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Medical Journal Review

April 2020

WAO Reviews – Editors' Choice

The Editors’ Choice comes to you from Juan Carlos Ivancevich, MD, and John J. Oppenheimer, MD, FACAAI, FAAAAI. They select articles for their importance to clinicians who care for patients with asthma and allergic/immunologic diseases, and whenever possible, for their accessibility to everyone.

Global trends in anaphylaxis epidemiology and clinical implications
Turner PJ, Campbell DE, Motosue MS, Campbell RL
Journal of Allergy and Clinical Immunology: In Practice 2020;8(4):1169-1176.
https://doi.org/10.1016/j.jaip.2019.11.027

This is an interesting article, which explores the varied forms of anaphylaxis from a global perspective. The authors acknowledge the difficulty in examining this literature, noting that many regions have not yet developed reliable systems with which to monitor anaphylaxis. Currently, the most robust data sets available are based largely on hospital admissions, which have many limitations, including misdiagnosis, misclassification, and generalizability. Despite this, there are convincing data of a global increase in rates of all-cause anaphylaxis which medication- and food-related anaphylaxis largely drive. Interestingly, there is no evidence of parallel increases in global all-cause anaphylaxis mortality.

Intranasal corticosteroids in allergic rhinitis in COVID-19 infected patients: An ARIA-EAACI statement
Bousquet J, Akdis C, Jutel M, Bachert C, Klimek L et al.
Allergy 2020; Published online ahead of print (31 March)
https://doi.org/10.1111/all.14302

In these very scary times of COVID-19, this proposed joint statement from Allergic Rhinitis and its Impact on Asthma (ARIA) and European Academy of Allergy Asthma and Clinical Immunology (EAACI) regarding the use of intranasal corticosteroids for the treatment of allergic rhinitis gives some sense of comfort. The authors conclude that in patients with COVID-19 infection, intra-nasal corticosteroid therapy can be continued in allergic rhinitis at the recommended dose. They note that suppression of the immune system has not been proven, and more sneezing after discontinuation could lead to greater spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The expert panel, however, does point out that these recommendations are conditional due to the paucity of data and will require revision regularly as our knowledge increases.

Atopy modifies the association between inhaled corticosteroid use and lung function decline in patients with asthma
Marcon A, Marchetti P, Antó JM, Cazzoletti L, Cerveri I et al.
Journal of Allergy and Clinical Immunology: In Practice 2020;8(3):980-988.e10.
https://doi.org/10.1016/j.jaip.2019.10.023

It is known that patients with allergic inflammation generally demonstrate a better short-term response to inhaled corticosteroids (ICSs); however, studies regarding long-term effects are few. In this study, Marcon et al, examined whether allergic sensitization can modify the association between ICS use and lung function decline over a 20-year span in adult asthma, via mining data from the European Community Respiratory Health Survey. The authors measured ICS use (no use and use for 8 years) and FEV1 decline among subjects with asthma over the 2 periods between consecutive examinations, exploring whether the association between ICS use and FEV1 decline was modified by allergic sensitization (IgE > 0.35 kU/L for any of house-dust mite, timothy grass, cat, or Cladosporium). They found that FEV1 decline was similar for non-ICS users, as well as ICS users for less than 1.3 years, with and without allergic sensitization. However, among subjects on ICSs for a longer period, sensitization was associated with an attenuated decline (Pinteraction = .006): in the group treated for more than 8 years;  with FEV1 decline on average 27 mL/y (95% CIBonferroni-adjusted, 11-42) lower for subjects with sensitization compared with non-sensitized subjects. Overall, this indicates that biomarkers of allergy can predict a more favorable long-term response to ICSs.

Allergen immunotherapy: What is the added value of real-world evidence from retrospective claims database studies?
Devillier P, Demoly P, Molimard M
Expert Review of Respiratory Medicine 2020; Published online ahead of print (4 March)
https://doi.org/10.1080/17476348.2020.1733417

While randomized controlled trials (RCTs) have demonstrated that allergen immunotherapy (AIT) has proven long-term efficacy in patients with allergic rhinitis (AR), they have limited generalizability and there is growing recognition that real-world evidence (RWE) is necessary to provide complementary data to those of RCTs and corroborate their findings in the real world setting. Until recently, data from the real-world setting investigating the benefits of AIT for the treatment of patients with grass and birch pollen-associated AR were sparse. New retrospective claims database studies from France and Germany have confirmed the sustained benefits of grass and birch pollen AIT in terms of significantly reduced progression of AR and asthma, and a significantly decreased risk of new-onset asthma. In this article, the authors explore the value of RWE, alongside data from traditional RCTs, focusing on the potential strengths and limitations of each.

Adherence to prescribed e-diary recording by patients with seasonal allergic rhinitis: Observational study
Di Fraia M, Tripodi S, Arasi S, Dramburg S, Castelli S et al.
Journal of Medical Internet Research 2020;22(3):e16642
https://doi.org/10.2196/16642

Electronic clinical diaries allow recording of disease severity scores in tandem with pollen exposure, which aids in making a clear diagnosis of seasonal allergic rhinitis. Unfortunately, prior studies have shown that patients who spontaneously download an e-diary app have a very low adherence to their recording. The objective of this study was to assess adherence of patients with seasonal allergic rhinitis to symptom recording via e-diary as explicitly prescribed by an allergist (within a blended care approach). In the pilot phase of the study, the authors recruited Italian children (Rome, Italy) and adults (Pordenone, Italy) with seasonal allergic rhinitis and instructed them to record their symptoms, medication intake, and general conditions daily through a mobile app (Allergy.Monitor) during the relevant pollen season. In the 194 subjects recruited, there was an impressive level of adherence demonstrated, but use slowly declined during monitoring in 3 phases – phase A: first week, ≥1267/1358, 90%; phase B: second to sixth week, 4992/5884, 80% to 90%; and phase C: seventh week onward, 2063/2606, 70% to 80%. The authors conclude that this study supports the use of e-diaries in addition to face-to-face visits for diagnosis and treatment of seasonal allergic rhinitis and deserves further investigation via a real-life study.

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