Corticosteroid allergy in asthma.

BACKGROUND: Glucocorticosteroids form the basis of therapy for asthma and other allergic diseases. However, they frequently cause delayed contact allergy and occasionally immediate allergy. The purpose of this study was to investigate the occurrence of corticosteroid allergy among patients with asthma and with some complaints caused by inhaled corticosteroids. METHODS: Patch tests with corticosteroids were performed in 51 asthma patients with side-effects from inhalant corticosteroids and in 50 symptom-free asthma patients using the Finn Chamber system. The corticosteroids and their vehicles were: betamethasone-17-valerate 1% in petrolatum, hydrocortisone-17-butyrate (Hc-17-B) 1% in ethanol, tixocortol-21-pivalate 1% in petrolatum, budesonide 0.1% in petrolatum, beclomethasone dipropionate 0.1 and 0.5% in petrolatum and as inhalant powder 200 microg, and fluticasone propionate 0.1 and 0.5% in petrolatum and as inhalant powder 250 microg. The results were read twice, on D4-5 and again on D10. RESULTS: Two patients in the symptomatic group reacted to corticosteroids in patch tests, one to betamethasone-17-valerate, Hc-17-B and budesonide, and the other to budesonide and Hc-17-B. The first patient suffered from widespread eczematous dermatitis when using beclomethasone. Fluticasone caused oropharyngeal irritation, hoarseness and shortness of breath. The second patient experienced a severe rash after the fourth budesonide inhalation. She had used various topical corticosteroids for her atopic dermatitis without any side-effects. None of the symptom-free patients showed positive results. CONCLUSIONS: Delayed allergy to corticosteroids occurs occasionally in asthma, perhaps in the same frequency as in dermatitis. A positive patch test reaction usually means clinical allergy, i.e. the patient cannot use that particular steroid. Cross allergy between corticosteroids is common. However, such patients usually tolerate some other common corticosteroids.

Detection and treatment of early asthma.

BACKGROUND: We sought answers to two questions: 1) how can mild, early asthma best be detected? 2) how should it be treated and the treatment effect monitored? METHODS: Eighty adult patients with early, mostly mild asthma and 30 control subjects were examined by lung-function and biochemical tests. Patients were randomly assigned to two treatment groups. One group was treated with an inhaled steroid (budesonide) for 6 weeks, and the other first with an inhaled beta2-agonist (terbutaline) for 6 weeks and then with an inhaled steroid for 2 weeks. RESULTS: Treatment with budesonide was effective: symptom scores, PEF, blood eosinophils, and sputum ECP values all improved. Terbutaline was ineffective by these criteria. For the detection of early asthma and for the following treatment effects, sputum and serum ECP assays are useful supplements to lung-function tests. CONCLUSIONS: Treatment of early, mild asthma with an inhaled steroid is effective and worthwhile. Detection of the disease remains a problem, as both lung-function and biochemical tests have low sensitivities.

Allergy to feathers.

Skin prick test reactivity to commercial and self-made feather-allergen extracts was examined in 269 consecutive adult patients with suspected allergic cutaneous or respiratory symptoms who had been referred to a university clinic. Some 177 subjects reacted to any inhalant allergen. Twenty-four (9% of the whole group and 14% of those positive to any inhalant allergen) reacted to commercial feather extracts from ALK (Hørsholm, Denmark), and 51 to any of the seven feather extracts used. Feather-mix RAST (Pharmacia, Sweden) was positive in three cases only. Skin prick test or CAP-RAST or both to house-dust mite were positive in 16 of those 24 subjects positive to the commercial feather extracts, but in only 23 of the 150 other atopic subjects (P < 0.001). A nasal challenge with a feather extract was made in 20 cases, always with negative result. In immunospot studies, concomitant allergy to feather-allergen extracts and house-dust mite could be demonstrated. Mite allergens in feather extracts were verified in RAST-inhibition studies. A clinically significant feather allergy was found in one patient only. The results suggest that true feather allergy is very rare, and most of the positive reactions seen in skin prick tests to feather extracts are probably caused by mite allergens present in feathers.

Comparison of a Multidose Powder Inhaler Containing Beclomethasone Dipropionate (BDP) with a BDP Metered Dose Inhaler with Spacer in the Treatment of Asthmatic Patients.

OBJECTIVE: The clinical efficacy, tolerability and acceptability of a new multidose powder inhaler (MDPI) [Easyhaler((R)), Orion Pharma, Finland] containing a high dose (500 microg/dose) of beclomethasone dipropionate (BDP) were compared with those of BDP metered dose inhaler administered with a large volume spacer (MDI-spacer). PATIENTS AND STUDY DESIGN: Recruited patients were adult asthmatics currently receiving 800 to 1000 microg/day of inhaled corticosteroid. The dose of BDP during the study was 1000 mg/day. The study was an open, randomised, parallel-group multicentre study and included a 2-week run-in period followed by a 12-week treatment period. RESULTS: 74 patients were randomised to both groups. During the run-in period the mean morning peak expiratory flow (PEF) was 489 and 478 L/min in the MDPI and MDI-spacer groups, respectively. During the last 2 weeks of the study the morning PEF was 485 L/min in the MDPI group and 477 L/min in the MDI-spacer group. Asthma symptom scores and use of rescue medication were low in both groups. The median dose of histamine required to decrease forced expiratory volume in 1 second (FEV(1)) by 15% was 1.05mg in the MDPI group and 0.64mg in the MDI-spacer group. The most frequent adverse events were hoarseness and sore throat. Mean serum cortisol levels were not affected in either treatment group. Patients' personal opinion regarding acceptability of the devices clearly favoured the MDPI. CONCLUSION: In conclusion, the novel powder inhaler was well tolerated and at least equally effective compared with the conventional MDI-spacer combination in the treatment of asthma with BDP. However, in everyday use the patients clearly favoured the powder inhaler.

Can early asthma be confirmed by laboratory tests?

We examined the performance of a number of laboratory tests in 23 patients who had had symptoms suggesting asthma, such as cough, sputum secretion, and chest tightness with wheezing, for less than a year. Even the best test, histamine challenge, had a sensitivity of only 48%. When more tests were added, sensitivity rose: with peak expiratory flow added, the sensitivity was 65%; with sputum eosinophil cationic protein (ECP) added, to 74%; and with serum ECP added, to 78%. Thus, a combination of tests measuring lung function and activation of eosinophils yielded fair, if not good, results. It appears that sensitivity could be increased further through the development of improved sputum tests.