Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2016 revision

BACKGROUND: Allergic rhinitis (AR) affects 10% to 40% of the population. It reduces quality of life and school and work performance and is a frequent reason for office visits in general practice. Medical costs are large, but avoidable costs associated with lost work productivity are even larger than those incurred by asthma. New evidence has accumulated since the last revision of the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines in 2010, prompting its update. OBJECTIVE: We sought to provide a targeted update of the ARIA guidelines. METHODS: The ARIA guideline panel identified new clinical questions and selected questions requiring an update. We performed systematic reviews of health effects and the evidence about patients' values and preferences and resource requirements (up to June 2016). We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evidence-to-decision frameworks to develop recommendations. RESULTS: The 2016 revision of the ARIA guidelines provides both updated and new recommendations about the pharmacologic treatment of AR. Specifically, it addresses the relative merits of using oral H1-antihistamines, intranasal H1-antihistamines, intranasal corticosteroids, and leukotriene receptor antagonists either alone or in combination. The ARIA guideline panel provides specific recommendations for the choice of treatment and the rationale for the choice and discusses specific considerations that clinicians and patients might want to review to choose the management most appropriate for an individual patient. CONCLUSIONS: Appropriate treatment of AR might improve patients' quality of life and school and work productivity. ARIA recommendations support patients, their caregivers, and health care providers in choosing the optimal treatment.

Phenotypes and endotypes of rhinitis and their impact on management: a PRACTALL report.

Rhinitis is an umbrella term that encompasses many different subtypes, several of which still elude complete characterization. The concept of phenotyping, being the definition of disease subtypes on the basis of clinical presentation, has been well established in the last decade. Classification of rhinitis entities on the basis of phenotypes has facilitated their characterization and has helped practicing clinicians to efficiently approach rhinitis patients. Recently, the concept of endotypes, that is, the definition of disease subtypes on the basis of underlying pathophysiology, has emerged. Phenotypes/endotypes are dynamic, overlapping, and may evolve into one another, thus rendering clear-cut definitions difficult. Nevertheless, a phenotype-/endotype-based classification approach could lead toward the application of stratified and personalized medicine in the rhinitis field. In this PRACTALL document, rhinitis phenotypes and endotypes are described, and rhinitis diagnosis and management approaches focusing on those phenotypes/endotypes are presented and discussed. We emphasize the concept of control-based management, which transcends all rhinitis subtypes.

Occupational asthma: a practical approach.

Although evaluation of possible occupational asthma may be complex, it can be pursued systematically by first assessing whether asthma is present, and then determining whether asthma is caused or triggered by the workplace or by alternative or confounding nonoccupational explanations. A detailed history is of great importance in raising suspicion of occupational asthma, but studies have shown that even detailed histories obtained by experienced specialists can lead to inaccurate conclusions about the presence or absence of occupational asthma. Consequently, objective measurements should be performed to establish the diagnosis of occupational asthma whenever possible. If the patient is still working in the workplace, work-related changes in spirometry or peak flow measurements can confirm the diagnosis. For occupational asthma from some airborne sensitizers, immediate-type skin testing or in vitro tests for specific IgE may establish sensitization. However, there is evidence that for some isocyanates, in vitro tests for specific IgG serum antibody levels correlate better with documented bronchospasm from isocyanate exposure, even though the IgG antibody is not thought to be pathogenic. Controlled, specific inhalation tests may be valuable, but they should be performed only under experienced medical supervision. Intervention should be focused on reducing or avoiding harmful workplace exposures so that permanent lung impairment and need for chronic medical treatment are avoided. Assessment of permanent impairment/disability from occupational asthma optimally should be determined 2 years after the removal from occupational exposure, when improvement has been shown to plateau and the patient will likely have reached maximal medical improvement.

Newer and alternative non-steroidal treatments for asthmatic inflammation.

Although most patients with asthma can be effectively managed with minimal toxicity using available treatments, some patients are relatively resistant to treatment or are at risk for adverse effects from treatment, such as high-dose systemic corticosteroids. In considering new or alternative therapeutic candidates for asthma treatment, those possessing anti-inflammatory properties are of greatest interest because inflammation is recognized as having central importance in the pathogenesis of persistent asthma. Of non-steroidal agents that have well-established positions in asthma treatment, nedocromil and cromolyn possess significant anti-inflammatory effects, and theophylline and beta agonists possess some anti-inflammatory effects of potential relevance to asthma. In addition, there are a number of newer or alternative therapies that have theorized or demonstrated anti-inflammatory effects in asthma, including leukotriene modifier agents, anti-IgE, gold, nebulized lidocaine, cyclosporine, intravenous immunoglobulin, methotrexate, hydroxychloroquine, dapsone, and troleandomycin. This review summarizes available data about these agents for asthma, focusing on their putative or proven mechanisms of action, evidence for clinical benefit, and their potential role as corticosteroid sparing agents, and principal toxicities. The review also discusses factors that confound assessment of the clinical benefit of agents in asthma, including variability in the natural history of asthma, heterogeneity of airway inflammation, and varying responses to treatment in different subsets of asthmatics.

In vitro demonstration of IgE antibody to folate-albumin in anaphylaxis from folic acid.

BACKGROUND: Folic acid (the synthetic form of folate B vitamins in foods) is widely used in vitamin supplements. Anaphylaxis from ingestion or injection of folic acid suggests IgE antibody-mediated mechanisms, but this has not been demonstrated previously in vitro. OBJECTIVE: This study was conducted to better define the mechanism of folic acid hypersensitivity and cross-reactivity among folic acid congeners. METHODS: Skin testing was performed with folic acid congeners in a woman who developed anaphylaxis after ingestion of 2 different multivitamin preparations containing folic acid. In vitro immunologic serum studies were conducted using a folate-human serum albumin (HSA) conjugate prepared by a novel application of carbodiimide condensation. RESULTS: The patient had positive immediate-type skin test reactions to folic acid and several folate analogues including leucovorin (folinic acid). Urticaria developed during graded oral test dosing with leucovorin. Using a dot immunoblot assay or an ELISA for IgE antibody to folate-HSA, results of the patient's serum testing were positive, whereas results of sera from normal control subjects were negative, the first in vitro demonstration of IgE to a folic acid-protein conjugate. By ELISA, the positive result of the patient's serum was inhibited significantly by serum coincubation with folate-HSA, but not HSA or folic acid. CONCLUSIONS: Immediate hypersensitivity to folic acid and possibly other vitamins can be mediated by IgE antibody to conjugates formed between vitamins and self-proteins or polypeptides. Leucovorin can have clinically important immunologic cross-reactivity with folic acid. A diet rich in natural folates (pteroylpolyglutamates) appears useful as a management strategy for providing adequate nutrition to patients with folic acid hypersensitivity.

Executive Summary of Joint Task Force Practice Parameters on Diagnosis and Management of Rhinitis.

Rhinitis is a significant cause of widespread morbidity, medical treatment costs, reduced work productivity and lost school days. Although sometimes mistakenly viewed as a trivial disease, symptoms of allergic and non-allergic rhinitis may significantly impact a patient's quality of life, by causing fatigue, headache, cognitive impairment and other systemic symptoms. In addition, many antihistamines commonly used for treatment can themselves cause performance impairment that may contribute to fatal automobile accidents, work place accidents, decreased work productivity and in children, impaired school performance. Appropriate management of rhinitis may be an important component in effective management of coexisting or complicating respiratory conditions, such as asthma, sinusitis, or chronic otitis media. Rhinitis may be caused by allergic, non-allergic, infectious, hormonal, occupational, and other factors. Defining the causes of rhinitis in an individual is important because different rhinitis syndromes may require different therapeutic approaches for optimal management, an important consideration as more treatment options become available. This Executive Summary reviews key points about diagnosis and management of rhinitis contained in the comprehensive document, Diagnosis and Management of Rhinitis: Complete Guidelines of Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology, and Joint Task Force Algorithm and Annotations for Diagnosis and Management of Rhinitis. These documents represent a consensus opinion of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology, a national panel co-sponsored by the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology, and the Joint Council on Allergy, Asthma and Immunology.

Joint Task Force Algorithm and Annotations for Diagnosis and Management of Rhinitis.

The algorithm and text annotations in this document are intended to assist clinical decision making about patients who present with symptoms of rhinitis. This document complements the Executive Summary of Joint Task Force Practice Parameters for Diagnosis and Management of Rhinitis (Ann Allergy, Asthma, Immunol 1998; 81:463-468) and Diagnosis and Management of Rhinitis: Complete Guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology (Ann Allergy, Asthma, Immunol 1998;81:478-578). The Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology is co-sponsored by the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology and the Joint Council of Allergy, Asthma and Immunology.

Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology.

This document contains complete guidelines for diagnosis and management of rhinitis developed by the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology, representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology and the Joint Council on Allergy, Asthma and Immunology. The guidelines are comprehensive and begin with statements on clinical characteristics and diagnosis of different forms of rhinitis (allergic, non-allergic, occupational rhinitis, hormonal rhinitis [pregnancy and hypothyroidism], drug-induced rhinitis, rhinitis from food ingestion), and other conditions that may be confused with rhinitis. Recommendations on patient evaluation discuss appropriate use of history, physical examination, and diagnostic testing, as well as unproven or inappropriate techniques that should not be used. Parameters on management include use of environmental control measures, pharmacologic therapy including recently introduced therapies and allergen immunotherapy. Because of the risks to patients and society from sedation and performance impairment caused by first generation antihistamines, second generation antihistamines that reduce or eliminate these side effects should usually be considered before first generation antihistamines for the treatment of allergic rhinitis. The document emphasizes the importance of rhinitis management for comorbid conditions (asthma, sinusitis, otitis media). Guidelines are also presented on special considerations in patients subsets (children, the elderly, pregnancy, athletes and patients with rhinitis medicamentosa); and when consultation with an allergist-immunologist should be considered.

Algorithm for the diagnosis and management of asthma: a practice parameter update: Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma and Immunology.

This algorithm on the diagnosis and treatment of asthma is intended to complement and update the previously published Practice Parameters for the Diagnosis and Treatment of Asthma. Both documents were developed by the Joint Task Force on Practice Parameters, representing the AAAAI, ACAAI, and the JCAAI. The authors of this asthma algorithm have attempted to include all the elements essential for the diagnosis and care of patients with asthma. Every effort was made to keep the algorithm clear and concise, yet thorough and complete (Fig 1). Each component of the algorithm is elaborated further in a brief annotation. For further discussion, the reader is referred to the more extensive Practice Parameters for the Diagnosis and Treatment of Asthma.

Recent findings in asthma likely to impact patient care.

The management of asthma is becoming increasingly complex as more pharmacologic agents become available and we gain increased understanding of the pathogenetic processes of asthma and the risks for potentially irreversible airway remodeling that might be increased by suboptimal management and interactions with concomitant disease states such as gastroesophageal reflux. Although physicians now have greater responsibility to make use of this increasing knowledge to provide more effective management for their asthma patients, they also have a greater opportunity to increase the overall quality of life of patients under their care.

Extensive subcutaneous fibrosis in a patient treated with alum precipitated allergenic extract.

BACKGROUND: Alum-precipitated allergenic extract (Allpyral) used for immunotherapy has been associated with subcutaneous nodule formation at injection sites. OBJECTIVE: We describe a severe localized reaction at the site of Allpyral injections and evaluate possible mechanisms for this reaction. METHODS: Case report with cutaneous patch testing and CAT scan imaging. RESULTS: The patient developed extensive subcutaneous inflammation and fibrosis with overlying skin changes which appear to be permanent. CAT scan findings were corroborative and cutaneous patch testing to aluminium was positive. CONCLUSIONS: Alum-precipitated allergenic extract used for immunotherapy caused extensive subcutaneous fibrosis with overlying skin changes at the site of injections. The lesions are disfiguring and appear to be permanent. This may be due in part to a type IV hypersensitivity response to the aluminum component of Allpyral extract. A CAT scan was valuable in demonstrating structural changes associated with this lesion.

Drug eruptions and isotypic antibody responses to streptokinase after infusions of anisoylated plasminogen-streptokinase complex (APSAC, anistreplase).

BACKGROUND: Anisoylated plasminogen-streptokinase complex (APSAC, anistreplase) is a thrombolytic agent (131 kd) used for treatment of myocardial infarction. Like its principal antigenic determinant, streptokinase, APSAC has been reported to cause a variety of allergic reactions. OBJECTIVE: This study was intended to determine any association between isotypic antibody responses to streptokinase and observed allergic reactions to APSAC. METHODS: We measured sequential IgM, IgG, IgA, and IgE antistreptokinase serum levels in 21 patients who received APSAC or tissue-type plasminogen activator in a prospective, double-blind study. RESULTS: Of 11 patients who received APSAC, four had maculopapular rashes and one had urticaria; those with maculopapular rashes had significantly higher rises in serum IgM, IgG, IgA, and IgE antistreptokinase levels. We could not, however, define a temporal relationship between rises in antistreptokinase levels of a particular isotype and the onset of maculopapular rashes. The patient who had urticaria had no antistreptokinase responses but had also received several other potentially causal drugs. None of 10 patients who received tissue-type plasminogen activator had allergic reactions or significant rises in serum antistreptokinase levels. CONCLUSION: The more vigorous panisotypic antistreptokinase responses observed in patients who received APSAC and had maculopapular rashes may reflect generalized immune system activation that included other immune responses (such as cell-mediated hypersensitivity) that were responsible for these reactions.

Occupational asthma in a latex doll manufacturing plant.

BACKGROUND: Occupational asthma caused by latex has been reported in health care workers and workers in glove manufacturing plants. OBJECTIVE: We report occupational asthma from latex in a newly identified occupational setting, a latex doll manufacturing plant. METHODS: We evaluated an index case of asthma associated with work in a latex doll manufacturing plant by performing a workplace challenge and evaluating the work environment. We then performed an occupational survey and skin testing of 22 workers in the doll manufacturing plant. RESULTS: The patient, a 21-year-old woman, had severe immediate bronchospasm within minutes of beginning a workplace challenge where sanding of latex parts was performed. Two of 22 workers surveyed (including the patient) reported flushing, rhinoconjunctivitis, and wheezing on exposure to sanded doll parts. These two workers were the only subjects surveyed to have a history of atopy and positive immediate-type skin test responses to a raw latex extract and to common aeroallergens. CONCLUSIONS: Sanding or grinding of solid latex during the manufacturing process may result in a significant incidence of occupational asthma and rhinoconjunctivitis from latex sensitization. Atopic workers appear to be most susceptible to developing latex sensitivity in this setting.