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Medical Journal Review

April 2023

WAO Reviews – Editors' Choice

The WAO Reviews editors, Juan Carlos Ivancevich, MD, and John J. Oppenheimer, MD - FACAAI - FAAAAI, select articles on a monthly basis for their importance to clinicians who care for patients with asthma and allergic/immunologic diseases.

Cross-sectional study to describe allergic rhinitis flare-ups and associated airways phenotype in house dust mite sensitization
de Gabory L, Amet S, Le Maux A et al
PLoS One 2023;18(3):e0283246

In this observational, multicenter, cross-sectional study of patients aged > 5 years with house dust mite allergic rhinitis (HDM-AR) eligible for allergen immunotherapy (AIT) and without prior AIT for at least 12 months, the authors examined flare-ups that occurred during the preceding 12 months. Data were collected using medical records and patient questionnaires examining variables that were associated with the occurrence of > 2 AR flare-ups. Included were 1701 patients (average age: 23 years, 51.5% males, 30.4% children, 17.7% adolescents, and 51.9% adults). Severe and persistent AR affected 70.9% of them and 53.7% showed polysensitization. Asthma was associated with AR in 34.4% and was well-controlled in 58.5%. The occurrence of at least one AR flare-up in the year was reported by 77.7%, with an annual rate in the whole population of 2.6 ± 3.9 and a duration of 14.1 ± 17.1days. Deeply or moderately AR-related degraded quality of life (QoL) was experienced by 39.5% and 64.6%, respectively. The occurrence of > 2 AR flare-ups was reported by 54.5% and was associated with polysensitization, AR intermittence, and severity of underlying disease.

Pathogenesis of allergic diseases and implications for therapeutic interventions
Wang J, Zhou Y, Zhang H et al
Signal Transduction and Targeted Therapy 2023;8:138 (24 March)

Allergic diseases such as allergic rhinitis (AR), allergic asthma (AAS), atopic dermatitis (AD), food allergy (FA), and eczema are systemic diseases caused by an impaired immune system. This review aimed to assess the epidemiology, pathogenesis, and therapeutic interventions of allergic diseases, including AR, AAS, AD, and FA. Accompanied by high recurrence rates, the steadily rising incidence rates of these diseases are attracting increasing attention. The pathogenesis of allergic diseases is complex and involves many factors, including maternal-fetal environment, living environment, genetics, epigenetics, and the body’s immune status. It exhibits a marked heterogeneity, with phenotype and endotype defining visible features and associated molecular mechanisms, respectively. With the rapid development of immunology, molecular biology, and biotechnology, many new biological drugs have been designed for the treatment of allergic diseases, including anti-immunoglobulin E (IgE), anti-interleukin (IL)-5, and anti-thymic stromal lymphopoietin (TSLP)/IL-4, to control symptoms. For doctors and scientists, it is becoming more and more important to understand the influencing factors, pathogenesis, and treatment progress of allergic diseases.

International consensus statement on allergy and rhinology: Allergic rhinitis – 2023
Wise SK, Damask C, Roland LT, et al
International Forum of Allergy and Rhinology 2023;13(4):293-859

In this ICAR-Allergic Rhinitis 2023 update the expert panel present 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the previous 2018 document. Originally presented topics from 2018 have also been reviewed and updated. ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic, with stepwise iterative peer review and consensus performed for each topic. Through this approach the authors provide a comprehensive evaluation of AR based upon the currently available evidence. This is a wonderful resource for the practicing allergist as well as ENT.

Allergen challenge tests in allergen immunotherapy: State of the art
Zieglmayer P, Zieglmayer R, Lemell P
Allergologie Select 2023;7:25-32

Allergen challenge tests, such as conjunctival (CAC) nasal (NAC), or bronchial (BAC) challenge tests, or challenges in allergen exposure chambers (AEC) are accepted by regulatory agencies for allergy immunotherapy (AIT) phase II studies. In light of the use of these challenge procedures in the approval process, it is important that allergist be familiar with these techniques. This article provides a great review of the available allergen challenge test methods, summarizing the safety and limitations for each, and discusses their potential for use in AIT trials.

Stepping down treatment in chronic spontaneous urticaria: What we know and what we don't know
Terhorst-Molawi D, Fox L, Siebenhaar F, Metz M, Maurer M
American Journal of Clinical Dermatology 2023; Published online ahead of print

In chronic spontaneous urticaria (CSU), wheals, angioedema, or both appear spontaneously for > 6 weeks. Current recommended treatment options for urticaria target mast cell mediators such as histamine, or activators, such as autoantibodies. The goal of CSU treatment is to treat the disease until it is gone as effectively and safely as possible. As at present no cure is available, the treatment is aimed at continuously suppressing disease activity, with complete control of the disease and a normalization of quality of life. To achieve this, pharmacological treatment should be continued until no longer needed.

CSU directed therapy should follow the basic principles of treating as much as needed and as little as possible taking into consideration that the activity of the disease may vary. Since CSU is a disease with spontaneous remission, it is hard to tell in patients with complete control and no signs or symptoms, when medication is no longer needed. The current international guideline for urticaria suggests that the treatment can be stepped down once a patient is free of signs and symptoms; yet, as of now, it is unclear over which period, with what intervals and with which dosages CSU treatment should be stepped down. Guidance on this is needed for all recommended therapies. However, there is a lack of controlled trials which focus on the step down and discontinuation of these treatments. In this review, the authors explore what is known and what needs to be investigated through further studies to aid in optimizing the step-down process.

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