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Medical Journal Review

March 2019

WAO Reviews - Editors' Choice

The Editors select articles for their importance to clinicians who care for patients with asthma and allergic/immunologic diseases, and whenever possible they seek articles that everyone can access freely. The Editors’ Choice comes to you from Juan Carlos Ivancevich, MD, WAO Web Managing Editor, and summary author, John J. Oppenheimer, MD, FACAAI, FAAAAI, WAO Reviews Editor.

The global incidence and prevalence of anaphylaxis in children in the general population: A systematic review
Wang Y, Allen KJ, Suaini NHA, McWilliam V, Peters RL, Koplin JJ
Allergy 2019; Published online ahead of print (28 January). doi: 10.1111/all.13732.

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Surprisingly, despite its significance, thus far there is no systematic review of the global epidemiology of anaphylaxis in the general pediatric population. In this publication, Wang and colleagues performed a rigorous systematic review on the topic, finding 59 articles. Of these, 5 reported cumulative incidence, 39 reported incidence rate and 17 reported prevalence data. The authors found the incidence of anaphylaxis in children worldwide varied quite widely, ranging from 1 to 761 per 100,000 person-years for total anaphylaxis and 1 to 77 per 100,000 person-years for food-induced anaphylaxis. In these studies, the NIAID/FAAN definition of anaphylaxis was the most commonly used. Gender and ethnicity were demographic risk factors associated with anaphylaxis in children. Increasing total and/or food-induced anaphylaxis incidence over time was reported in 19 studies. Furthermore, they found that studies in developing countries are underrepresented. The authors conclude that to accurately compare anaphylaxis incidence between countries and investigate the time trends, further studies using a standardized definition is required.

Patients allergic to fish tolerate ray based on the low allergenicity of its parvalbumin
Kalic T, Morel-Codreanu F, Radauer C Ruethers T, Taki AC et al
JACI: In Practice 2019; 7(2):500-508.e.11  doi: 10.1016/j.jaip.2018.11.011.

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It is known that clinical reactions to bony fish species are common in patients with allergy to fish and are caused by parvalbumins of the β-lineage. Since cartilaginous fish, such as rays and sharks, contain mainly α-parvalbumins, and their allergenicity is not well understood, the authors examined whether clinical cross reactivity existed. They found that most patients allergic to bony fish tolerated ray, because of low allergenicity of its α-parvalbumin. The authors suggest that careful clinical workup and in vitro IgE-testing for cartilaginous fish will improve patient management and may allow the addition of an alternative to bony fish into a bony fish allergic patient’s diet.

Etiology analysis of nonspecific chronic cough in children of 5 years and younger
Chen X, Peng WS, Wang L
Medicine 2019; 98(3):e13910. doi: 10.1097/MD.0000000000013910.

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To better understand the etiology of non-specific, chronic cough in children 5 years of age and under, Chen and colleagues retrospectively examined 85 cases of children in this age group, who suffered from nonspecific chronic cough. They found that 27 cases were due to cough variant asthma (31.8%), 32 cases had upper airway cough syndrome (37.6%), 16 cases had cough after infection (18.8%), 3 cases had gastroesophageal reflux cough (3.5%), 2 cases had allergic cough (2.4%), and 5 cases had unknown causes of cough (5.9%). The authors reinforce that etiologies of cough may vary based upon geographic location and thus these results may not be universal.

Effect of epicutaneous immunotherapy vs placebo on reaction to peanut protein ingestion among children with peanut allergy: The PEPITES Randomized Clinical Trial
Fleischer DM, Greenhawt M, Sussman G, Bégin P, Nowak-Węgrzyn A et al
JAMA 2019; Published online ahead of print (22 February). doi: 10.1001/jama.2019.1113.

Presently there are no approved treatments for peanut allergy. Several hopeful interventions are undergoing study. In this study by Fleishcher and colleagues, the authors assessed the efficacy and safety of epicutaneous immunotherapy in children with peanut allergy in this phase 3, randomized, double-blind, placebo-controlled multicenter trial. Three hundred fifty-six (356) peanut-allergic children (aged 4-11 years) without a history of a severe anaphylactic reaction who had a positive double-blind, placebo-controlled food challenge with an eliciting dose of 300mg or less of peanut protein received daily treatment with either peanut patch containing 250 μg of peanut protein (n = 238) or placebo (n = 118) for 12 months. The primary outcome was the percentage difference in responders between the peanut patch and placebo patch based on eliciting dose (highest dose at which objective signs/symptoms of an immediate hypersensitivity reaction developed) determined by food challenges at baseline and at 1 year. Participants with baseline eliciting dose of 10 mg or less were responders if the post-treatment eliciting dose was 300 mg or more; participants with baseline eliciting dose greater than 10 to 300 mg were responders if the post-treatment eliciting dose was 1000mg or more. Among 356 subjects randomized (median age, 7 years; 61.2%male), 89.9% completed the trial; with a mean treatment adherence of 98.5%. The responder rate was 35.3% in those stratified to peanut patch treatment vs 13.6% in placebo (difference, 21.7% [95%CI, 12.4%-29.8%; P < .001]). The pre-specified lower bound of the CI threshold of 15% however was not met. TEAEs, were primarily patch application site reactions, and occurred in 95.4% and 89% of active and placebo groups, respectively. The all-causes rate of discontinuation was 10.5% in the peanut-patch group vs 9.3% in the placebo group.

A systematic review of epinephrine stability and sterility with storage in a syringe
Parish HG, Morton JR, Brown JC
Allergy Asthma & Clinical Immunology 2019; 15:7. doi: 10.1186/s13223-019-0324-7. eCollection 2019.

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Despite epinephrine’s lifesaving abilities in the treatment of anaphylaxis, epinephrine autoinjectors are neither universally available nor affordable. As little is known about the effects on epinephrine when it is drawn up in advance and stored as prefilled syringes, this study examined the stability and sterility of epinephrine when stored in syringes through examining the literature regarding this topic. The authors found three studies that addressed this issue, and this limited evidence suggests that syringes filled with 1 mg/mL epinephrine are stable and sterile for 90 days. The authors stress that further research is needed, to explore the duration of stability and sterility of prefilled syringes with the 1 mg/mL dose, but it also should also examine a variety of storage conditions and syringe brands.

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