Levocetirizine in persistent allergic rhinitis and asthma: effects on symptoms, quality of life and inflammatory parameters

Background Levocetirizine (LCZ) has been shown to be effective in allergic rhinitis. We evaluated its clinical efficacy, antinflammatory actions and its effects on quality of life (QoL) with a specific instrument in the asthma-rhinitis comorbidity. Methods Fifty adult patients with persistent rhinitis with/without asthma were enrolled. After a 1-week run-in for baseline evaluation, they were randomized to LCZ or placebo for 8 weeks. Cromolyn and salbutamol were permitted on demand. Rhinoconjunctivitis and asthma symptoms were evaluated by diary cards. QoL was assessed by the specific Rhinasthma questionnaire and the generic SF-36 at different time-points. Nasal scrapings and lavages were also performed for inflammatory cell count and mediator assessment. Results Ten patients dropped out for unrelated reasons and the remaining completed the study with no side-effect. Symptoms began to decrease in the active group at the second week of treatment when the difference with the placebo group became significant (0.05) and so remained until the end of the trial. Starting from 2 weeks of therapy, there was a significant decrease vs. baseline in all the four components of the Rhinasthma questionnaire only in the active group. The intergroup comparison became significant (P<0.05) at 4 weeks. The SF-36 detected only sporadic differences between groups. Eosinophils and neutrophils in nasal scraping were significantly decreased in the LCZ group vs. baseline at all times. Nasal mediators were under the detection limits and no analysis could be performed. In the active group, only two patients used rescue medications compared with 13 patients in the placebo group. Conclusions LCZ is clinically effective and capable of improving the rhinitis-asthma-related QoL.

Randomized double-blind controlled study with sublingual carbamylated allergoid immunotherapy in mild rhinitis due to mites

BACKGROUND

The clinical efficacy of sublingual immunotherapy (SLIT) in mite allergy and in mild disease is still a matter of debate, thus we performed a long-term clinical trial.

METHODS

The study was randomized, double-blind and placebo-controlled. After a 1-year assessment, 68 patients with mild rhinitis with/without asthma due to mites were randomized to drugs + placebo or drugs + SLIT for 2 years. Sublingual immunotherapy was given as soluble tablets of monomeric carbamylated allergoid. Clinical scores for asthma and rhinitis (0, absent to 3, severe) and drug consumption were assessed by diary card in the period November-February. Quality of life was assessed before and after each observation period and pharmaco-economy data were evaluated as well.

RESULTS

Fifty-six patients completed the study. The rate of dropouts was similar in the two groups. No relevant side effect was reported. There was a significant reduction of total clinical scores (P < 0.05) in the active group vs placebo at the first year, but not at the second whereas nasal obstruction significantly improved in both years (P < 0.05). The reduction of drug intake score was significant only at the first year. No change was observed concerning most of the Short Form-36 items, because at baseline all patients displayed a normal profile. A significant change in SLIT group was seen for the item 'change in health status'. The need for extra visits was significantly lower in the active group (25%vs 43%).

CONCLUSIONS

Sublingual immunotherapy was clinically effective and safe in mite-induced mild disease.

Rhinitis and asthma in athletes: an ARIA document in collaboration with GA2LEN

This consensus document is aimed at reviewing evidence that the rhinitis-asthma links have peculiar features in athletes. Beside a review of epidemological data on the high prevalence of rhinitis and asthma in athletes, the effects on intense physical exercise on the immune system and repiratory functions are discussed, with special reference to the role of allergens and pollutants. In extending the Allergic Rhinitis and its Impact on Asthma (ARIA) recommendations to athletes, the issue is addressed of adapting diagnosis and management to criteria set by the International Olympic Committee (IOC) and regulations adopted by the World Anti-Doping Agency (WADA).

What do we need to learn to optimize the SLIT alternative?

Allergen-specific immunotherapy (IT) is the only treatment of allergy in adults and children capable of modifying the immune response at early steps. As a consequence, IT improves symptoms, prevents the onset of new sensitizations, reduces the risk of developing asthma and its clinical efficacy lasts many years. The main rationale for administering sublingually IT (SLIT) is to reduce the occurrence of side effects, still yet preserving the immunological effects. SLIT with the most common allergens have been used in many studies with significant clinical effectiveness in both asthma and rhinitis. The pharmacokinetic of allergens administered through non injection routes is complex. Peptide absorption across oral mucosa occurs mainly by passive diffusion but delivery of proteins has some limitations. Moreover, the molecular mechanisms responsible for the efficacy of SLIT are poorly defined. In this review we focus on the anatomy/histology of the oral cavity as well as on the associated immunological structures to envisage what may happen when an allergen is kept in the mouth. Moreover, the induction of immune responses in this particular immunological environment is also discussed.

Impact of children's respiratory allergies on caregivers

BACKGROUND

Despite the great attention that has been paid to HRQoL in children with respiratory allergy, few studies have addressed this aspect in relation to caregivers. The aim of our study was to evaluate the impact of childhood respiratory allergies on caregivers by means of a new method.

METHODS

119 parents of children suffering from allergies (75 suffering from asthma and 44 suffering from rhinitis) were recruited from three Italian Allergy Units. Parents were asked to complete the Disease Impact On Caregiver (DIOC), a new non disease specific questionnaire, validated on the Italian population. The questionnaire consists of 31 items grouped in four factors (Performance, Personal gratification, Psychophysical endurance, Socio-emotional domain) and covers the life aspects that could be affected by the assistance duties towards an ill family member.

RESULTS

Child's asthma resulted to have a worse impact on many aspects of a parents' life than rhinitis. Differences resulted to be statistically significant in 19 aspects out of the 31 assessed. The worse impact of asthma versus rhinitis was confirmed in the following domains: Performance (24.0 +/- 18.2 vs 11.5 +/- 17.8), Personal gratification (26.3 +/- 20.5 vs 12.1 +/- 16.5) and Psychophysical endurance (35.0 +/- 24.8 vs 18.8 +/- 21.7). In the Socio-emotional domain no difference emerged.

CONCLUSIONS

Compared to parents of rhinitics, parents of asthmatic children appear to be more compromised in their resistance to stress, mood, emotional stability, amount of spare time and leisure activities. Our results suggest the need of giving the due attention to these problems both in clinical practice and in research, in order to avoid possible interferences of the caregiver's distress in the optimization of treatment outcome.

Adherence to treatment: assessment of an unmet need in asthma

BACKGROUND

In asthma, as in other chronic conditions, poor adherence to treatment and to medical advice is common and contributes to substantial worsening of the disease and increased health care costs.

OBJECTIVE

The aim of the present study was to evaluate patients' self-reported adherence to asthma medication regimens and to identify possible correlations between treatment adherence and depression, anxiety, and coping strategies.

METHODS

Sixty-three asthmatic outpatients (27 men and 36 women; mean age +/- SD, 38.5 +/- 14.1) were consecutively enrolled during their routine control visit. Patients were asked to complete 3 different questionnaires: the Adherence Schedule in Asthma, the Hospital Anxiety and Depression Scale, and the Coping Orientations to Problem Experienced questionnaires.

RESULTS

Depression was detected in 32.3% of patients and anxiety in 34.9%. A negative correlation was found between older age and perception of family support (rho = -0.33). The presence of anxiety displayed a positive correlation with difficulty in accepting the illness (rho = 0.33) and a negative correlation with acceptance of illness limitations (p = -0.30); it was also positively correlated with fear of the side effects of medication (rho = 0.37). The presence of depression was negatively correlated with acceptance of illness limitations (rho = -0.32), knowledge of the illness (p = -0.29), and with ability to identify worsening signs (rho = -0.31).

CONCLUSION

This study shows how different factors may modulate adherence to asthma treatment. The opportunity to identify reasons for nonadherence through a simple assessment will allow a tailored intervention to be planned for each patient.

Chronic cough and QoL in allergic and respiratory diseases measured by a new specific validated tool-CCIQ

Even though chronic cough (CC) is a bothersome symptom, only a small number of studies have evaluated its specific burden on health-related quality of life (HRQL). The aim of the present study was to assess how the presence of CC interferes with HRQL. A total of 95 outpatients were enrolled during medical consultation at our "Chronic Cough Center". A health status measure (SF-36) and a new HRQL questionnaire specific for CC (CCIQ) were administered before the initial visit. Compared to the reference sample, CC patients reported significantly lower scores in 5 of 8 SF-36 domains: Social functioning (t=10.292), Physical role limitation (t=9.667), Emotional role limitation (t=7.712), General health (t=5.154) and Vitality (t=4.426). The analysis of CCIQ scores showed a disability due to CC, independent of its etiology. The greatest disabilities were observed in the Social relationship (58.33) domain, followed by Sleep/Concentration (54.26), Mood (51.49) and Daily activities (47.69). Sleep, disturbing the partner, and irritability were the three outstanding aspects, affecting 80% of patients. These results show that CC has a high negative impact on HRQL, and they further suggest that the CCIQ is a useful tool for obtaining a global evaluation including its impact and therapeutic options.

Systemic reactions from skin testing: literature review

The skin prick test (SPT) is the most appropriate diagnostic approach to identify IgE sensitization to aeroallergens, foods, hymenoptera venom and some pharmacological compounds. SPT is considered a safe diagnostic approach, but several fatal or near-fatal reactions have been described. Based on the literature, the occurrence of systemic reactions with inhalant allergens has diminished over the last thirty years, whereas fresh food, hymenoptera venom and antibiotic SPT still carry some risk. In general, the risk of systemic reactions is lower with SPT than with intradermal testing. Some patients (history of previous anaphylactic reactions, small children, pregnant women, uncontrolled asthma, high degree of reactivity) should be considered at higher risk of systemic/anaphylactic reactions. Based on the literature, the risk of fatality due to SPT is extremely remote, and severe/anaphylactic reactions are rare. Nevertheless, this risk cannot be completely excluded, especially in highly susceptible subjects. Physicians who perform SPT should be aware of this and apply simple precautional rules.

Lung myofibroblasts as targets of salmeterol and fluticasone propionate: inhibition of alpha-SMA and NF-kappaB

Lung myofibroblasts play a major role in the pathophysiology of asthma, contributing not only to tissue remodelling but also to airway inflammation. Nevertheless, only recently, attention has been focused on these cells as potential targets for anti-allergic drugs. Herein, we analysed the pharmacological response of lung myofibroblasts to beta2-agonists associated or not to inhaled corticosteroids, investigating their effects on (i) the constitutive and transforming growth factor-beta (TGF-beta)-induced expression of alpha-smooth muscle actin (alpha-SMA), the main functional marker of myofibroblastic differentiation and contractility; (ii) isometric contraction and (iii) tumour necrosis factor-alpha (TNF-alpha)-induced nuclear translocation of the pro-inflammatory transcription factor nuclear factor-kappaB (NF-kappaB). The beta2-agonist salmeterol (SMl) has on human lung myofibroblasts new direct anti-contractile/anti-inflammatory effects that are amplified by the combined use of low concentrations of the glucocorticoid fluticasone propionate (FP). First, SMl and/or FP (10(-12) M) inhibits the constitutive and TGF-beta-induced expression of alpha-SMA. Second, the two drugs block the TNF-alpha-induced nuclear translocation of the pro-inflammatory transcription factor NF-kappaB. Finally, SMl decreases TNF- alpha-induced production of the inflammatory cytokine IL-6. The complementary anti-inflammatory/ anti-contractile effects displayed by SMl and FP on lung myofibroblasts in vitro may be related to the improvement in lung function and symptom control obtained in vivo by the early use of low doses of glucocorticoids in combination with long-acting beta2-agonists.

Quality of life and polysensitization in young men with intermittent asthma

BACKGROUND

Health-related quality of life (HRQoL) represents an important variable in asthma management. To date, to our knowledge, no study has explored the relationship between HRQoL and sensitization in patients with asthma.

OBJECTIVE

To evaluate the relationships among HRQoL and sensitization, pulmonary function, and bronchial hyperreactivity in a group of young men with intermittent asthma.

METHODS

We studied 185 conscripts with intermittent asthma and bronchial hyperreactivity. The Asthma Quality of Life Questionnaire was used. Skin prick testing, spirometry, and methacholine challenge were performed in all participants.

RESULTS

The Asthma Quality of Life Questionnaire median scores were greater than 4, indicating suboptimal HRQoL. Polysensitization was significantly associated with the worst HRQoL, whereas pulmonary function and bronchial hyperreactivity category were not.

CONCLUSIONS

This study provides the first evidence that HRQoL is associated with polysensitization in intermittent asthma and underlines the importance of evaluating this issue when managing young patients with slight respiratory symptoms.

A new tool to evaluate the impact of chronic urticaria on quality of life: chronic urticaria quality of life questionnaire (CU-QoL)

BACKGROUND

Health-related quality of Life in patients with chronic urticaria is evaluated by mean of generic instruments or questionnaire designed for skin diseases. No disease-specific tool is now available for the assessment of chronic urticaria impact from patients' viewpoint.

OBJECTIVE

The aim of our study is to develop and validate a new questionnaire specifically designed for the assessment of quality of life in chronic urticaria (Chronic Urticaria Quality of Life Questionnaire -- CU-Q(2)oL).

METHODS

In the development phase of CU-Q(2)oL an initial list of items of 37 items was compiled and given to 80 patients with chronic urticaria; the 23 most significant items were selected and converted into questions evaluating the answers on a Likert scale of five steps. The validation procedure involved 125 patients (86 F and 39 M) (age 42.17 +/- 9.24 years).

RESULTS

Following a statistical analysis, CU-Q(2)oL showed a six-dimensional structure and good levels of internal consistency for the extracted factors: Pruritus (0.79), Swelling (0.65), Impact on life activities (0.83), Sleep problems (0.77), Looks (0.83) and Limits (0.74). In stable conditions CU-Q(2)oL showed a good reliability, ranged between 0.64 and 0.92. Responsiveness to clinical changes was accomplished.

DISCUSSION

These results provide evidence that CU-Q(2)oL has specificity enough for being a valid tool for detecting the relative burden of CU on subjective wellbeing, and for obtaining a global evaluation both of CU impact and of treatments, taking into account the patient's point of view. The CU-Q(2)oL was easily and quickly filled up and well accepted by the patients.

Seasonal and perennial allergic rhinitis: is this classification adherent to real life?

BACKGROUND

Allergic rhinitis is traditionally subdivided into seasonal (SAR) and perennial (PAR), although the new definitions of persistent and intermittent were recently proposed. We assessed the validity of the traditional classification in a large group of subjects suffering from allergic rhinitis alone.

METHODS

Young males referred to a Navy Military Hospital for routine fitness visit, and reporting symptoms of rhinitis alone were selected. According to the sensitization they were subdivided into (i) sensitized to pollens only (seasonal, SAR), (ii) to perennial allergens only (perennial, PAR) and (iii) to both (mixed, MAR). Spirometry, methacholine challenge, severity and characteristics of symptoms were assessed in all participants.

RESULTS

Of 19 325 subjects, 2347 had allergic rhinitis. Seventy-two percent of the subjects had MAR, 17% SAR and 11% PAR. Ocular involvement and irritative symptoms were more frequent in SAR (P < 0.03), whereas obstruction was predominant in PAR (P < 0.01). Nasal symptoms varied according to the period of the year in SAR (P < 0.01) and PAR (P < 0.03). An overt bronchial obstruction was detected in 12% of PAR patients, in 7.8% of MAR, and in 4.2% of SAR. forced expiratory volume/1 s was significantly lower during season in SAR patients only (P < 0.05). The FEF25-75 was impaired in 22.5% MAR patients, 21% PAR, and 14% SAR, with a seasonal change in SAR (P < 0.05) and PAR (P < 0.001). Bronchial hyperreactivity was present in 82.2% of PAR, 73.6% of MAR, and 53.5% of SAR, with a seasonal change in SAR (P < 0.001) and MAR (P < 0.05).

CONCLUSIONS

This study provides evidence that up to 80% of allergic rhinitics have a mixed form, and SAR and PAR definitions are poorly adherent to real life. Lung involvement is frequent in patients reporting nose symptoms alone.

Pharmacokinetics of radiolabelled Par j 1 administered intranasally to allergic and healthy subjects

BACKGROUND

Local nasal immunotherapy is accepted as an alternative to the injection route for allergic rhinitis. Despite this, little is known about the kinetics of the allergen after nasal delivery in allergic subjects.

OBJECTIVE

We aimed at assessing the biodistribution of 123I-radiolabelled Par j 1 in Parietaria-allergic subjects, in comparison with healthy volunteers.

METHODS

Purified Par j 1 was radiolabelled with 123I and sprayed into the nostrils of three control subjects and three Parietaria-allergic volunteers. Dynamic and static scintigraphic images of the head were recorded at serial times and blood samples were obtained to measure the plasma radioactivity, and to assess the presence of circulating radiolabelled species by gel chromatography.

RESULTS

In Parietaria-sensitized subjects, the radiolabelled allergen was rapidly cleared from the nasal cavity and transported to pharynx, and little local persistence was seen. This differed from healthy subjects where nasal clearance of the tracer was slower and nasal radioactivity persisted up to 24 h. The increase in plasma radioactivity paralleled swallowing of the allergen in both groups, and plasma chromatographic profile did not differ between allergic and healthy volunteers.

CONCLUSIONS

Sensitization to the allergen affects its local biodistribution. Gastrointestinal absorption is relevant also for the intranasal route.

Continuing Medical Education: an international reality

We are all aware today of the growing interest in continuing medical education (CME) programmes in many European Countries and it is important to understand why and how CME could become an international reality. It is obvious that patients need a good doctor--the best possible--as far as medical knowledge, attention to the patient's quality of life and cost-control is concerned. All European health care systems have to take into consideration everything that causes patient dissatisfaction, risk management and unjustified expenses. An example is the increase of claims and complaints against doctors and the strong attention of patients to medical procedures. In other words, medicine worldwide is becoming a service industry and has to consider quality and quantity of performances as well as to pay attention to personal responsibility. The object of our work is to evaluate the CME systems present in Europe, to show the work done on CME by the CME Committee of the European Academy of Allergology and Clinical Immunology and to highlight the Consensus Report on CME approved by an international panel of CME experts.

Randomized controlled open study of sublingual immunotherapy for respiratory allergy in real-life: clinical efficacy and more

BACKGROUND

Some aspects of sublingual immunotherapy (SLIT) still need to be addressed: magnitude of the clinical efficacy, effect on the bronchial hyperreactivity adherence to treatment, preventive effect. We attempted to clarify these points in a randomized open, controlled, two parallel group study in a real-life setting.

METHODS

Five hundred and eleven patients with allergic rhinitis with or without intermittent asthma were randomized to drugs only or drugs + SLIT (rate 2 : 3) for 3 years. The clinical score (symptoms + drug intake) was measured each year during the allergen exposure. Pulmonary function test, methacholine challenge and skin tests were performed at the beginning and at the end of the study. Adherence to treatment was assessed by measuring the consumed extract.

RESULTS

Three hundred and nineteen patients received SLIT and 192 drugs only. Dropouts were 15% in the SLIT group and 12% in the controls. There was a significant improvement of clinical scores in the SLIT group: baseline 147 +/- 3.3, first year 72.9 +/- 1.3, second year 68.3 +/- 1.8, third year 54.7 +/- 2.8 (P < 0.0001 vs baseline).

CONTROL GROUP

baseline 138 +/- 2.3, first year 124.1 +/- 3.7, second year 111 +/- 3.3, third year 121 +/- 3.8 (P = NS). Only four patients reported systemic itching. Adherence was >80% in 72% and >60% in 18% of patients. The number of patients with a positive MCh challenge decreased significantly after 3 years only in the SLIT group. New skin sensitizations appeared in 38% of the controls and in 5.9% of the SLIT patients (P = 0.01).

CONCLUSION

Sublingual immunotherapy approximately halved the clinical scores and significantly reduced the bronchial hyperreactivity. Similarly to subcutaneous immunotherapy, SLIT displayed a preventive effect on the onset of new skin sensitizations. The adherence rate was quantitatively satisfactory.

Prophylactic management of children at risk for recurrent upper respiratory infections: the Preventia I Study

BACKGROUND

Given the morbidity and mortality of asthma and the recent dramatic increase in its prevalence, pharmacologic prophylaxis of this disease in children at risk would represent a major medical advance.

OBJECTIVES

The Preventia I Study was designed to evaluate the efficacy and long-term safety of loratadine in reducing the number of respiratory infections in children at 24 months. A secondary objective was to investigate the benefit of loratadine treatment in preventing the onset of respiratory exacerbations.

METHODS

Preventia I was a randomized placebo-controlled study involving 22 countries worldwide. The children were 12-30 months of age at enrollment and had experienced at least five episodes of ENT infections, and no more than two episodes of wheezing during the previous 12 months. Phase I was a 12-month double-blind period during which the children were treated with loratadine 5 mg/day (2.5 mg/day for children</=24 months of age) or placebo. Phase II was a double-blind follow-up period without study medication.

RESULTS

Of the 412 children enrolled, 342 and 310 completed Phase I and Phase II, respectively. The results showed a significant decrease in the number of infections in the whole population of children. However, no difference was observed between the loratadine and placebo group. When considering secondary end-points, loratadine was shown to reduce the number of respiratory exacerbations during the treatment phase. None of the 204 children who received loratadine discontinued the study because of drug-related events. Loratadine treatment was not more sedative than placebo and was not associated with cardiovascular events.

CONCLUSION

The strong decrease in the rate of infections in the children at risk of recurrent infections, while not being influenced by loratadine treatment, should encourage future reflection in terms of prophylactic management. This study also confirms the long-term safety of loratadine and its metabolites in young children.

A new tool to assess and monitor the burden of chronic cough on quality of life: Chronic Cough Impact Questionnaire

INTRODUCTION

Chronic cough, one of the most frequent causes for a patient to consult a medical practitioner, limits the course of normal activities in everyday life of the patient affected (work, physical activities, social relations, night sleep). By now, there are few validated questionnaires for the evaluation of the impact of this symptom in the patient's quality of life (QoL). For this reason, we created a new questionnaire for the assessment of QoL in patients affected by chronic cough (Chronic Cough Impact Questionnaire, CCIQ).

MATERIALS AND METHODS

In the development procedure of CCIQ an initial questionnaire of 40 items was compiled and given to a first pool of 170 patients, each coming to our attention because of chronic cough; then the 25 most significant items were detected and converted into questions evaluating the answers on a Likert scale of five steps. Consequently, this final questionnaire underwent a validation procedure to assess its construct validity, internal consistency, reliability, and responsiveness. 95 patients (44.2% F, 55.8% M) were evaluated (age 53.69 +/- 11.7 years).

RESULTS

Following a statistical analysis, CCIQ showed a four-dimensional structure and good levels of internal consistency for the extracted factors: sleep/concentration (79.98), relationship (86.98), daily life impact (69.04), and mood (65.41). In stable conditions CCIQ showed a good reliability, ranged between 0.67 and 0.88. Responsiveness to clinical changes was accomplished.

DISCUSSION

These results provide evidence that CCIQ has specificity enough for being a valid tool for detecting the relative burden of cough on subjective well-being, and for obtaining a global evaluation both of chronic cough impact and of treatments for it, taking into account the patient's point of view. The CCIQ was easily and quickly filled in by the patients while waiting, and it was accepted by the patients.

Evaluation of food-pollen cross-reactivity by nose-mouth cross-challenge in pollinosis with oral allergy syndrome

BACKGROUND

Oral allergy syndrome (OAS) is often associated with pollen-induced rhinitis, and there are preferential associations between causative substances. If OAS and rhinitis are both immunoglobulin (Ig)E-mediated and there are cross-reacting proteins, it is expected that similar reactions can be elicited in the nose and mouth. In order to test this hypothesis we performed a series of 'cross-challenges' with foods and pollens in both the nose and the mouth.

METHODS

Nine patients with ascertained OAS due to vegetables and rhinitis due to pollens were studied. On the first day a nasal challenge with pollen extracts and an oral challenge with fresh food was carried out. After a week, washout nasal challenge with food and an oral challenge with pollens were performed. Immediate symptoms, mucosal tryptase and soluble eosinophil cationic protein (ECP) were assessed after each challenge.

RESULTS

The administration of pollen into the nose and food into the mouth elicited symptoms as expected, but the cross-challenge had no clinical effect. In parallel, tryptase and ECP increased after nasal challenge with pollens, whereas foods did not elicit a measurable response.

CONCLUSION

The cross-reactivity between foods and pollens, when evaluated at the shock organ, was not clinically evident. This data can be explained with a low concentration of cross-reagent epitopes in pollen extracts and food homogenized because of degradation. The different behaviour upon challenge suggests that different immunological mechanisms may act in the nose and mouth.

Bilateral Gasser's ganglion sarcoidosis: diagnosis, treatment and unsolved questions

Magnetic resonance imaging is currently the best means for confirming clinical suspicion of neurosarcoidosis as well as being useful in the follow-up of corticosteroid-treated patients. We report the case of a 34 year old male presenting suspected Heerfordt's syndrome with concentric facial hypesthesia. Mediastinal and parotid sarcoidosis was diagnosed and magnetic resonance imaging showed bilateral sarcoid involvement of Gasser's ganglion cisternae (such involvement was not revealed by computed tomography). The patient received corticosteroid therapy, with a clinical and radiological improvement. Magnetic resonance imaging showed disappearance of Gasser's ganglion lesions despite the persistence of mild facial hypesthesia. This case is noteworthy for its extremely rare lesion site. Post-treatment discrepancy between the clinical picture and imaging results is probably due to low MRI resolution threshold. 18-FDG positron emission tomography imaging might perhaps overcome the limits of magnetic resonance imaging.

Benefits of omalizumab as add-on therapy in patients with severe persistent asthma who are inadequately controlled despite best available therapy (GINA 2002 step 4 treatment): INNOVATE

BACKGROUND

Patients with severe persistent asthma who are inadequately controlled despite Global Initiative for Asthma (GINA) 2002 step 4 therapy are a challenging population with significant unmet medical need. We determined the effect of omalizumab on clinically significant asthma exacerbations (requiring systemic corticosteroids) in the first omalizumab study to exclusively enrol patients from this difficult-to-treat patient population.

METHODS

Following a run-in phase, patients (12-75 years) inadequately controlled despite therapy with high-dose inhaled corticosteroids (ICS) and long-acting beta(2)-agonists (LABA) with reduced lung function and a recent history of clinically significant exacerbations were randomized to receive omalizumab or placebo for 28 weeks in a double-blind, parallel-group, multicentre study.

RESULTS

A total of 419 patients were included in the efficacy analyses. The clinically significant asthma exacerbation rate (primary efficacy variable), adjusted for an observed relevant imbalance in history of clinically significant asthma exacerbations, was 0.68 with omalizumab and 0.91 with placebo (26% reduction) during the 28-week treatment phase (P = 0.042). Without adjustment, a similar magnitude of effect was seen (19% reduction), but this did not reach statistical significance. Omalizumab significantly reduced severe asthma exacerbation rate (0.24 vs 0.48, P = 0.002) and emergency visit rate (0.24 vs 0.43, P = 0.038). Omalizumab significantly improved asthma-related quality of life, morning peak expiratory flow and asthma symptom scores. The incidence of adverse events was similar between treatment groups.

CONCLUSIONS

In patients with inadequately controlled severe persistent asthma, despite high-dose ICS and LABA therapy, and often additional therapy, omalizumab significantly reduced the rate of clinically significant asthma exacerbations, severe exacerbations and emergency visits. Omalizumab is effective and should be considered as add-on therapy for patients with inadequately controlled severe persistent asthma who have a significant unmet need despite best available therapy.