Selected articles


Validation of the ARIA items to assess allergic rhinitis control (ARIA-C)

By | New, Selected articles

Valero A, Del Cuvillo A, Navarro AM, Colás C, Sastre J, Mullol J.

[published online ahead of print, 2020 May 25]. Allergy. 2020;10.1111/all.14418. doi:10.1111/all.14418.

Allergic rhinitis is a chronic disease with a high prevalence with an impact on quality of life. The original Allergic Rhinitis and Its Impact on Asthma Guideline (ARIA) severity classification uses 4 items (sleep, daily activities/sport, work/school performance and troublesome symptoms) and defines allergic rhinitis as mild (no items affected) or moderate/severe (1 to 4 items affected). A validated modified three-level ARIA (mARIA) classification was proposed to discriminate allergic rhinitis severity between moderate (1 to 3 items affected) and severe (4 items affected).

The aim of this prospective, observational, cross-sectional study was to use the 4 original ARIA items to validate a three-level evaluation of allergic rhinitis control (ARIA-C): controlled, partially controlled and not controlled, by estimating control of symptoms, impairment in activities and respiratory function.

A total of 252 adult participants with moderate-to-severe allergic rhinitis were included using both mARIA severity criteria and a reflective total nasal symptom score (rTNSS) ≥ 8. They followed their routine treatments and were interviewed twice a month. Demographic, concomitant diseases, allergic sensitization, AR severity and impact on quality of life data were collected. Additionally, participants’ control was assessed with the validated Spanish version of the Rhinitis Control Assessment Test (RCAT).

At baseline, 20 % of the participants had their allergic rhinitis controlled with the ARIA-C. At follow-up, 30 % of them were controlled and 40 % partially controlled.

Disease control was evaluated and showed that the three categories of ARIA-C can effectively discriminate between controlled, partially controlled and not controlled allergic rhinitis. Its validation shows favorable and statistically significant results for test-retest reliability, convergent validity, discrimination among groups, and responsiveness to change.

These results suggest that the ARIA-C can be used to obtain a fast screening of patients with inadequate allergic rhinitis control, or to help their communication with specialists.

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Rinitis Alergica

Validation of the MASK-air® App for Assessment of Allergic Rhinitis

By | New, Selected articles

Sastre J, Del Cuvillo A, Colás C, et al.

Allergy. 2020 May 25. doi: 10.1111/all.14415. Online ahead of print.

A mobile application (MASK-air®) has demonstrated usefulness in assessing patient behaviour in allergic rhinitis. This app measures general, nasal, ocular and asthma symptoms with a visual scale and daily medication intake.

The objective of this study was to validate the app for allergic rhinitis, comparing it to a written questionnaire for a month.

A total of 252 participants were randomly assigned to one of two groups: participants with allergic rhinitis who used the Spanish version of the app on a daily basis and participants with allergic rhinitis who were asked to use the questionnaire at days 1, 3, 7, 14, 21 and 28 and at a final visit one week later.

The usefulness of the allergic rhinitis app was evaluated at baseline and at the end using the Rhinitis Control Assessment Tool questionnaire. Other allergic rhinitis outcomes included treatment adherence, reflective total nasal symptom score, ocular symptom score, the modified ARIA severity classification, a quality-of-life questionnaire and daily visual analogue scales for nasal, conjunctival, asthma, and global for overall allergy symptoms, and the asthma control test for asthmatic patients at baseline and at end of study. Participants and specialists’ satisfaction with the app were evaluated using a Likert scale.

Most participants in the app group (90 %) had downloaded it to their smartphone and 92 % of them used it. Most users (88 %) reported being satisfied or very satisfied with the app, with 72% of the specialists reporting that their patients were satisfied.

At the end of the study, a relevant improvement on the Rhinitis Control Assessment Tool score was observed, but with no significant or clinically relevant difference between groups. Other outcomes were not different between study groups either.

This study demonstrated that the app contributed to the improvement of allergic rhinitis as effectively as the written questionnaire. It has shown that the MASK-air® app is practical ad useful.

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urticaria angioedema hipersensibilidad

IgM and IgA in Addition to IgG Autoantibodies against FcεRIα Are Frequent and Associated with Disease Markers of Chronic Spontaneous Urticarial

By | New, Selected articles

Altrichter S, Zampeli V, Ellrich A, Zhang K, Church MK, Maurer M.

Allergy. 2020 May 23. doi: 10.1111/all.14412. Online ahead of print.

Chronic spontaneous urticaria (CSU) is a mast cell–driven skin disease characterized by the recurrence of transient wheals, angioedema, or both for more than 6 weeks. IgG-autoantibodies against the high affinity IgE-receptor, FcεRIα, contribute to the pathogenesis of autoimmune chronic spontaneous urticaria.

The objective of this study was to develop an ELISA to assess serum levels of IgG, IgM and IgA autoantibodies against FcεRIα and to explore if their presence is linked to clinical features of CSU including the response to autologous serum skin testing (ASST).

Serum samples of 35 people with CSU and 52 healthy controls were tested using an ELISA for IgG, IgM and IgA autoantibodies to FcεRIα. 24 % of CSU patients had high serum levels of IgG-anti-FcεRIα compared to 6 % in healthy controls. IgM and IgA levels were positive for more than half of people with CSU, compared to 5 % in healthy controls. Elevated IgM, but not IgG nor IgA autoantibodies, were significantly more common in ASST-positive CSU patients (72 %) compared with ASST-negative patients (33 %). Also, elevated levels of IgM-anti-FcεRIα, but not of IgG or IgA against FcεRIα, were linked to low blood basophil and eosinophil counts.

In conclusion, people with CSU have increased serum levels of IgM-anti-FcεRIα which may relate to characteristics of autoimmune CSU.

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enfoque rinitis alergica

Local Allergic Rhinitis Revisited

By | New, Selected articles

Vardouniotis A, Doulaptsi M, Aoi N, Karatzanis A, Kawauchi H, Prokopakis E.

Curr Allergy Asthma Rep. 2020 May 19;20(7):22. doi: 10.1007/s11882-020-00925-5.

Chronic rhinitis can be classified in allergic rhinitis and non-allergic rhinitis (NAR). Allergic rhinitis is an inflammatory disease of the nasal mucosa with symptoms such as nasal discharge, sneezing, nasal itching and congestion. It is characterized by eosinophilic inflammation as a result of IgE-sensitization to seasonal or perennial aeroallergens. NAR is a highly heterogeneous group that includes disorders characterized by either immunological or neurogenic inflammation (hormonal rhinitis, rhinitis of the elderly, gustatory rhinitis, drug-induced rhinitis and occupational rhinitis).

Local allergic rhinitis (LAR) is neither classical allergic rhinitis neither NAR. Its symptoms, duration, severity and complications are similar to those of allergic rhinitis and can affect adults and children. It is characterized by a localized nasal allergic response and the absence of systemic atopy since specific IgE antibodies are produced locally. A Th2 pattern of mucosal cell infiltration during natural exposure to aeroallergens and a positive nasal allergen provocation test (NAPT) response, with the release of inflammatory mediators such as mast cells, eosinophils, IgE, B cells, and T cells, are detected.

LAR is an underdiagnosed entity that affects a significant number of people with chronic rhinitis, mainly in Mediterranean countries. It is a chronic condition that tends to worsen and is associated with conjunctivitis and bronchial symptoms. Its diagnosis is a challenge and should be based on a detailed clinical history, the demonstration of a nasal allergic response to aeroallergens by NAPT in patients with negative skin prick test and non-detectable serum sIgE, and the exclusion of chronic rhinosinusitis with/without nasal polyps.

Oral antihistamines and intranasal corticosteroids, alone or in an intranasal formulation of fluticasone + azelastine in severe cases, are the two traditional bases of allergic rhinitis treatment. Clinical experience indicates that these drugs are similarly effective in LAR patients. Also, subcutaneous immunotherapy has shown to be effective and well tolerated in LAR. A correct early diagnosis through nasal allergen challenge enables the establishment of an etiologic treatment, improving quality of life and preventing the development of lower airway disease.

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serum ige eosinofilos

Allergic Respiratory Disease Care in the COVID-19 Era: A EUFOREA Statement

By | New, Selected articles

Glenis K S, Peter W H, Claus B, et al.

World Allergy Organ J. 2020 May 16;100124. doi: 10.1016/j.waojou.2020.100124. Online ahead of print.

Acute COVID-19 infection and onset of seasonal allergic rhinitis share some features, which may be confusing, especially in those new to such symptoms. Cough and fever are the most prominent symptoms of COVID-19, while conjunctivitis and itching are allergic rhinitis symptoms. Sudden and complete anosmia may be an early sign of COVID-19 infection, differentiating it from allergic rhinitis. The EUFOREA expert teams makes an overview of recommendations for people with seasonal allergic rhinitis.

Given that 44 % of all COVID-19 transmission occurs from asymptomatic people, it is important to keep seasonal allergic rhinitis under the best possible control in order to diminish symptoms, such as sneezing, rhinorrhoea and coughing, which may be responsible for viral spread to others via aerosol formation in those who do not realise that they also have COVID-19.

They recommend that seasonal allergic rhinitis treatment to be started early and used regularly in the pollen season. Systemic corticosteroids should be avoided as they may suppress the immune system. There is no contraindication to the use of intranasal corticosteroids, as they do not reduce immunity and normalize the structure and function of the nasal mucosa. Asthma inhalers should be continued as before and taken regularly to maintain control in the pollen season. Inhaled corticosteroids and inhaled corticosteroids combinations with bronchodilators, long acting beta agonists protect against virally induced asthma exacerbations and may be beneficial in COVID-19. Also, treatment with biologicals for people with more severe asthma and severe chronic rhinosinusitis with nasal polyps should be continued to avoid aggravation of these diseases. Ongoing allergen-specific immunotherapy (AIT) should be continued, if feasible within the health care system, as long as no COVID-19 infection has been diagnosed. New AIT treatments are not advised, except for sublingual immunotherapy, which requires only one does under supervision.

In case of COVID-19 infection, oral corticosteroids may be needed in asthma patients for severe virus-evoked exacerbations. NSAIDs, which were suggested to be avoided for all possible patients, are vital in NSAID-sensitive asthma.

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Nivel de dímero D en plasma

Efficacy and Safety of Active Vitamin D Supplementation in Chronic Spontaneous Urticaria Patients.

By | New, Selected articles

Ahmed Mohamed A, Hussein MS, Salah EM, Eldemery A, Darwish MM, Ghaith DM, Attala RA, El Borolossy R.

J Dermatolog Treat. 2020 Apr 29:1-22. doi: 10.1080/09546634.2020.1762838. [Epub ahead of print]

Chronic spontaneous urticaria is one of the most common cutaneous disorders, characterized by the recurrence of transient wheals, angioedema or both for more than 6 weeks. Vitamin D has a main role in bone homeostasis, but also has immunomodulatory action in innate and adaptive immunity. Some studies have shown that vitamin D plays also a role in the improvement of clinical symptoms of chronic urticaria.

The aim of this study was to assess the association between serum levels of vitamin D and chronic spontaneous urticaria and to evaluate its efficacy and safety.

The study included 77 participants with chronic spontaneous urticaria and 67 healthy controls. They were randomized to receive 0,25 ug of alfacalcidol daily or placebo for 12 weeks.

Participants with chronic spontaneous urticaria had a significantly lower serum vitamin D than healthy controls at the beginning of the study. 12 weeks after administration of alfacalcidol, participants with chronic spontaneous urticaria showed a significant higher level of serum vitamin D compared to placebo. Additionally, mean serum level of IL6, CRP and TNFa significantly also decreased in these participants.

Although vitamin D deficiency is more common in people with chronic spontaneous urticaria, supplementation with alfacalcidol may have a beneficial role as add-on therapy of chronic spontaneous urticaria with no relevant side effects.

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International expert consensus on the management of allergic rhinitis (AR) aggravated by air pollutants: Impact of air pollution on patients with AR: Current knowledge and future strategies.

By | New, Selected articles

Naclerio R, Ansotegui IJ, Bousquet J, Canonica GW, D’Amato G, Rosario N, Pawankar R, Peden D, Bergmann KC, Bielory L, Caraballo L, Cecchi L, Cepeda SAM, Chong Neto HJ, Galán C, Gonzalez Diaz SN, Idriss S, Popov T, Ramon GD, Ridolo E, Rottem M, Songnuan W, Rouadi P.

World Allergy Organ J. 2020 Apr 3;13(3):100106. doi: 10.1016/j.waojou.2020.100106. eCollection 2020 Mar.

Exposition to pollution and climate change worsen symptoms in people with allergic rhinitis. The aim of this study was to summarize the conclusions of an International Expert Consensus on the management of allergic rhinitis aggravated by air pollution.

Epidemiological and clinical studies have shown that co-exposure to aeroallergens and pollutants have an immunological effect that induces inflammatory responses with recruitment of inflammatory cells, cytokines and interleukins. In addition, allergic rhinitis symptoms can be mediated by a neurogenic component upon contact with environmental irritants. Other studies that included specific pollutants exposure and allergen challenge propose that pollution can exacerbate allergic airway disease and increase responsiveness.

Although there have been advances in the understanding of the mechanistic ways of airway inflammation, there is lack of evidence about the benefits of management of allergic rhinitis aggravated by pollution. Fexofenadine, a non-sedating oral antihistamine as shown to improve allergic rhinitis symptoms aggravated by pollution, however, more studies with other related antihistamines in mitigating symptoms resulting from co-exposure to pollution and allergens are needed.

Nevertheless, an individual and careful approach with avoidance measures and conventional pharmacotherapy can improve symptoms caused by allergic rhinitis and air pollution.

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vitamina modulador rinitis

Defining biomarkers to predict symptoms in subjects with and without allergy under natural pollen exposure.

By | New, Selected articles

Gökkaya M, Damialis A, Nussbaumer T, Beck I, Bounas-Pyrros N, Bezold S, Amisi MM, Kolek F, Todorova A, Chaker A, Aglas L, Ferreira F, Redegeld FA, Brunner JO, Neumann AU, Traidl-Hoffmann C, Gilles S.

J Allergy Clin Immunol. 2020 Apr 6. pii: S0091-6749(20)30419-X. doi: 10.1016/j.jaci.2020.02.037. [Epub ahead of print]

The exposition to airborne pollen is the main cause of seasonal allergic rhinitis. This exposition induces local and systemic allergic immune responses in sensitized and non-sensitized individuals. The mechanisms of action of the expression of symptoms under natural pollen exposure is not fully understood. The aim of this study was to monitor the humoral immune response under natural pollen exposure to categorise and understand nasal biomarkers for in-season symptom severity and to identify protective factors.

50 participants with seasonal allergic rhinitis and non-allergic rhinitis were included from November 2015 to October 2016. Immune monitoring to compare humoral immune response kinetics and cross-sectional and interseasonal differences in levels of serum and nasal, total and Bet v 1-specific immunoglobulin isotypes, immunoglobulin free light chains, cytokines and chemokines was performed every 4 weeks out of season and bi-weekly within the main pollen season. Nasal immune variables were registered with non-supervised principal component analysis and single immune variables were correlated with in-season severity by Spearman test.

Participants with seasonal allergic rhinitis had symptoms in 0 to 13 days after airborne pollen exposure, depending on the pollen type. 4 out of 7 non-allergic participants also exhibited in-season symptoms. Non-allergic participants had lower cumulative symptoms than participants with seasonal allergic rhinitis but followed the pollen exposure with similar kinetics. Seasonal allergic rhinitis participants had higher levels of nasal eotaxin-2, MDC and MCP-1, non-allergic participants had higher levels of IL-7. Non-supervises principal component analysis and Spearman correlations identified nasal IL-8, IL-33, Bet v 1-specific IgG4 and sIgE antibodies a prognostic for seasonal symptom severity.

Nasal IL-8, IL-33, sIgG3 and sIgE could be predictive biomarkers for pollen-specific symptom expression, irrespective of atopy, while nasal pollen-specific IgA and IgG isotypes seem to be potentially protective within the humoral compartment.

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skin microdyalisis

Chronic urticaria in the real-life clinical practice setting in the UK: results from the non-interventional multicentre AWARE study.

By | New, Selected articles

Savic S, Leeman L, El-Shanawany T, Ellis R, Gach JE, Marinho S, Wahie S, Sargur R, Bewley AP, Nakonechna A, Randall R, Fragkas N, Somenzi O, Marsland A.

Clin Exp Dermatol. 2020 Apr 4. doi: 10.1111/ced.14230. [Epub ahead of print]

Chronic urticaria is a group of skin conditions that include chronic spontaneous urticaria and chronic inducible urticaria. Symptoms include itchy wheals and/or angioedema for a period longer than 6 weeks. The objective of this study was to provide information demonstrating the real-life burden of chronic urticaria in the UK.

The non-interventional AWARE study (A World-wide Antihistamine-Refractory chronic urticaria patient Evaluation) collected data from a representative sample of chronic urticaria patients worldwide. A subset of UK patients aged 18-75 diagnosed with H1-antihistamine-refractory chronic spontaneous urticaria was analysed.

Baseline analysis included 252 UK patients, mostly female (77,8%) with moderate-to-severe disease activity and a spontaneous component to their chronic urticaria. Comorbidities included depression/anxiety (24,6%), asthma (23,8%) and allergic rhinitis (12,7%). 57,9% of the patients had undergone a treatment. Their mean Dermatology Life Quality Index score was 9,5 with report of reduction in work productivity and activity. These patients referred a high need to use healthcare resources. Chronic spontaneous urticaria severity was linked to gender, obesity, anxiety and diagnosis.

Only 28,5% of UK patients completed all nine study visits, which limits analysis of long-term treatment patterns and disease impact. Chronic urticaria patients reported high rates of healthcare resource use and impairment in quality of life, work productivity and activity at baseline, which highlights the need to ensure appropriate management to optimise patient quality of life and reduce the socioeconomic burden of chronic urticaria in the UK.

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Urticaria cronica angioedema

Urticaria and Angioedema Across the Ages

By | New, Selected articles

Saini S, Shams M, Bernstein JA, Maurer M.

J Allergy Clin Immunol Pract. 2020 Apr 13. pii: S2213-2198(20)30329-9. doi: 10.1016/j.jaip.2020.03.030. [Epub ahead of print]

Chronic urticaria symptoms include itchy wheals, angioedema, or both, caused by the release of histamine, prostaglandin metabolites, leukotrienes, platelet activating factor and other proinflammatory mediators, which in turn lead to vasodilation and extravasation, sensory nerve activation and cellular infiltration.

Chronic urticaria is a common clinical condition that impairs quality of life of people and represent an important health burden. International Consensus guidelines have been published that recommend the use of standard terminology and definitions for different types of chronic urticaria, such as chronic spontaneous urticaria and chronic inducible urticaria. However, there is a lack in the understanding of mechanistic pathways and treatment in some more vulnerable populations, such as children, elderly people and pregnant or lactating women.

40-50% of the patients are effectively treated with monotherapy with a non-sedating H1-antihistamine or 2-4 times the recommended dose of a non-sedating H1-antihistamine. Biologics like omalizumab or immunosuppressants such as cyclosporin are used when patients fail to respond to simpler treatments. There is evidence that omalizumab can be safely used in the vulnerable populations, however cyclosporin has a greater toxicity and is not appropriate in these populations.

Additional therapies for vulnerable chronic urticaria patients are needed.

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