November 2021

Nov 22

Metabolomics Reveals Process of Allergic Rhinitis Patients with Single- and Double-Species Mite Subcutaneous Immunotherapy

By Bilastina Selected articles

Zheng, P., Yan, G., Zhang, Y., Huang, H., Luo, W., Xue, M., Li, N., Wu, J. L., & Sun, B.

Metabolites . 2021 Sep 9;11(9):613. doi: 10.3390/metabo11090613.

Allergic rhinitis is also known as anaphylactic rhinitis and includes infectious inflammatory conditions of the nasal mucosa triggered by exposure to atopic allergens. House dust mites are the most common allergens in patients with rhinitis. Allergen immunotherapy (AIT) is the only treatment that can change the course of allergic rhinitis, but there is a lack of knowledge in relation to AIT with single or mixed allergens. The aim of this study was to assess and compare the clinical efficacy of single-mite subcutaneous immunotherapy or double-mite subcutaneous immunotherapy using the visual analogue scale (VAS) score and rhinoconjunctivitis quality of life questionnaire score to evaluate and compare its clinical efficacy.

Patients with allergic rhinitis caused by Dermatophagoides pternussinus and Dermatophagoides farinae received a single-mite and double-mite subcutaneous immunotherapy, respectively.

There was no significant difference in efficacy between treatments. A total of 57 metabolites were identiﬁed, among which down-stream metabolites (5(S)-HETE (Hydroxyeicosatetraenoic acid), 8(S)-HETE, 11(S)-HETE, 15(S)-HETE and 11-hydro TXB2) in the ω-6-related arachidonic acid and linoleic acid pathway showed signiﬁcant differences after approximately one year of treatment with single-mite or double-mite subcutaneous immunotherapy, and the changes of the above serum metabolic components were correlated with the magnitude of rhinoconjunctivitis quality of life questionnaire improvement, respectively.

The major difference found was with 11(S)-HETE, which decreased more with single-mite immunotherapy, having the possibility to be used as a biomarker to distinguish the two treatments.

In conclusion, both treatments showed therapeutic effects on patients with allergic rhinitis, with no differences in efficacy. The production of different inflammation-related metabolites can lead to potential biomarkers.

This document is only available for registered healthcare professionals

Nov 22

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Lachnospira is a signature of antihistamine efficacy in chronic spontaneous urticaria

By Bilastina Artículos seleccionados, Selected articles

Liu, R., Peng, C., Jing, D., Xiao, Y., Zhu, W., Zhao, S., Zhang, J., Chen, X., & Li, J.

Exp Dermatol. 2021 Sep 24. doi: 10.1111/exd.14460. Online ahead of print.

Chronic urticaria is a condition driven by mast cells, with an average lifetime prevalence of 1.4%. Chronic spontaneous urticaria is a common type of chronic urticaria that impacts quality of life and has a high economic and social burden. Chronic spontaneous urticaria is treated with oral second-generation antihistamines, however only half of the patients respond to up to quadruple doses of these antihistamines. It is known that gut microbiota can affect their efficacy. The objective of this study was to explore the relationship between gut microbiota and the efficacy of antihistamines in people with chronic spontaneous urticaria.

The gut microbiota of fecal samples from 15 responders to antihistamine monotherapy and 15 non-responders was assessed by 16S rDNA sequencing, and the differential bacterial species between them were confirmed by quantitative polymerase chain reaction (qPCR). Samples from 30 responders and 30 non-responders were used to confirm the differential bacterial species by qPCR.

The main difference between responders and non-responders was the presence of Lachnospiraceae and its subordinate taxa. The quantity of Lachnospira was higher in responders than non-responders.

In conclusion, the presence of Lachnospira has shown to have a moderate diagnostic value in assessing the efficacy of chronic urticaria with antihistamines.

This document is only available for registered healthcare professionals

Nov 22

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The International EAACI/GA²LEN/EuroGuiDerm/APAAACI Guideline for the Definition, Classification, Diagnosis and Management of Urticaria

By Bilastina Artículos seleccionados, Selected articles

Zuberbier T, Abdul Latiff AH, Abuzakouk M, et al.

Allergy . 2021 Sep 18. doi: 10.1111/all.15090. Online ahead of print.

Urticaria is a mast-cell-driven condition with symptoms such as wheals, angioedema, or both. Chronic spontaneous urticaria and chronic inducible urticaria reduce the quality of life, affecting performance at school and work.

This document is an update and revision of the international guideline for urticaria, from a consensus conference held on the 3^rd of December of 2020. It covers the definition and classification of urticaria and outlines expert-guided and evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

The objective of this guideline is to facilitate a definition and classification of urticaria, helping with data interpretation from different centers and areas of the world.

The table below summarizes the guideline.

How should urticaria be classified?
We recommend that urticaria is classified based on its duration as acute (<= 6 weeks) or chronic (> 6 weeks).	↑ ↑	Strong consensus* Expert consensus
We recommend that urticaria is classified as spontaneous (no definite eliciting factor involved) or inducible (specific definite factor involved).	↑ ↑	Strong consensus* Expert consensus
Should we maintain the current guideline classification of chronic urticaria?
We recommend that the current guideline classification of chronic urticaria should be maintained.	↑ ↑	Strong consensus* Expert consensus
Should routine diagnostic measures be performed in acute urticaria?
We recommend against any routine diagnostic measures in acute spontaneous urticaria.	↓ ↓	Strong consensus* Expert consensus
Should differential diagnoses be considered in patients with chronic spontaneous urticaria?
We recommend that differential diagnoses be considered in all patients with signs or symptoms suggestive of chronic urticaria based on the guideline algorithm.	↑ ↑	Strong consensus* Expert consensus
What routine diagnostic measures should be performed in chronic spontaneous urticaria?
We recommend limited investigations. Basic tests include differential blood count, CRP and/or ESR, and in specialized care total IgE and IgG anti-TPO, and more biomarkers as appropriate. We recommend performing further diagnostic measures based on the patient history and examination, especially in patients with long standing and/or uncontrolled disease.	↑ ↑	Consensus** Expert consensus
Should routine diagnostic measures be performed in inducible urticaria?
We recommend using provocation testing to diagnose chronic inducible urticaria. We recommend using provocation threshold measurements and the UCT to measure disease activity and control in patients with chronic inducible urticaria, respectively.	↑ ↑	Strong consensus* Expert consensus
Should patients with chronic urticaria be assessed for disease activity, impact, and control?
We recommend that patients with CU be assessed for disease activity, impact, and control at every visit.	↑ ↑	Strong consensus* Expert consensus
Which instruments should be used to assess and monitor disease activity in chronic spontaneous urticaria patients?
We recommend the use of the urticaria activity score, UAS7, and/or of the angioedema activity score, AAS, for assessing disease activity in patients with chronic spontaneous urticaria.	↑ ↑	Strong consensus* Expert consensus
Which instruments should be used to assess and monitor quality of life impairment in chronic spontaneous urticaria patients?
We recommend the use of the chronic urticaria quality of life questionnaire, CU-Q2oL, and the angioedema quality of life questionnaire, AE-QoL, for assessing quality of life impairment in patients with chronic spontaneous urticaria.	↑ ↑	Strong consensus* Expert consensus
Which instruments should be used to assess and monitor disease control in chronic spontaneous urticaria patients?
We recommend the use of the urticaria control test, UCT, and/or the angioedema control test, AECT, for assessing disease control in patients with CSU.	↑ ↑	Strong consensus* Expert consensus
Should treatment aim at complete symptom control in urticaria?
We recommend aiming at complete symptom control in urticaria, considering as much as possible the safety and the quality of life of each individual patient.	↑ ↑	Strong consensus* Expert consensus
Should patients with chronic spontaneous urticaria be advised to discontinue medication that is suspected to worsen the disease?
We recommend advising patients with chronic spontaneous urticaria to discontinue medication that is suspected to worsen the disease, e.g. NSAIDs.	↑ ↑	Strong consensus* Expert consensus
Should modern 2nd generation H1-antihistamines be used as first-line treatment of urticaria?
We recommend a 2nd generation H1-antihistamine as first-line treatment for all types of urticaria.	↑ ↑	Strong consensus* Evidence and consensus-based
Is an increase in the dose to up to four-fold of modern 2nd generation H1-antihistamines useful and to be preferred over other treatments in urticaria?
We recommend updosing of a 2nd generation H1-antihistamine up to 4-fold in patients with chronic urticaria unresponsive to a standard-dosed 2nd generation H1-antihistamines as second line treatment before other treatments are considered.	↑ ↑	Strong consensus* Evidence and consensus-based
Should modern 2nd generation H1-antihistamines be taken regularly or as needed?
We suggest 2nd generation H1-antihistamines to be taken regularly for the treatment of patients with chronic urticaria.	↑	Strong consensus* Evidence and consensus-based
Should different 2nd generation H1-antihistamines be used at the same time?
We suggest against using different H1-antihistamines at the same time.	↓	Consensus*** Evidence and consensus-based
If there is no improvement, should higher than fourfold doses of 2nd generation H1-antihistamines be used?
We recommend against using higher than 4-fold standard dosed H1-antihistamines in chronic urticaria	↓ ↓	Strong consensus* Evidence and consensus-based
Is omalizumab useful as add-on treatment in patients unresponsive to high doses of H1-antihistamines?
We recommend adding on omalizumab* for the treatment of patients with CU unresponsive to high dose 2nd generation H1-antihistamines. *currently licensed for chronic spontaneous urticaria	↑ ↑	Strong consensus* Evidence and consensus-based
Is ciclosporin useful as add-on treatment in patients unresponsive to high doses of H1-antihistamine?
We suggest using ciclosporin for the treatment of patients with CU unresponsive to high dose of 2nd generation H1-antihistamine and omalizumab.	↑	Strong consensus* Evidence and consensus-based
Should oral corticosteroids be used as add-on treatment in the treatment of urticaria?
We recommend against the long-term use of systemic glucocorticosteroids in CU.	↓ ↓	Strong consensus* Evidence and consensus-based
We suggest considering a short course of rescue systemic glucocorticosteroids in patients with an acute exacerbation of CU.	↑	Strong consensus* Evidence and consensus-based
Are H2-antihistamines useful as add-on treatment in patients unresponsive to low or high doses of H1-antihistamines?
We cannot make a recommendation for or against the combined use of H1- and H2-antihistamines in patients with chronic urticaria.	0	Strong consensus* Expert consensus
Could any other treatment options be recommended for the treatment of urticaria?
We cannot make a recommendation with respect to further treatment options as standard therapies, but these may be considered in special cases, which also include those where financial or legal limitations for the recommended algorithm treatment exist.	0	Strong consensus* Expert consensus
Should the same treatment algorithm be used in children?
We suggest using the same treatment algorithm with caution (e.g. weight adjusted dosage) in children with chronic urticaria	↑	Strong consensus* Expert consensus
Should the same treatment algorithm be used in pregnant women and during lactation?
We suggest using the same treatment algorithm with caution both in pregnant and lactating women after risk-benefit assessment. Drugs contraindicated or not suitable in pregnancy should not be used	↑	Strong consensus* Expert consensus

*≥90% agreement

**>75% agreement

***≥70% agreement

This document is only available for registered healthcare professionals

Nov 22

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Predictive features associated with chronic spontaneous urticaria recurrence

By Bilastina Artículos seleccionados, Selected articles

Elias Toubi, Zahava Vadasz

J Dermatol . 2021 Sep 14. doi: 10.1111/1346-8138.16119. Online ahead of print.

Chronic spontaneous urticaria is an autoimmune condition for, at least, 50% of the cases, and sometimes it is associated with other autoimmune diseases such as thyroid autoimmunity and systemic lupus erythematosus. They have an increased prevalence of autoreactive T-cell responses to FceRI and serum anti-thyroid antibodies. There are still a lot of unclear aspects to be determined, namely how long CSU will last. Most patients with chronic spontaneous urticaria are concerned about the probability of recurrence and wish for the existence of clinical or laboratory markers. The aim of this study was to understand the prevalence and characteristics of the recurrence of chronic spontaneous urticaria to prevent stressful comorbidities.

The study included 180 regular patients from the local registry. Chronic spontaneous urticaria lasted more than 5 years in 47 (26%) patients and was resolved during the first year in 23 (13%) patients. 21% of the patients reported recurrence of chronic spontaneous urticaria after a full remission between 1 and 10 years (mean 2.9 years).

In the search for predictive clinical or laboratory markers, the main differences found are registered in the table below.

	Recurrent urticaria	General urticaria	P value
Bronchial asthma	10/25 (40%)	45/180 (25%)	p=0.049
Total immunoglobulin E	10/25 (40%)	34/150 (23%)	p=0.04
Anti-thyroid peroxidase antibodies	11/25 (44%)	32/160 (20%)	p=0.003

In conclusion, the prevalence of chronic spontaneous urticaria after a full remission is significantly higher in patients with bronchial asthma, increased levels of total IgE and autoimmunity. More studies are needed to support these findings.

This document is only available for registered healthcare professionals

Nov 22

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The effect of face mask usage on the allergic rhinitis symptoms in patients with pollen allergy during the covid-19 pandemic

By Bilastina Artículos seleccionados, Selected articles

Mengi E, Kara CO, Alptürk U, Topuz B

Am J Otolaryngol . 2021 Sep 10;43(1):103206. doi: 10.1016/j.amjoto.2021.103206. Online ahead of print.

Allergic rhinitis is an inflammation of the nasal mucosa mediated by IgE. It is characterized by nasal discharge, nasal obstruction, nasal itching, and sneezing. Allergic rhinitis prevalence has been increasing worldwide and it is believed that it affects up to 40% of the population. The objective of this study was to assess the use of face masks on allergic rhinitis symptomatology in people allergic to pollen and who were using face masks during the COVID-19 pandemic.

A total of 50 participants answered over the telephone a 15-item questionnaire which was developed by a team of allergic rhinitis experts. Participants were selected from those who had had allergy tests between 2013 and 2019.

The mean age of the participants was 34.34±9.41 years old and 60% were female. The number of participants who defined their nasal symptoms as severe-moderate in the pre-pandemic was higher (46 participants) than the number of participants with severe-moderate symptoms during the pandemic (28 participants). Patients who used mask had a statistically significant decrease in nasal and ocular symptoms (p<0,001), in sneezing (p=0,029) and nasal discharge (p=0,039).

In conclusion, the use of face mask reduced allergic rhinitis symptoms in people with pollen allergy, which supports the use of face masks for people with allergic rhinitis.

This document is only available for registered healthcare professionals

Metabolomics Reveals Process of Allergic Rhinitis Patients with Single- and Double-Species Mite Subcutaneous Immunotherapy

Lachnospira is a signature of antihistamine efficacy in chronic spontaneous urticaria

The International EAACI/GA²LEN/EuroGuiDerm/APAAACI Guideline for the Definition, Classification, Diagnosis and Management of Urticaria

Predictive features associated with chronic spontaneous urticaria recurrence

The effect of face mask usage on the allergic rhinitis symptoms in patients with pollen allergy during the covid-19 pandemic

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