using U.S. Census data and post-data Horvitz-Thompson sampling weights to adjust for sampling bias.

RESULTS

Of 74,977 National Health and Wellness Survey respondents, 3,654 had experienced chronic cough in the previous 12 months, for a weighted prevalence of 5.0%. Respondents with chronic cough were older and more predominantly female than respondents without chronic cough (both P < .001). Compared with matched respondents without chronic cough, those with chronic cough had lower mean scores on the Medical Outcomes Study 36-item Short Form Survey v2 physical (P < .001) and mental (P < .001) component summary scores. More respondents with chronic cough than matched controls experienced severe anxiety and severe depression in the past 2 weeks, work productivity impairment, impaired sleep quality and daytime sleepiness, as well as more emergency department visits and hospitalizations in the past 6 months (P < .001 for all comparisons).

CONCLUSIONS

The burden of chronic cough manifests itself as reduced health-related quality of life, increased anxiety and depression, impaired sleep and work productivity, and greater health care utilization.

Erratum to "IgE allergy diagnostics and other relevant tests in allergy, a World Allergy Organization position paper" [World Allergy Organ J 13/2 (2020) 100080]

[This corrects the article DOI: 10.1016/j.waojou.2019.100080.].

Peanut allergy diagnosis: A 2020 practice parameter update, systematic review, and GRADE analysis

Given the burden of disease and the consequences of a diagnosis of peanut allergy, it is important that peanut allergy be accurately diagnosed so that an appropriate treatment plan can be developed. However, a test that indicates there is peanut sensitization present (eg, a "positive" test) is not always associated with clinical reactivity. This practice parameter addresses the diagnosis of IgE-mediated peanut allergy, both in children and adults, as pertaining to 3 fundamental questions, and based on the systematic reviews and meta-analyses, makes recommendations for the clinician who is evaluating a patient for peanut allergy. These questions relate to when diagnostic tests should be completed, which diagnostic tests to utilize, and the utility (or lack thereof) of diagnostic testing to predict the severity of a future allergic reaction to peanut.

Rhinitis 2020: A practice parameter update

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.

IgE allergy diagnostics and other relevant tests in allergy, a World Allergy Organization position paper

Currently, testing for immunoglobulin E (IgE) sensitization is the cornerstone of diagnostic evaluation in suspected allergic conditions. This review provides a thorough and updated critical appraisal of the most frequently used diagnostic tests, both in vivo and in vitro. It discusses skin tests, challenges, and serological and cellular in vitro tests, and provides an overview of indications, advantages and disadvantages of each in conditions such as respiratory, food, venom, drug, and occupational allergy. Skin prick testing remains the first line approach in most instances; the added value of serum specific IgE to whole allergen extracts or components, as well as the role of basophil activation tests, is evaluated. Unproven, non-validated, diagnostic tests are also discussed. Throughout the review, the reader must bear in mind the relevance of differentiating between sensitization and allergy; the latter entails not only allergic sensitization, but also clinically relevant symptoms triggered by the culprit allergen.

From the Pages of Allergy Watch: February 2020

A new Annals feature in 2018, "From the Pages of AllergyWatch" is devoted to publishing synopses of Allergy and Asthma literature relevant to a topic of emphasis. These unbiased synopses and comments by our Editors have been previously printed in the AllergyWatch bimonthly newsletter, and it is our hope that presenting carefully selected article summaries and comments in the Annals will serve as a valuable educational resource for practicing allergists.

Cutaneous Allergy

A new Annals feature in 2018, "From the Pages of AllergyWatch" is devoted to publishing synopses of Allergy and Asthma literature relevant to a topic of emphasis. These unbiased synopses and comments by our Editors have been previously printed in the AllergyWatch bimonthly newsletter, and it is our hope that presenting carefully selected article summaries and comments in the Annals will serve as a valuable educational resource for practicing allergists.

AllergyWatch

A new Annals feature in 2018, "From the Pages of AllergyWatch" is devoted to publishing synopses of Allergy and Asthma literature relevant to a topic of emphasis. These unbiased synopses and comments by our Editors have been previously printed in the AllergyWatch bimonthly newsletter, and it is our hope that presenting carefully selected article summaries and comments in the Annals will serve as a valuable educational resource for practicing allergists. For this issue of 'From the Pages of Allergy Watch' articles are presented that coincide with the theme of this month's Annals. The first article addresses the impact of allergic rhinitis on work productivity in affected patients. The second article review data from a large number of children presenting to Canadian emergency departments with asthma exacerbations and the impact of certain viral pathogens. The last article reviewed investigates data showing that patients who 'run out' of asthma inhalers were more likely to present to the emergency room for their asthma care.

Chronic Cough and Gastroesophageal Reflux in Children: CHEST Guideline and Expert Panel Report

BACKGROUND

Whether gastroesophageal reflux (GER) or GER disease (GERD) causes chronic cough in children is controversial. Using the Population, Intervention, Comparison, Outcome (PICO) format, we undertook four systematic reviews. For children with chronic cough (> 4-weeks duration) and without underlying lung disease: (1) who do not have gastrointestinal GER symptoms, should empirical treatment for GERD be used? (2) with gastrointestinal GER symptoms, does treatment for GERD resolve the cough? (3) with or without gastrointestinal GER symptoms, what GER-based therapies should be used and for how long? (4) if GERD is suspected as the cause, what investigations and diagnostic criteria best determine GERD as the cause of the cough?

METHODS

We used the CHEST Expert Cough Panel's protocol and American College of Chest Physicians (CHEST) methodological guidelines and GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. Delphi methodology was used to obtain consensus.

RESULTS

Few randomized controlled trials addressed the first two questions and none addressed the other two. The single meta-analysis (two randomized controlled trials) showed no significant difference between the groups (any intervention for GERD vs placebo for cough resolution; OR, 1.14; 95% CI, 0.45-2.93; P = .78). Proton pump inhibitors (vs placebo) caused increased serious adverse events. Qualitative data from existing CHEST cough systematic reviews were consistent with two international GERD guidelines.

CONCLUSIONS

The panelists endorsed that: (1) treatment(s) for GERD should not be used when there are no clinical features of GERD; and (2) pediatric GERD guidelines should be used to guide treatment and investigations.

AllergyWatch

The articles reviewed in this month's edition of From the Pages of Allergy Watch were selected to coincide with the food allergy theme. The first article investigates potential inflammatory markers in children who outgrow their food allergy. The article reviewed by Dr Khan investigates the usefulness of behavioral therapy intervention to help allay anxiety for parents of children with food allergy. The article reviewed by Dr Oppenheimer explores the immunologic mechanism associated with the development of tolerance in young children with cow's milk allergy. The last article reported accidental ingestions of foods that may or may not have been listed in the precautionary food label.

Etiologies of Chronic Cough in Pediatric Cohorts: CHEST Guideline and Expert Panel Report

BACKGROUND

There is no published systematic review on the etiologies of chronic cough or the relationship between OSA and chronic cough in children aged ≤ 14 years. We thus undertook a systematic review based on key questions (KQs) using the Population, Intervention, Comparison, Outcome format. The KQs follow: Among children with chronic (> 4 weeks) cough (KQ 1) are the common etiologies different from those in adults? (KQ 2) Are the common etiologies age or setting dependent, or both? (KQ 3) Is OSA a cause of chronic cough in children?

METHODS

We used the CHEST Expert Cough Panel's protocol and the American College of Chest Physicians (CHEST) methodological guidelines and Grading of Recommendations Assessment, Development, and Evaluation framework. Data from the systematic reviews in conjunction with patients' values and preferences and the clinical context were used to form recommendations. Delphi methodology was used to obtain consensus.

RESULTS

Combining KQs 1 and 2, we found moderate-level evidence from 10 prospective studies that the etiologies of cough in children are different from those in adults and are setting dependent. Data from three studies found that common etiologies of cough in young children were different from those in older children. However, data relating sleep abnormalities to chronic cough in children were found only in case studies.

CONCLUSIONS

There is moderate-quality evidence that common etiologies of chronic cough in children are different from those in adults and are dependent on age and setting. As there are few data relating OSA and chronic cough in children, the panel suggested that these children should be managed in accordance with pediatric sleep guidelines.

Use of Management Pathways or Algorithms in Children With Chronic Cough: CHEST Guideline and Expert Panel Report

BACKGROUND

Using management algorithms or pathways potentially improves clinical outcomes. We undertook systematic reviews to examine various aspects in the generic approach (use of cough algorithms and tests) to the management of chronic cough in children (aged ≤ 14 years) based on key questions (KQs) using the Population, Intervention, Comparison, Outcome format.

METHODS

We used the CHEST Expert Cough Panel's protocol for the systematic reviews and the American College of Chest Physicians (CHEST) methodological guidelines and Grading of Recommendations Assessment, Development and Evaluation framework. Data from the systematic reviews in conjunction with patients' values and preferences and the clinical context were used to form recommendations. Delphi methodology was used to obtain the final grading.

RESULTS

Combining data from systematic reviews addressing five KQs, we found high-quality evidence that a systematic approach to the management of chronic cough improves clinical outcomes. Although there was evidence from several pathways, the highest evidence was from the use of the CHEST approach. However, there was no or little evidence to address some of the KQs posed.

CONCLUSIONS

Compared with the 2006 Cough Guidelines, there is now high-quality evidence that in children aged ≤ 14 years with chronic cough (> 4 weeks' duration), the use of cough management protocols (or algorithms) improves clinical outcomes, and cough management or testing algorithms should differ depending on the associated characteristics of the cough and clinical history. A chest radiograph and, when age appropriate, spirometry (pre- and post-β₂ agonist) should be undertaken. Other tests should not be routinely performed and undertaken in accordance with the clinical setting and the child's clinical symptoms and signs (eg, tests for tuberculosis when the child has been exposed).

Children With Chronic Wet or Productive Cough--Treatment and Investigations: A Systematic Review

BACKGROUND

Systematic reviews were conducted to examine two related key questions (KQs) in children with chronic (> 4 weeks' duration) wet or productive cough not related to bronchiectasis: KQ1-How effective are antibiotics in improving the resolution of cough? If so, what antibiotic should be used and for how long? KQ2-When should they be referred for further investigations?

METHODS

The systematic reviews were undertaken based on the protocol established by selected members of the CHEST expert cough panel. Two authors screened searches and selected and extracted data. The study included systematic reviews, randomized controlled trials (RCTs), cohort (prospective and retrospective) studies, and cross-sectional studies published in English.

RESULTS

Data were presented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowcharts, and the summaries were tabulated. Fifteen studies were included in KQ1 (three systematic reviews, three RCTs, five prospective studies, and four retrospective studies) and 17 in KQ2 (one RCT, 11 prospective studies, and five retrospective studies). Combining data from the RCTs (KQ1), the number needed to treat for benefit was 3 (95% CI, 2.0-4.3) in achieving cough resolution. In general, findings from prospective and retrospective studies were consistent, but there were minor variations.

CONCLUSIONS

There is high-quality evidence that in children aged ≤ 14 years with chronic (> 4 weeks' duration) wet or productive cough, the use of appropriate antibiotics improves cough resolution. There is also high-quality evidence that when specific cough pointers (eg, digital clubbing) are present in children with wet cough, further investigations (eg, flexible bronchoscopy, chest CT scans, immunity tests) should be conducted. When the wet cough does not improve by 4 weeks of antibiotic treatment, there is moderate-quality evidence that children should be referred to a major center for further investigations to determine whether an underlying lung or other disease is present.

Use of Management Pathways or Algorithms in Children With Chronic Cough: Systematic Reviews

BACKGROUND

Use of appropriate cough pathways or algorithms may reduce the morbidity of chronic cough, lead to earlier diagnosis of chronic underlying illness, and reduce unnecessary costs and medications. We undertook three systematic reviews to examine three related key questions (KQ): In children aged ?14 years with chronic cough (> 4 weeks' duration), KQ1, do cough management protocols (or algorithms) improve clinical outcomes? KQ2, should the cough management or testing algorithm differ depending on the duration and/or severity? KQ3, should the cough management or testing algorithm differ depending on the associated characteristics of the cough and clinical history?

METHODS

We used the CHEST expert cough panel's protocol. Two authors screened searches and selected and extracted data. Only systematic reviews, randomized controlled trials (RCTs), and cohort studies published in English were included.

RESULTS

Data were presented in Preferred Reporting Items for Systematic Reviews and Meta-analyses flowcharts and summary tabulated. Nine studies were included in KQ1 (RCT = 1; cohort studies = 7) and eight in KQ3 (RCT = 2; cohort = 6), but none in KQ2.

CONCLUSIONS

There is high-quality evidence that in children aged ?14 years with chronic cough (> 4 weeks' duration), the use of cough management protocols (or algorithms) improves clinical outcomes and cough management or the testing algorithm should differ depending on the associated characteristics of the cough and clinical history. It remains uncertain whether the management or testing algorithm should depend on the duration or severity of chronic cough. Pending new data, chronic cough in children should be defined as > 4 weeks' duration and children should be systematically evaluated with treatment targeted to the underlying cause irrespective of the cough severity.