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Clinical and histological characteristics during chronic urticaria with dermal neutrophilic infiltrate: Proposal of a diagnostic score

By | New, Selected articles

A Brehon, P Moguelet, V Seta, E Amsler, A Fajac, A Barbaud, A Soria, JB Monfort

J Eur Acad Dermatol Venereol . 2021 Nov 6. doi: 10.1111/jdv.17788. Online ahead of print.

There are some arguments on whether neutrophilic urticaria (NU) is distinct from chronic spontaneous urticaria (CSU), although with no consensus. This study aimed to compare clinical, biological, and histological characteristics and therapeutic responses between NU and CSU.

This was an observational, retrospective study that included adults with chronic urticarial rash who had undergone a skin biopsy. One dermatologist and one cytopathologist blindly and independently reviewed the biopsies [cytology counting technique for a precise proportion of neutrophilic/eosinophilic polynuclear cells (PNN/PNEo)]. NU was defined by an inflammatory dermal infiltrate composed of at least 60% PNN, without leukocytoclasia/vasculitis.

Forty-four patients were included, and their biopsies were classified into two groups: NU (n=28) and CSU (n=16). From the bibliography, there are no characteristics related to PNN at histology, but an increase in erythrocyte sedimentation rate in the NU group (p=0.03). Colchicine also showed to be more effective in cases of significant neutrophilic infiltrate: 42.85% effectiveness in NU group versus 6.25% in CSU group.

Two other findings were a statistically associated relation with neutrophilic venulitis (p=0.04) (corresponding to an intraparietal aggregation of PNN without vasculitis) and a basophilic interstitial flame figure corresponding to degranulation of the PNN cytoplasm and exclusively associated with NU (p=0.04).

A diagnostic score was established using strict quantitative histological criteria (intensity of neutrophilic infiltrate, the existence of neutrophilic venulitis, basophilic flame figures, and intense leukocytoclasia), which allows the classification of urticarial eruptions into NU or UCS.

This score will allow diagnosis and homogenization of NU patients (it correctly classified 40 of the 44 patients from the study).

In conclusion, NU is an independent entity as some histological images were significantly (neutrophilic venulitis) or exclusively (basophilic flame figure) associated with an intense neutrophilic infiltrate. A prospective study is needed to validate this new score.

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Impact of Allergic Rhinitis and Asthma on COVID-19 Infection, Hospitalization and Mortality

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Jianjun Ren, et al.

J Allergy Clin Immunol Pract . 2021 Oct 30;S2213-2198(21)01202-2. doi: 10.1016/j.jaip.2021.10.049. Online ahead of print.

The COVID-19 pandemic has impacted worldwide health. Underlying diseases have been shown to affect the prevalence and outcomes of COVID-19. Allergic rhinitis and asthma can increase the susceptibility and severity of COVID-19, but it is not known to which extension. This study aimed to study the role of allergic rhinitis and/or asthma in COVID-19 infection, severity, and mortality and evaluate whether its long-term medication can affect COVID-19 outcomes.

A total of 70,557 persons who had a SARS-CoV-2 test between March 16 and December 31, 2020, in the UK Biobank were analyzed. The rate of COVID-19 infection, hospitalization, and mortality concerning existing allergic rhinitis and/or asthma were statistically analyzed, together with the impact of long-term medications and the risk of hospitalization and death due to COVID-19 infection.

People with allergic rhinitis had lower positive rates of SARS-CoV-2 tests (RR:0.75; 95%CI, 0.69-0.81, p<0.001), with men having a lower susceptibility (RR:0.74; 95%CI, 0.65-0.85, p<0.001) than women (RR:0.8; 95%CI, 0.72-0.9, p<0.001). People with asthma had comparable results if they were <65 years-old (RR:0.93; 95%CI, 0.86-1, p=0.044). People with asthma who tested positive for SARS-CoV-2 had a higher risk of hospitalization (RR:1.42; 95%CI, 1.32-1.54, p<0.001). COVID-19 mortality was not impacted by allergic rhinitis or asthma. There was no relation between COVID-19 infection and severity and conventional medications for allergic rhinitis and/or asthma.

In conclusion, allergic rhinitis and asthma (<65 years old) may be a protective factor against COVID-19 infection, with asthma increasing the risk of hospitalization.

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What Basophil Testing Tells Us About CSU Patients – Results of the CORSA Study

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João Marcelino, et al.

Front Immunol. 2021 Sep 28;12:742470. doi: 10.3389/fimmu.2021.742470. eCollection 2021

Chronic spontaneous urticaria (CSU) is a common condition in adults and children, impacting the quality of life. Recent studies characterized chronic spontaneous urticaria as an autoantibody-driven condition, with mast cells and basophils being activated through two distinct pathways: type I autoimmune CSU, where IgE autoantibodies are cross-linked by self-antigens; and type IIb autoimmune CSU, where IgG and IgM autoantibodies are directed against IgE receptors on the surface of mast cells and basophils. Basophil testing is the most effective way to diagnose type IIb autoimmune CSU: a positive basophil test correlates to long disease duration, higher disease activity, poor response to antihistamines and omalizumab, and a better response to cyclosporine and fenebrutinib.

The objective of this study was to identify features of basophil test-positive patients.

This was a cross-sectional study that included 85 participants with CSU. They were tested for basophils with the basophil-activation test (BAT), the basophil histamine release assay (BHRA), and data were statistically analyzed.

Of all the participants, 44% tested positive with the BAST, and 28% tested positive with BHRA. These participants had higher activity and impact of disease, less disease control, and lower total serum IgE. In contrast, they had a higher rate of positive autologous serum skin test (ASST), angioedema, nocturnal symptoms, symptoms more than five days/week, and thyroid autoantibodies. The ASST was a good predictor of a positive basophil test when combined with angioedema, thyroid autoantibodies, and low IgE.

This study showed that a positive basophil test is related to known characteristics of type II autoimmune CSU, allowing a better approach to these patients’ condition management.

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Prevalence, Management, and Anaphylaxis Risk of Cold Urticaria: A Systematic Review and Meta-Analysis

By | Artículos seleccionados, New, Selected articles

Connor Prosty, Sofianne Gabrielli, Michelle Le, Luis F. Ensina, Xun Zhang, Elena Netchiporouk and Moshe Ben-Shoshan.

J Allergy Clin Immunol Pract . 2021 Oct 18;S2213-2198(21)01129-6. doi: 10.1016/j.jaip.2021.10.012. Online ahead of print.

Chronic spontaneous urticaria can be caused by specific triggers, namely cold, exercise or heat. Chronic inducible urticaria (CIndU) can coexist with chronic spontaneous urticaria and is defined as a particular trigger that provokes the symptoms. Cold inducible urticaria is one example of physical urticaria caused by exposure to cold air, liquids, or objects and is associated with significant morbidity and risk for anaphylaxis.

The objective of this study was to evaluate the prevalence of cold urticaria among cases of chronic urticaria and chronic inducible urticaria, evaluate its management, and determine the rate of associate anaphylaxis.

The investigators did bibliographic research in PubMed and EMBASE for papers on cold urticaria and/or chronic inducible urticaria in the past ten years. An analysis was made to determine the prevalence of cold urticaria among CIndU and chronic urticaria cases, its management with H1-antihistamines and omalizumab, and the rate of associated anaphylaxis.

The research identified 22 studies, of which 14 were included in the meta-analysis. The pooled prevalence of cold urticaria among patients with chronic urticaria and CIndU was, respectively, 7.62% [CI95%; 3.45%-15.99%; I2=98%] and 26.10% [CI95%; 14.17%-43.05%; I2=97%]. 95.67% of the cases of cold urticaria were managed by H1-antihistamines [CI95%; 92.47%-97.54%; I2=38%], and by omalizumab in 5.85% of the cases [CI95%; 2.55%-13.22%; I2=83%]. The pooled prevalence of anaphylaxis was 21.49% [CI95%; 15.79%-28.54%; I2=69%].

In conclusion, cold urticaria is common in cases of chronic urticaria and CIndU and frequently triggers anaphylaxis. H1-antihistamines are commonly used for its management, followed by omalizumab.

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Particulate Matter Exposure and Allergic Rhinitis: The Role of Plasmatic Extracellular Vesicles and Bacterial Nasal Microbiome

By | New, Selected articles

Jacopo Mariani, Simona Iodice, Laura Cantone, Giulia Solazzo, Paolo Marraccini, Emanuele Conforti, Pallav A. Bulsara, Maria Stella Lombardi, Robert P. Howlin, Valentina Bollati and Luca Ferrari

Int J Environ Res Public Health. 2021 Oct 12;18(20):10689. doi: 10.3390/ijerph182010689.

Particulate matter (PM) exposure is known to worsen respiratory conditions, namely allergic rhinitis. Allergic rhinitis prevalence is rising, affecting the quality of life. The objective of this study was to investigate the molecular mechanisms beneath the triggering of nasal and systemic inflammation by particulate matter, specifically the release of plasmatic extracellular vesicles and the relation between the host and nasal microbiome.

The study included 26 participants with allergic rhinitis and 24 matched healthy participants, whose reaction to PM10 and PM25 exposure was assessed on the bacteria-derived-extracellular vesicles portion (bEV) and the host-derived-extracellular vesicles (hEV), and also on the bacterial nasal microbiome (bNM). The function of bNM as a modifier of PM effects on the extracellular vesicles signaling network in the context of allergic rhinitis was also evaluated.

This study has shown an association between particulate matter exposure in participants with allergic rhinitis, both in the context of bNM composition and plasmatic extracellular vesicles release, affecting in different ways the release of extracellular vesicles and the composition of bNM. More studies are needed to better understand the link between particulate matter exposure and bNM modulation and plasmatic extracellular vesicles release and characterize the different responses observed in participants after particulate matter exposure.

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

By | Artículos seleccionados, 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.

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Lachnospira is a signature of antihistamine efficacy in chronic spontaneous urticaria

By | 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.

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

By | 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 3rd 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

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Predictive features associated with chronic spontaneous urticaria recurrence

By | 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.

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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

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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.

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Allergic rhinitis and COVID-19: friends or foes?

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F Gani

Eur Ann Allergy Clin Immunol . 2021 Sep 10. doi: 10.23822/EurAnnACI.1764-1489.234. Online ahead of print.

Allergic rhinitis is a usual condition that affects around 40% of the world population. During the COVID-19 pandemic, there was an increase in observational studies on the effect of asthma and chronic obstructive pulmonary disease and the risk of developing COVID-19. Still, there were no studies on allergic rhinitis and COVID-19.

This review aimed at assessing the risk of patients with allergic rhinitis developing worse COVID-19 outcomes. It also evaluated if COVID-19 can influence allergic rhinitis symptoms and influence the psychological conditions of pediatric and adult patients with allergic rhinitis.

The authors performed a comprehensive review of the literature. It included a set of different keywords, such as allergic rhinitis, rhinitis, allergy, atopy, COVID-19, and SARS-CoV-2.

From the articles selected, allergic rhinitis patients, appear to be protected from COVID-19 infection. However, there is not enough data on the influence of allergic rhinitis and the severity of COVID-19 disease; there is some information that being an allergic rhinitis patient does not increase the risk of a poor prognosis SARS-CoV-2 infection. The authors suggest that patients with allergic rhinitis follow their treatment accordingly, especially while the COVID-19 pandemic persists.

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Advances and highlights in allergic rhinitis

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Yuan Zhang, Feng Lan, Luo Zhang

Allergy . 2021 Aug 11. doi: 10.1111/all.15044. Online ahead of print.

Allergic rhinitis incidence has been growing in the past years, representing a medical and economic burden worldwide. This review describes the main findings with regards to allergic rhinitis for the past two years, including risk factors for the growing prevalence of allergic rhinitis, its strategy for the diagnosis, immunological mechanisms underlying the condition, and therapies used during the COVID-19 pandemic. It also aims at describing future perspectives.

Some of the most critical risk factors for allergic rhinitis are environmental exposures, climate changes, and lifestyle. There is an essential need to understand the connection between environmental exposures and health to design risk profiles instead of using single predictors and help eliminate adverse health outcomes in these conditions.

A newly defined allergic rhinitis phenotype, dual allergic rhinitis, includes perennial and seasonal related nasal symptoms but is more connected to seasonal allergic allergens. This indicates that it is crucial to assess inflammation at the local sites.

The authors suggest a combination of precise diagnosis in local sites and territories and traditional diagnostic methods to improve the precision medicine-based approach to managing allergic rhinitis.

In conclusion, further understanding of changes in cell profiles after treatment is needed. Apart from the usual treatments for allergic rhinitis during the current pandemic, social distancing, washing hands, and disinfection are also great aids in managing patients with allergic rhinitis.

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Association of severity of allergic rhinitis with neutrophil-to-lymphocyte, eosinophil-to-neutrophil, and eosinophil-to-lymphocyte ratios in adults

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Aydin Kant, Kadriye Terzioğlu

Allergol Immunopathol (Madr). 2021 Sep 1;49(5):94-99. doi: 10.15586/aei.v49i5.204. eCollection 2021.

Allergic rhinitis is an immunoglobulin E-mediated disorder of the nasal mucosa, with symptoms such as recurrent sneezing, rhinorrhea, and nasal congestion. People with allergic rhinitis suffer from sleep disturbances, emotional distress, and impaired social activity, which results in a reduced quality of life. This study aimed to assess the practicality of inflammatory parameters of neutrophil-to-lymphocyte ratio (NLR), eosinophil-to-neutrophil ratio (ENR), and eosinophil-to-lymphocyte ratio (ELR) as markers used to distinguish between intermittent and persistent allergic rhinitis.

This double-center, retrospective study included 205 patients with allergic rhinitis and 49 healthy individuals who acted as a control group. Patients with active infection were excluded. NLR, ENR, and ELR were calculated using the results from the participants’ complete blood count. A statistical analysis was also performed.

The participants with allergic rhinitis had significantly higher levels of absolute eosinophils, ENR, and ELR, and also lower levels of NLR when compared to healthy controls. A total of 80% of participants with persistent allergic rhinitis had significantly higher levels of absolute eosinophils, ENR, and ELR and significantly lower levels of NLR than patients with intermittent allergic rhinitis.

In conclusion, allergic rhinitis severity is classified according to the patient’s anamnesis, with serum eosinophil levels and the proportions of ENR and ELR in patients with persistent allergic rhinitis, highlighting the severity of the disease.

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Meta-analyses of the efficacy of pharmacotherapies and sublingual allergy immunotherapy tablets for allergic rhinitis in adults and children

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Eli O. Meltzer, Dana Wallace, Howard S. Friedman, Prakash Navaratnam, Erin P. Scott, Hendrik Nolte

Rhinology . 2021 Aug 31. doi: 10.4193/Rhin21.054. Online ahead of print.

Allergic rhinitis impacts the quality of life of people who suffer from it, such as sleep impairment and reduction in work and school productivity. Current treatment options for seasonal and perennial allergic rhinitis include pharmacotherapy and immunotherapy. These meta-analysis aimed to assess the efficacy of pharmacotherapies and sublingual immunotherapy tablets (SLIT) versus placebo on people with nasal symptoms associated with both types of allergic rhinitis.

A systematic search identified randomized, double-blind, placebo-controlled trials with these comparisons. The primary outcome was the mean numerical difference in total nasal symptom score (TNSS) between active treatment and placebo at the end of the assessment timeline. A meta-analysis estimated the mean difference for each group of medication weighted by the inverse of the trial variance.

Most pharmacotherapy trials did not allow rescue symptom-relieving medicines but were allowed in sublingual immunotherapy tablets. The following table includes total nasal symptom scores for children and adults with allergic rhinitis.

 

Seasonal allergic rhinitis TNSS mean numerical difference (95%CI) vs. placebo

Perennial allergic rhinitis TNSS mean numerical difference (95%CI) vs. placebo

Intranasal corticosteroids 1.38 (1.18-1.58) 0.82 (0.66-0.97)
Combination intranasal antihistamines+corticosteroids 1.34 (1.15-1.54)
Intranasal antihistamines 0.72 (0.56-0.89)
Oral antihistamine 0.62 (0.35-0.90) 0.27 (0.11-0.42)
SLIT tablets 0.57 (0.41-0.73) 0.65 (0.42-0.88)
Montelukast 0.48 (0,36-0,60)

 

In conclusion, all treatments significantly improved nasal symptoms when compared with placebo. SLIT-tablets improved TNSS, even using rescue symptom-relieving pharmacotherapy. However, since trials have considerable heterogeneity, it is difficult to compare treatment effects among treatment classes.

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Bilastine 10 and 20 mg in paediatric and adult patients: an updated practical approach to treatment decisions

By | Articles about Bilastine, Publicaciones sobre Bilastina

Amalia Leceta, Aintzane García, Ander Sologuren, Cristina Campo

Drugs Context . 2021 Aug 10;10:2021-5-1. doi: 10.7573/dic.2021-5-1. eCollection 2021

Bilastine is a non-drowsy H1-antihistamine for treating allergic conditions such as rhinoconjunctivitis and urticaria in people of all ages. This review aims to update a former article, focusing on recent clinical data on the use of bilastine in children and adults.

Data was collected from recent clinical studies in children and adults from Faes Farma. Most of the new information was updated on paediatric and elderly use. The European Medicines Agency approval took place in 2017 following a Paediatric Investigation Plan from 2009. Faes Farma received questions related to drug interactions involving bilastine and other concomitant medicines and the use of bilastine in special populations or for the treatment of specific conditions. The summarized advice from specialists consisted of interactions involving the cytochrome P450 isozyme system, leading to changes in drug exposure and, therefore, clinical efficacy and safety. Elderly patients are at particular risk of drug-drug interactions due to the number of concurrent medicines and comorbidities. Of importance are also potential drug-drug interactions between bilastine and drugs with a narrow therapeutic index.

In conclusion, although bilastine has a favorable pharmacokinetic profile, decisions on its use should rely on evidence, expert opinions, and the SmPC of bilastine. Nevertheless, further studies are needed to answer specific questions regarding its use.

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