Will Sublingual Immunotherapy Offer Benefit for Asthma?

Evidence shows that sublingual immunotherapy (SLIT) is indicated in patients with allergic rhinitis (AR). In this article we discuss whether SLIT could offer benefit for children and adults with asthma. We reviewed individual trials on SLIT in asthmatic patients, but also asthma data reported in some SLIT trials conducted in AR patients. Findings were complemented with data from systematic reviews and meta-analysis on the subject since 2000 and some guidelines that mention immunotherapy for asthma treatment. In AR patients with concomitant persistent asthma, SLIT reduces medication needs while maintaining symptom control. This holds especially true for house dust mite SLIT. Data on pollen SLIT and lung symptom improvement with SLIT, however, are less convincing. Therefore, we suggest SLIT should be added as an optional add-on therapy for patients with asthma whenever a causative allergen has been demonstrated and AR is associated with asthma. For the future, SLIT should be studied in specifically designed asthma studies in allergic asthmatics without AR.     

Allergic Cycle: Relationships Between Asthma Allergic Rhinitis, and Atopic Dermatitis

Details of the symptomatic history of 118 asthmatic patients with allergic rhinitis (AR), 18 asthmatic patients with atopic dermatitis (AD), and 6 asthmatic patients with both AR and AD were investigated. All 142 patients had atopic (64 cases) or mixed-type asthma (78 cases). In 118 (83%) and 66 (46%) of the 142 patients, asthmatic attacks were mainly associated with autumn and the rainy season in Japan, respectively. In 84 (68%) of 124 patients with AR, AR-related symptoms were mainly associated with spring. In 68 patients (55%), AR appeared 1-33 years (mean, 10.5 years) before the initial appearance of asthma. In patients with asthma and AR, 102 (82%) of 124 cases had an inverse relationship between the peak times of symptoms consistent with asthma and AR. In 84 (82%) and 80 (78%) of 102 patients with an inverse relationship between the peak times of symptoms associated with asthma and AR, respectively, episodes of preceding AR and infectious rhinitis were not seen at each asthmatic attack. Of 24 asthmatic patients with AD, 12 (50%) had AD 1-23 years (mean, 14.3 years) after the initial appearance of asthma. In 18 (75%) of 24 patients, an inverse relationship between the peak times of symptoms consistent with asthma and AD was observed. These results have tempted us to consider an allergic cycle theory that asthma may be inactive when AR or AD is active; i.e., one active allergic reaction occurs at only one site among allergic sites of the body, including the bronchi, nasal mucosa, and skin.     

Relation of perimenstrual asthma with disease severity and other allergic co-morbidities—the first report of perimenstrual asthma prevalence in Saudi Arabia

BackgroundPerimenstrual asthma (PMA) has been documented in 30–40% of asthmatic women; however, there have been few epidemiological investigations of PMA in practice.ObjectivesDetermination of the prevalence of perimenstrual asthma in a sample of female Saudi asthmatic patients, and to study the relation of PMA to asthma severity, aspirin-induced asthma and to other allergic co-morbidities.Study designData were analysed from all female asthmatic patients followed up in the unit from January 2008 to May 2009 who were not pregnant, not on oral contraceptive pills, not menopausal, nor had had a hysterectomy. They were asked about exacerbation of their asthma state regarding worsening of symptoms, need for more rescue medications and even visits to emergency room just before or in the first days of menstruation, or both. Moreover, relation with aspirin-induced asthma and other associated allergic co-morbidities recorded in their medical files with prevalence of PMA was reported.ResultsThe prevalence was found to be 8.2%. Asthma severity was found to be significantly related to PMA (p<0.0001). Aspirin-induced asthma and allergic co-morbidities were more prone to occur in cases with PMA than other studied asthmatics.ConclusionWe have found a low prevalence of PMA in Saudi women of fertile age compared to other studies published. Study findings support the hypothesis that PMA is related to asthma severity.     

The atopic march: from skin to the airways

Many patients with atopic eczema (AE) would "march" to develop allergic rhinitis (AR) and asthma. Physicians, patients and their families often do not appreciate the significance of these diseases as co-morbidities of atopy.The aim of this study was to evaluate the prevalence and severity of airway atopies in patients with AE. AR and asthma severity were assessed in consecutive AE patients seen at a pediatric dermatology clinic by ARS (allergic rhinitis score) and ACT (asthma control test). Eczema severity (SCORAD and Nottingham Eczema Severity Score: NESS) were recorded.110 patients with AE and 42 patients without AE were recruited. Allergic rhinitis and asthma were significantly more prevalent in patients with AE [odds ratio for AR was 2.9 (CI: 1.3 - 6.5) and for asthma 4.3 (CI: 1.3 - 16.10)]. 23 (45%) of the AE patients with AR reported that they were currently on oral antihistamine whereas none of the non-AE group reported such usage. Both groups reported relatively higher sneezing and nasal congestion scores and low "eye watering" score. Comparing mild with moderate-to-severe AE, there was essentially no difference between the prevalence of allergic rhinitis and asthma, or severity of symptoms by ARS and ACT, but females reported more severe symptoms of sneezing and itching nose.We conclude that allergic disorders of airway are very common among AE patients independent of the eczema severity. Most of the patients have mild-to-moderate AR and asthma. There is a lot of room for parent/patient education, and childhood eczema may prompt early awareness of these airway co-morbidities of atopy.     

The impact of concomitant allergic rhinitis on asthma control: a cross-sectional nationwide survey in China

Objectives: Understanding the interactions between allergic rhinitis (AR) and asthma is important for asthma management. This study explored the clinical features of AR as a comorbidity in Chinese asthmatic patients and its impact on asthma control. Methods: This cross-sectional survey was conducted among 20?051 patients with asthma in an out-patient setting and covered all of the territories of China. The patients were interviewed face-to-face. A standardized questionnaire was completed by each patient. AR was defined according to the ARIA criteria. The level of asthma control was assessed by the Asthma Control Test. A score ≤19 indicated poorly controlled asthma. Results: AR was present in 69.9% of patients with asthma. Of them, 72.4% had intermittent symptoms, and 93.1% presented with moderate/severe symptoms. Cold air, irritant air and household mites were the most common triggers for AR. A higher percentage of patients with AR experienced poorly controlled asthma compared with those without AR (56.2% versus 51.5%, p?p?p?p?p?=?0.004) and a prior skin prick test (OR: 0.90, p?=?0.003) showed a significantly negative association with poorly controlled asthma. Conclusion: This study confirms that concomitant AR and asthma are highly prevalent in China and that AR is associated with poor asthma control.     

Diagnostic et fréquence de la rhinite allergique chez l'enfant asthmatique

This prospective study aimed to: 1) validate a paediatric questionnaire score from which allergic rhinitis (AR) could be diagnosed, 2) estimate its prevalence in asthmatic children, and 3) ascertain if AR is an additional risk factor for the severity of asthma. The questionnaire, modified from the adult form of the SFAR, was administered to 352 asthmatic children seen in consultation between June 2005 and April 2006. AR was diagnosed in 200 of these children (56.8%). AR was mild and intermittent in 45% of cases, moderate-to-severe and intermittent in 11%, mild and persistent in 27% and moderate-to-severe and persistent in 17%. A total score ≥ 9 was discriminant for AR (sensitivity = 90.5%, specificity = 94.7%, positive predictive value = 95.8%, negative predictive value = 88.3%, Youden's Index = 0.86). The proportion of children having mild or moderate-to-severe asthma was independent of the presence of AR (43.5% vs 48.6% and 56.5 vs 51.3%, respectively).     

哮喘患者自诉诱发哮喘的感冒并非都是感冒

目的　调查哮喘患者自认为是诱发哮喘的感冒中，有多少人实际上是过敏性鼻炎，并探讨其临床特点及其与哮喘发病的关系。方法　按照预先设计的调查表对１０３ 例患者进行调查，根据是否患过敏性鼻炎将患者分为过敏性鼻炎合并哮喘组（４９ 例）和单纯哮喘组（５４ 例） 详细询问患者每次感冒和哮喘发作的具体症状和相关病史并作体检，同时进行鼻分泌物涂片查嗜酸细胞和过敏原皮肤试验。结果　１０３ 例患者中４９ 例所说的感冒实际上属于过敏性鼻炎，占４７－６％ ；过敏性鼻炎合并哮喘组的哮喘首发年龄明显低于单纯哮喘组，分别为（２８±１３） 岁和（３６ ±１６） 岁，两组比较差异有显著性（Ｐ＜０．０１）；哮喘的好发季节和发作时间与过敏性鼻炎基本一致。结论　（１） 哮喘患者自诉诱发哮喘的感冒并非都是感冒，４７－６％ 的患者所说的感冒实际上是过敏性鼻炎；（２） 过敏性鼻炎与支气管哮喘的发病关系密切；（３）认真鉴别感冒和过敏性鼻炎对于预防哮喘的发生具有重要临床意义。     

MicroRNA in Chronic Rhinosinusitis and Allergic Rhinitis

The prevalence of allergic rhinitis (AR) is on the increase and this condition is frequently associated with asthma, thus leading to the concept that these two conditions are different aspects of the same disease. There is now accumulating evidence that AR often precedes the onset of asthmatic symptoms. This notion has important implications, not only for the diagnosis and management of these common allergic conditions but also for the potential progression of disease. Very little is known about the risk factors responsible for the progression of AR to asthma; current treatment options can control symptoms but do not prevent or cure the disease. However, there are recent data supporting the notion that it is possible to prevent new asthma cases by modifying the immune response and clinical outcome with allergen immunotherapy. This review article evaluates the impact of AR on the development of asthma, examines putative predictors for the progression of AR to asthma, and reviews recent, promising literature suggesting that early treatment of allergic individuals with immunotherapy may aid in asthma prevention.     

A common pathway: asthma and allergic rhinitis.

Historically, the structural and functional differences within the respiratory tract have been the basis for separating the airway into upper and lower entities. For centuries, researchers suggested similar mechanisms in asthma and rhinitis. The implications of such a connection are significant in that asthma and allergic rhinitis (AR) are associated with a high prevalence in adults and children, substantial health care costs, and, often, serious negative effects on quality of life. The importance of the unified airway hypothesis lies in the rational approach to treatment. Management approaches that consider the association between asthma and AR may improve overall outcomes in patients with both diseases. Because the treatment of AR may affect concomitant asthma, significant improvements in health status may occur in some patients. The following review discusses the epidemiology of asthma and AR, provides evidence for common pathophysiological mechanisms, and discusses a therapeutic approach that has positive effects on both diseases, and thereby may maximize benefits and outcomes for patients with concomitant asthma and AR.     

May T1 diabetes mellitus protect from asthma?

BackgroundType 1 diabetes mellitus (T1DM) may be associated with allergy. It was previously reported that >20% of children with T1DM had allergic rhinitis (AR), but none was asthmatic. This finding was surprising as allergic rhinitis is frequently associated with asthma and asthma prevalence is about 10% of the general paediatric population. Thus, it was hypothesized that T1DM could protect from asthma.ObjectivesThe aim of this preliminary study was to evaluate the pulmonary function and the response to bronchodilation testing in children, suffering from T1DM with associated AR, comparing them with a control group of children with AR alone.MethodsTwenty children with T1DM and AR were compared with 59 children with AR alone; spirometry and bronchodilation testing were performed in all patients.ResultsThere were no statistically significant differences in both “at baseline” and after bronchodilation testing about FVC, FEV₁, and FEF_25–75 values. However, changes in “post-bronchodilator” values of FEF_25–75 (ΔFEF_25–75) were significantly higher in children with AR alone than in children with T1DM and AR (p = 0.04).ConclusionsThis preliminary study could sustain the hypothesis that T1DM in children suffering also from AR might exert a protective effect of preventing the possible evolution in asthma.     

The asthma and allergic rhinitis link.

During the past 10 years, our understanding of asthma and allergic rhinitis (AR) has evolved. The historic perspective of these allergen-induced disorders as distinct and separate entities is being displaced by current thinking that they are described better as a continuum of inflammation involving one common airway. Therefore, traditional therapies originally indicated for AR and asthma are being reassessed to explore their potential value in both upper- and lower-airway diseases. Recently, there has been a renewed interest in the role that histamines play in lower-airway disease, and interest is increasing in the leukotrienes (LTs), which are far more potent inflammatory mediators than histamines, and the role they play in upper-airway disease. Given the pivotal role that LTs play as potent inflammatory mediators in the pathophysiological state of inflammation of both airways, LT receptor antagonists recently have emerged as important therapeutic advances that have potential clinical value in both asthma and allergic rhinitis. The prevalence of asthma and AR is increasing in the general population, and a high proportion of new patients have coexisting upper- and lower-airway disease. Estimates show that 60-78% of patients who have asthma have coexisting AR. The following review discusses the epidemiology of asthma and AR, provides evidence for common pathophysiological mechanisms, and discusses a therapeutic approach that has positive effects on both diseases and may maximize benefits and outcomes for patients with concomitant asthma and AR.     

The Relationship between Asthma and Allergic Rhinitis in the Iraqi Population

BackgroundRecently, extensive research has established that epidemiologic and therapeutic links exist between allergic rhinitis and asthma. The objective of this study was to clarify this association in Iraq.MethodsThe data included in this study were collected from five surveys for asthma and allergic rhinitis that were performed during the period from September 2000 to July 2008. These surveys were parts of Tikrit University College of Medicine PHC program.ResultsThe frequency of allergic rhinitis (AR) was 61.6% among individuals with asthma versus 6% among non-asthmatic (control) subjects (Odd Ratio [OR] = 25.5; P < 0.0001). All studies indicated a significant frequency of AR among asthmatic patients in comparison with non-asthmatic subjects, whether the patients were adults or children (OR for adults = 14.9 and 22.5, for children 34.7 and 48.4; P < 0.001 for all). Furthermore, the high frequency of AR in asthmatic patients was seen whether the study was a community based study (CBS) (OR = 14.9 and 48.4; P < 0.0001) or a hospital based study (HBS) (OR = 22.5 & 34.7; P < 0.0001). The frequency of current asthma was 51.8% among individuals with AR versus 5.4% among control subjects (OR = 23.1; P < 0.0001).ConclusionsThis study provided evidence that AR and asthma are strongly associated with each other and the treatment approach should consider the entire airway rather than only a part.     

Asthma in elite athletes: how do we manage asthma‐like symptoms and asthma in elite athletes?

Introduction: Asthma is frequent in elite athletes and the high prevalence of asthma might be associated with specific types of sport. It has been suggested that chronic endurance training might increase the number of neutrophils in the airways, and this may reflect airway injury. The use of anti‐asthmatic medication in elite athletes is also currently under scrutiny in order to reduce the risk of under‐treatment or over treatment. Objectives: Determine the use of anti‐asthmatic medication and the prevalence of asthma‐like symptoms and asthma in Danish elite athletes. Further, to determine whether elite athletes with asthma‐like symptoms have asthma and investigate the airway inflammation and airway reactivity to mannitol. Materials and Methods: Three cross‐sectional studies: (i) Applications for Abbreviated Therapeutic Use Exemption (ATUE) certificates in 2005 were studied (N = 694); (ii) a questionnaire survey of elite athletes (N = 418); and (iii) a clinical study of elite athletes. A total of 54 elite athletes (19 with physician‐diagnosed asthma) participated together with two control groups: (i) 22 non‐athletes with physician‐diagnosed asthma (steroid naïve for 4 weeks before the examination) and (ii) 35 non‐athletes without asthma. Examinations: questionnaires, exhaled nitric oxide (eNO), spirometry, skin prick test, mannitol test and blood samples. Induced sputum was done in subjects with asthma. Results: (i) Anti‐asthmatic medication was included in 445 (64%) of all ATUE certificates. A total of 308 (69%) elite athletes applied for inhaled corticosteroids (ICS), and most ATUE certificates were handled by general practitioners (GP) (78%). (ii) A total of 329 (79%) elite athletes completed the questionnaire; 181 (55%) reported asthma‐like symptoms and 46 (14%) had asthma. Anti‐asthmatic medication was currently taken by 24 (7%) elite athletes. Elite athletes participating in endurance sports had higher prevalences of asthma‐like symptoms (74%), use of anti‐asthmatic medication (15%) and current asthma (24%) than all other athletes (P < 0.01). (iii) No difference in lung function, eNO, airway reactivity (AR) to mannitol and atopy between elite athletes with and without asthma‐like symptoms was found. Elite athletes with physician‐diagnosed asthma had less AR [Response Dose Ratio (RDR) 0.02 (0.004) vs 0.08 (0.018) P < 0.01], and fewer sputum eosinophils [0.8% (0–4.8) vs 6.0% (0–18.5), P < 0.01] than non‐athletes with physician‐diagnosed asthma. Conclusion: Most applications for ATUE certificates were handled by GPs, and the majority concerned anti‐asthmatic medication. We found signs of under‐treatment of elite athletes with asthma, and endurance athletes had the highest prevalence of asthma‐like symptoms and asthma. The prevalence of asthma‐like symptoms was higher than the prevalence of asthma, and we showed that symptoms alone should not be used to diagnose asthma. We demonstrated that asthma‐like symptoms are independent of lung function, eNO, RDR and atopy in elite athletes. Elite athletes with physician‐diagnosed asthma seem to have less airway reactivity and fewer sputum eosinophils than non‐athletes with physician‐diagnosed asthma, but more studies are needed to further investigate if and how the asthma phenotype of elite athletes differs from that of classical asthma.     

Prevalence,Demographics, and Health Outcomes of Comorbid Asthma and Overweight in Urban Children

Background. Asthma and overweight are epidemic in urban children but the relationship between these conditions is not fully understood. This study presents demographic and risk profiles of comorbidity for overweight asthmatic children, characterizes morbidity by comparing health outcomes among overweight asthmatics and healthy weight asthmatics, and examines socioeconomic factors associated with comorbidity. Objective. To construct a demographic profile of overweight asthmatic children in an urban setting and identify factors that contribute to prevalence. Method. Cross-sectional study of 5250 children in New York City public elementary schools using a parent-report questionnaire on body mass index, socioeconomic status, asthma, and asthma-related outcomes. Results. Prevalence of overweight (body mass index ≥ 85th percentile for age and gender) was 50.9%. The prevalence of overweight and ever being diagnosed with asthma was 10.9%. The prevalence of overweight with current asthma was 6.2%. Overweight current asthmatics had more night symptoms, missed school days, and asthma medication use than healthy weight asthmatics. Almost 50% of overweight current asthmatic children reported emergency department visits for asthma compared with 30% of healthy weight asthmatics. Comorbidity was most prevalent among males, Latinos, and children in low-income households, with the highest prevalence among Puerto Ricans. In multivariate analysis stratified by gender, the most significant factors associated with comorbidity among girls were low income and minority race/ethnicity, while among boys significant factors were parental education and parental history of asthma. Interestingly, there were few underweight children (7.8%) but they had high prevalence of asthma (13.8%). Conclusions. The comorbidity of overweight and asthma has a large impact on urban populations, causing greater disease burden than asthma alone. Overweight asthmatics show more uncontrolled asthma, evidenced by emergency department visits, quick-relief medication use, and days with asthma symptoms. The relationship between socioeconomic factors and the asthma–obesity comorbidity may vary by gender and requires further study to identify successful interventions to reduce disease in children.     

呼出气一氧化氮在哮喘中的临床意义

目的哮喘以慢性气道炎性反应为特征,主要涉及嗜酸性粒细胞的募集和活化。呼出气一氧化氮(fractional exhaled nitric oxide, FeNO)是气道炎症的一个非侵入性标志物。本文探讨了FeNO在哮喘中的临床意义。 方法我们评估了94例哮喘患者治疗前后的FeNO和肺功能参数及哮喘控制检测(asthma control test, ACT)评分,其中完成1个月随访的有75例,完成3个月随访的有73例,分析了我院哮喘患者控制水平的一些相关因素。 结果发现诊断时的FEV1%在预测哮喘控制时最具优势,哮喘患者根据ACT评分划分的不同控制状态的FeNO和肺功能参数无明显差异。FeNO和肺功能参数,ACT评分及血IgE,血嗜酸性粒细胞计数之间无明显相关性。FEV1%与ACT评分之前存在正相关(r＝0.04184,P＝0.0492)。无过敏性鼻炎(allergic rhinitis, AR)组,FeNO和ACT评分之间存在负相关(r＝0.2015,P＝0.0128)。3个月治疗后FeNO和ACT评分之间仍无明显相关性。 结论哮喘患者治疗前后的FeNO可以评估患者的治疗效果,而FeNO并不能预测哮喘的控制状态及恶化风险,FEV1%在预测哮喘控制方面具有临床意义。     

Prevalence of Allergic Diseases and Influencing Factors in Primary-School Children in the Ankara Region of Turkey

We have studied the prevalence of atopic disease, by questionnaire, in 3024 primary-school children from three different socioeconomic levels in Ankara. Physical examinations were also performed on these children. The cumulative prevalence of asthma, allergic rhinitis, allergic conjunctivitis, and atopiceczema was 6.9%, 11.7%, 4.6%, and 2.6%, respectively. Allergic rhinitis was more common in children older than 10 years. Most of the symptoms of asthmatic patients began in the first 3 years of life. The cumulative prevalence of allergic diseases was 23.4%. This study has estimated the prevalence of allergic diseases, including asthma, allergic rhinitis, allergic conjunctivitis, and allergic dermatitis, in the Ankara region of Turkey.     

High prevalence of asthma in patients with bronchiectasis in Hong Kong.

Eighty five Chinese patients with diffuse or localized bronchiectasis (non-cystic fibrosis) were studied regarding the prevalence of asthma. Twenty three of the 85 had concomitant asthma, diagnosed by history and reversibility on lung function testing either spontaneously or after bronchodilator. None fulfilled the diagnostic criteria of allergic bronchopulmonary aspergillosis (ABPA). Asthma preceded the onset of bronchiectasis in 13 patients and developed after long duration of bronchiectasis in seven, while the temporal onset could not be differentiated in three patients. Patients with both asthma and bronchiectasis had inferior spirometric values, higher prevalence of bronchial hyperresponsiveness to methacholine, higher prevalence of skin atopy, elevated serum immunoglobulin E (IgE), and more sputum eosinophilia, compared with their non-asthmatic counterparts. Possible mechanisms by which asthma and bronchiectasis predispose to each other include asthmatic obstruction contributing to development of bronchiectasis, and sensitization of airways with increased lability due to microbial colonization of the ectatic bronchial tree.     

Chlamydophila pneumoniae infection status is dependent on the subtypes of asthma and allergy.

This study was undertaken to investigate the association of Chlamydophila pneumoniae infection (CPI) with asthma and allergy. One hundred forty-one patients with asthma aged 3-21 years, 125 healthy controls aged 3-21 years, and 62 allergic but nonasthmatic patients aged 4-20 years participated in this study. C. pneumoniae-specific antibodies were measured by ELISA. There were no significant differences in the percentage of patients positive for C. pneumoniae-specific antibodies between the three groups. Significantly more allergic asthmatic patients were positive for C. pneumoniae-specific IgA and IgA + IgG than nonallergic asthmatic patients, and this difference remained significant after adjustment for age and gender: adjusted odds ratio (OR) = 5.9 (1.7-26.2) and p = 0.01 for IgA, and OR = 5.2 (1.6-25.8) and p = 0.02 for IgA + IgG. The prevalence of the C. pneumoniae-specific IgA and the IgA + IgG positivity also was significantly lower in the nonallergic asthmatic group than in the allergic and control groups (p < 0.005). No food/drug-allergic patient was positive for C. pneumoniae-specific IgA, whereas 41.6% of the inhalative-allergic patients were positive for this antibody (p = 0.002). In our population CPI does not associate directly with asthma and allergy, but chronic or recurrent infection is associated with allergic asthma and inhalative allergy as opposed to nonallergic asthma and noninhalative allergy.