Allergic Conjunctivitis Management: Update on Ophthalmic Solutions.

PURPOSE OF REVIEW: The aim of this review, is to present an updated revision of topical management of SAC and PAC, based on the available scientific evidence and focused on the impact of ophthalmic solution formulations on eye surface. RECENT FINDINGS: Physicians treating ocular allergy should be aware of tear film and tear film disruption in SAC and PAC, and how eye drop composition and additives affect the physiology of the allergic eye. Seasonal and perennial allergic conjunctivitis (SAC and PAC) are the most frequent causes of ocular allergy (OA), and both conditions are underdiagnosed and undertreated. SAC and PAC are immunoglobulin E (IgE)-mediated hypersensitivity reactions. The additional tear film disruption caused by the release of inflammatory mediators increases and exacerbates the impact of signs and symptoms and may trigger damage of the ocular surface. Comorbidities are frequent, and dry eye disease in particular must be considered. Clinical guidelines for the management of SAC and PAC recommend topical therapy with antihistamines, mast cells stabilizers or dualaction agents as first-line treatment, but care should be taken, as many medications contain other compounds that may contribute to ocular surface damage.

Real-life experience after 3 months with tezepelumab before marketing approval.

BACKGROUND: Tezepelumab is a monoclonal antibody targeting thymic stromal lymphopoietin (TSLP), implicated in asthma pathogenesis, and that has been approved for patients with severe uncontrolled asthma in Spain in October 2023. This study evaluates our experience with Tezepelumab for those patients who received the indicated drug off-label prior to its commercialization. METHODS: We conducted a real-life observational study on three patients from the Severe Asthma Unit of the Hospital Universitario de Fuenlabrada, Spain, who received Tezepelumab off-label before its official approval. We analyzed symptoms control based on ACT, exacerbations, reductions in the doses of oral corticosteroid, lung function, blood changes and safety at 3 months of treatment. RESULTS: Tezepelumab demonstrated efficacy in improving asthma control and a notable reduction in emergency department visits. OCS use decreased, with one patient halving their prednisone dose. Lung function, particularly FEV1 and FEV1/FVC parameters, improved, but no significant changes were observed in FeNO levels, blood eosinophil counts and total IgE. The treatment exhibited a favorable safety profile with no reported adverse effects during the study period. CONCLUSIONS: In this preliminary real-world experience prior to the official approval of tezepelumab in Spain, this monoclonal antibody showed promising results and suggests its potential as a valuable alternative for the treatment of severe asthma.

Real-life experience after 3 months with tezepelumab before marketing approval / Experiencia de la vida real después de 3 meses con tezepelumab antes de la aprobación de comercialización

Background: Tezepelumab is a monoclonal antibody targeting thymic stromal lymphopoietin (TSLP), implicated in asthma pathogenesis, and that has been approved for patients with severe uncontrolled asthma in Spain in October 2023. This study evaluates our experience with Tezepelumab for those patients who received the indicated drug off-label prior to its commercialization. Methods: We conducted a real-life observational study on three patients from the Severe Asthma Unit of the Hospital Universitario de Fuenlabrada, Spain, who received Tezepelumab off-label before its official approval. We analyzed symptoms control based on ACT, exacerbations, reductions in the doses of oral corticosteroid, lung function, blood changes and safety at 3 months of treatment. Results: Tezepelumab demonstrated efficacy in improving asthma control and a notable reduction in emergency department visits. OCS use decreased, with one patient halving their prednisone dose. Lung function, particularly FEV1 and FEV1/FVC parameters, improved, but no significant changes were observed in FeNO levels, blood eosinophil counts and total IgE. The treatment exhibited a favorable safety profile with no reported adverse effects during the study period. Conclusions: In this preliminary real-world experience prior to the official approval of tezepelumab in Spain, this monoclonal antibody showed promising results and suggests its potential as a valuable alternative for the treatment of severe asthma.(AU)

Recent Advances in Allergen-Specific Immunotherapy as Treatment for Allergic Asthma: A Practical Overview.

The Global Initiative for Asthma Report updated in 2019 stated that potential benefits of allergen immunotherapy (AIT), compared to pharmacological and avoidance options, must be weighed against the risk of adverse effects and the inconvenience and cost of the prolonged course of therapy in asthma. Thus, with the aim of clarifying some aspects with regard to the possible use of AIT in allergic asthma treatment armamentarium, a group of expert allergists from the Spanish Allergy and Clinical Immunology Scientific Society (SEAIC), particularly from the Immunotherapy and Asthma Interest Groups developed a frequently asked questions in clinical practice. This document updates relevant topics on the use of AIT in asthma and could facilitate physician clinical decisions and improve health outcomes for individual patients.

Nut Allergy in Two Different Areas of Spain: Differences in Clinical and Molecular Pattern.

INTRODUCTION: Different clinical and molecular patterns of food allergy have been reported in different areas of the world. The aim of the study is to evaluate differences in allergen patterns among nut-allergic patients in two different areas of Spain. MATERIAL AND METHODS: A total of 77 patients with nut allergy from two different regions of Spain (Madrid and Asturias) were evaluated. RESULTS: Hazelnut, peanut, and walnut were the three most frequent nuts eliciting allergy in both regions, but in a different order. Patients from Madrid experienced systemic reactions more often than patients from Asturias (73.5% Madrid vs. 50.0%, p < 0.05). The percentage of sensitizations to LTP (Lipid Transfer Protein) was higher than Bet v 1 (p < 0.05) in the Madrid area. The percentage of sensitizations in Asturias area was similar to LTP than Bet v 1 (Pru p 3 46.4%, Bet v 1 42.9%, ns). Bet v 1 was the predominant allergen involved among hazelnut-allergic patients (56.2%), while LTP was more common in peanut-allergic patients (61.5%). CONCLUSION: Walnut, hazelnut, and peanut were the most frequent nuts eliciting allergy in Spain. Despite this, important differences in molecular pattern were appreciated not only between both regions, but also among nut-allergic patients in Asturias. The different molecular pattern was linked to the frequency of systemic symptoms.

The difficult management of anaphylaxis in the elderly.

PURPOSE OF REVIEW: In this article, an overview of the main characteristics of the anaphylaxis in the elderly, a subset of the population with particular clinical and physiological features that might influence the presentation and management of this entity, is performed. RECENT FINDINGS: Life expectancy of the population is increasing and so is the prevalence of allergic diseases in the elderly, including anaphylaxis. Older people present higher risk of fatalities after anaphylaxis, and some comorbidities and pharmacological treatments they may use might also increase that risk. SUMMARY: Recognition of the main triggers, the risk factors, and the wide variety of presenting symptoms of anaphylaxis is therefore helpful in its management, as well as a prompt initiation of the treatment and a complete follow-up.

Allergies to fruits and vegetables.

Allergic reactions to fruits and vegetables are frequently observed in older children and adolescents. They can result from a primary sensitization to food allergens or from a primary sensitization to inhalant allergens such as pollens or latex. In the case of fruit allergies, the stability of the allergens involved is crucial to the sensitization pathway and in the clinical presentation of the food allergy. Two patients allergic to fruits are presented and discussed in the light of the allergens involved. Patient 1 was a 14 yr-old girl with a grass and olive pollen allergy who developed oropharyngeal symptoms typical of the oral allergy syndrome (OAS) with multiple fruits from taxonomically unrelated families, and who was sensitized to profilin. Patient 2 was an 8 yr-old girl, with no pollen allergies, who developed systemic reactions to peach and apple, and who was sensitized to non-specific lipid transfer proteins (LTP). Profilins are labile allergens present in pollens and foods, and sensitization occurs through the respiratory route to pollen profilin. The cross-reactive IgE antibodies generated can elicit local reactions in the oropharyngeal mucosa (OAS) when exposed to fruit profilins. In contrast, LTPs are a family of stable allergens that resist thermal treatment and enzymatic digestion, and can thus behave as true food allergens inducing primary (non-pollen related) sensitizations and triggering systemic reactions. These two cases represent two distinct patterns of sensitization and clinical expression of fruit allergies that are determined by the panallergens involved (LTPs and profilins) and their intrinsic physicochemical properties. Additionally, these two cases also show the improved diagnostic value of Component Resolved Diagnosis, and strengthen its utility in the routine diagnosis and management of patients.

Safety and effectiveness of immunotherapy in patients with indolent systemic mastocytosis presenting with Hymenoptera venom anaphylaxis.

BACKGROUND: Anaphylaxis after Hymenoptera sting has been described in patients with mastocytosis. Venom immunotherapy (VIT) is a safe and effective way to treat patients with Hymenoptera anaphylaxis, but few studies have addressed its usefulness in patients with systemic mastocytosis. OBJECTIVE: To study the effectiveness and safety of VIT in patients with systemic mastocytosis having anaphylaxis after Hymenoptera sting. METHODS: A total of 21 mastocytosis patients-4 women (19%) and 17 men (81%) with a median age of 50 years (range, 29-74 years)-with Hymenoptera sting anaphylaxis who were treated with VIT and followed for a median of 52 months (range, 2-250 months) were studied. RESULTS: In 18 of 21 patients-16 of them lacking skin involvement-anaphylaxis was the presenting symptom. Six patients (29%) experienced adverse reactions during VIT, 3 during initiation and 3 during maintenance. Twelve patients (57%) were resting while undergoing VIT; 9 (75%) presented local reactions and 3 (25%) systemic reactions, 1 of which required intubation. The Hymenoptera specific IgE decreased from 4.15 kU/L (range, 0.44-100 kU/L) before immunotherapy to 1.2 kU/L (range, 0.34-69.4 kU/L) after 4 years (P < .003). CONCLUSION: Venom immunotherapy is effective to treat IgE-mediated Hymenoptera anaphylaxis in patients with mastocytosis. Its use is recommended despite a relatively high risk of adverse reactions during the build-up phase because it provides protection from anaphylaxis in around 3/4 of the patients.

Identification of a 7S globulin as a novel coconut allergen.

BACKGROUND: Coconut (Cocos nucifera) is a monocotyledonous plant of the Arecaceae family. Allergy to coconut is infrequent, with only 5 cases reported so far in the medical literature. OBJECTIVE: To identify coconut allergens in 2 patients allergic to this food. METHODS: We describe 2 patients allergic to coconut: an adult pollen-allergic patient monosensitized to coconut who presented with severe oropharyngeal symptoms and a child with a previous allergy to walnut, not allergic to pollen, who developed anaphylaxis on coconut ingestion. Both patients had positive skin prick test results and serum specific IgE (CAP) to coconut. IgE sodium dodecyl sulfate-polyacrylamide gel electrophoresis immunoblotting was performed to identify the allergens involved, and a strong IgE binding band detected in both patients was further analyzed by matrix-assisted laser desorption/ionization time-of-flight mass spectroscopy (MALDI-TOF MS). Stability to pepsin digestion of the coconut extract and its cross-reactivity with tree nuts were studied. RESULTS: An immunoblot showed an almost identical profile of IgE binding proteins in the coconut extract in both patients who reacted strongly to a band of approximately 29 kDa. The peptide analysis by MALDI-TOF MS of this band obtained the sequence GHGKREDPEKR. The protein with the highest correlation with this peptide was found to be a 7S globulin from Elaeis guineensis, another oil palm species also belonging to the Arecaceae family. The 29-kDa band was digested by pepsin in less than 1 minute. Cross-reactivity among coconut, walnut, and hazelnut was demonstrated by CAP inhibition in patient 2. CONCLUSION: We have identified a 7S storage protein as a novel coconut allergen.

Apple allergy across Europe: how allergen sensitization profiles determine the clinical expression of allergies to plant foods.

BACKGROUND: Allergy to a plant food can either result from direct sensitization to that food or from primary sensitization to pollen, latex, or another food. OBJECTIVE: We sought to investigate the primary sensitizers in apple allergy across Europe, the individual allergens involved, and whether these differences determine the clinical presentation. METHODS: Patients (n = 389) with positive case histories and skin prick test responses to fresh apple were selected in the Netherlands, Austria, Italy, and Spain. Skin prick tests and RASTs to a panel of pollens and plant foods were performed, as well as RASTs to Bet v 1 and the apple allergens Mal d 1, 2, 3, and 4. RESULTS: In the Netherlands, Austria, and Italy apple allergy is mild (>90% isolated oral symptoms) and related to birch pollinosis and sensitization to Bet v 1 and its apple homologue, Mal d 1, which has an odds ratio of local reactions of 2.85 (95% CI, 1.47-5.55). In Spain apple allergy is severe (>35% systemic reactions) and related to peach allergy and sensitization to Mal d 3 (nonspecific lipid transfer protein), which has an odds ratio of systemic reactions of 7.76 (95% CI, 3.87-15.56). CONCLUSION: The analysis of individual apple allergens in a clinical context has provided insight into the sensitization pathway and into the intrinsic risk an allergen bears to induce mild or severe food allergy. CLINICAL IMPLICATIONS: Information on the sensitization pathway is essential to develop preventive strategies in food allergy. The application of individual food allergens with a known intrinsic risk will improve the prognostic value of diagnostic tests.