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Medical Journal Review

August 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.

Guidelines of care for the management of atopic dermatitis in adults with topical therapies
Sidbury R, Alikhan A, Bercovitch L et al
Journal of the American Academy of Dermatology 2023;89(1):e1-320 (11 January)

New evidence has emerged since the 2014 guidelines that further informs the management of atopic dermatitis (AD) with topical therapies. These guidelines update the American Academy of Dermatology 2014 recommendations for management of AD with topical therapies. The author’s document provides evidence-based recommendations related to management of AD in adults using topical treatments via a multidisciplinary workgroup who conducted a systematic review and applied the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach for assessing the certainty of evidence and formulating and grading recommendations. They developed 12 recommendations regarding the management of AD in adults with topical therapies, including nonprescription agents and prescription topical corticosteroids (TCS), calcineurin inhibitors (TCIs), Janus kinase (JAK) inhibitors, phosphodiesterase-4 inhibitors (PDE-4), antimicrobials, and antihistamines. This is a great resource for the practicing allergist.

Effect of maternal egg intake during the early neonatal period and risk of infant egg allergy at 12 months among breastfeeding mothers: A randomized clinical trial
Nagakura KI, Sato S, Shinahara W et al
JAMA Network Open 2023;6(7):e2322318 (3 July)

Egg introduction in infants at age 4 to 6 months is associated with a lower risk of immunoglobulin E–mediated egg allergy (EA). However, whether their risk of EA at age 12 months is affected by maternal intake of eggs at birth is unknown. Thus, this study assessed the effect of maternal egg intake during the early neonatal period (0-5 days) on the development of EA in breastfed infants at age 12 month through a multicenter, single-blind (outcome data evaluators), randomized clinical trial at 10 medical facilities in Japan. Newborns with at least 1 of 2 parents having an allergic disease were included. Neonates whose mothers had EA or who were unable to consume breast milk after the age of 2 days were excluded. Data were analyzed on an intention-to-treat basis. Newborns were randomized (1:1) to a maternal egg consumption (MEC) group, wherein the mothers consumed 1 whole egg per day during the first 5 days of the neonate’s life, versus a maternal egg elimination (MEE) group, wherein the mothers eliminated eggs from their diet during the same period. The primary outcome was EA at age 12 months. Egg allergy was defined as sensitization to egg white or ovomucoid plus a positive test result in an oral food challenge or an episode of obvious immediate symptoms after egg ingestion. Three hundred and eighty newborns included (198 [52.1%] female), 367 (MEC: n = 183; MEE: n = 184) were followed up for 12 months. As would be expected, on days 3 and 4 after delivery, the proportions of neonates with ovalbumin and ovomucoid detection in breast milk were higher in the MEC group than in the MEE group (ovalbumin: 10.7% vs 2.0%; risk ratio [RR], 5.23; 95% CI, 1.56-17.56; ovomucoid: 11.3% vs 2.0%; RR, 5.55; 95% CI, 1.66-18.55). At age 12 months, the MEC and MEE groups did not differ significantly in EA (9.3% vs 7.6%; RR, 1.22; 95% CI, 0.62-2.40) or sensitization to egg white (62.8% vs 58.7%; RR, 1.07; 95% CI, 0.91-1.26). Overall it demonstrated that EA development and sensitization to eggs were unaffected by MEC during the early neonatal period.

Clinic versus home spirometry for monitoring lung function in patients with asthma
Oppenheimer J, Hanania NA, Chaudhuri R et al
Chest 2023;S0012-3692(23)00935-2 Published online ahead of print (27 June)

Studies examining agreement between home and clinic spirometry in patients with asthma are limited, with conflicting results. Understanding the strengths and limitations of telehealth and home spirometry has been highlighted following the SARS-CoV-2 pandemic. The purpose of this study was determined how well home and clinic measurements of trough FEV1 agree in patients with uncontrolled asthma via a post hoc analysis from the randomised, double-blind, parallel-group Phase IIIA CAPTAIN (205715; NCT02924688) and phase IIB (205832; NCT03012061) trials in patients with uncontrolled asthma.

Trough FEV1 measurements were collected via home spirometry and supervised in-person spirometry in the research clinic and they examined the time-course analyses of home and clinic trough FEV1, from which they generated post hoc Bland–Altman plots to assess agreement between home and clinic spirometry.  They found that treatment related improvements in FEV1 were observed in both trials using home and clinic spirometry; however, improvements measured by home spirometry were of lower magnitude and less consistent than clinic measurements. Bland–Altman plots suggested poor agreement between home and clinic trough FEV1 at baseline and Week 24. Overall, this indicates that that home spirometry was less consistent than and lacked agreement with clinic spirometry, suggesting that unsupervised home readings are not interchangeable with clinic measurements. The authors do note, however, that these findings may only be applicable to home spirometry using the specific device and coaching methods employed in these studies and that further research to optimise home spirometry use is needed.

Childhood body mass index trajectories and asthma and allergies: A systematic review
Chang CL, Ali GB, Pham J et al
Clinical & Experimental Allergy 2023; Early view (3 July)

Previous systematic reviews have focused on associations between single time point measures of Body Mass Index (BMI) and asthma and allergic diseases. The authors of this study point out that as BMI changes dynamically during childhood, examination of associations between longitudinal trajectories in BMI and allergic diseases is needed to fully understand the nature of these relationships. To understand better this potential association, they conducted a systematic review following the PRISMA guidelines, and two independent reviewers assessed the study quality using the ROBINS-E and GRADE tools. A narrative synthesis was performed as the statistical heterogeneity did not allow a meta-analysis. Their search found 11 studies met the inclusion criteria with a total of 37,690 participants between 0 and 53 years of age. Ten studies examined asthma outcomes, three assessed association with allergic rhinitis, two assessed eczema, and one assessed food allergy. High heterogeneity and high risk of bias were observed. Overall, the quality of evidence was very low. Nevertheless, two consistent findings were identified: (1) a persistently high BMI between 6 and 10 years of age may be associated with an increased risk of asthma at 18 years and (2) a rapid increase in BMI in the first 2 years of life may be associated with subsequent asthma. The authors conclude that maintaining a normal BMI trajectory during childhood may reduce the risk of asthma and suggest further research to confirm this finding.

Is there a rationale for supplementing with vitamin D patients under treatment with allergen immunotherapy?
Mario Di Gioacchino, Claudia Petrarca, Loredana Della Valle et al
Annals of Medicine 2023;55(1):2230864 (30 June)

In this commentary, the authors explore the data regarding use of Vitamin D as a modulating agent in allergic disease, finding allergic patients treated with allergen immunotherapy benefit from the simultaneous administration of Vitamin D, while Vitamin alone did not offer benefits in the prevention or treatment of allergies. They suggest that vitamin serum levels should be always evaluated in patients treated with allergen immunotherapy because these patients have the maximum clinical and immunological benefit with accompanying Vitamin D supplementation.

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