Allergen-specific immunotherapy provides immediate, long-term and preventive clinical effects in children and adults: the effects of immunotherapy can be categorised by level of benefit -the centenary of allergen specific subcutaneous immunotherapy

Allergen Specific Immunotherapy (SIT) for respiratory allergic diseases is able to significantly improve symptoms as well as reduce the need for symptomatic medication, but SIT also has the capacity for long-term clinical effects and plays a protective role against the development of further allergies and symptoms. The treatment acts on basic immunological mechanisms, and has the potential to change the pathological allergic immune response. In this paper we discuss some of the most important achievements in the documentation of the benefits of immunotherapy, over the last 2 decades, which have marked a period of extensive research on the clinical effects and immunological background of the mechanisms involved. The outcome of immunotherapy is described as different levels of benefit from early reduction in symptoms over progressive clinical effects during treatment to long-term effects after discontinuation of the treatment and prevention of asthma. The efficacy of SIT increases the longer it is continued and immunological changes lead to potential long-term benefits. SIT alone and not the symptomatic treatment nor other avoidance measures has so far been documented as the therapy with long-term or preventive potential. The allergic condition is driven by a subset of T-helper lymphocytes (Th2), which are characterised by the production of cytokines like IL-4, and IL-5. Immunological changes following SIT lead to potential curative effects. One mechanism whereby immunotherapy suppresses the allergic response is through increased production of IgG4 antibodies. Induction of specific IgG4 is able to influence the allergic response in different ways and is related to immunological effector mechanisms, also responsible for the reduced late phase hyperreactivity and ongoing allergic inflammation. SIT is the only treatment which interferes with the basic pathophysiological mechanisms of the allergic disease, thereby creating the potential for changes in the long-term prognosis of respiratory allergy. SIT should not only be recognised as first-line therapeutic treatment for allergic rhinoconjunctivitis but also as secondary preventive treatment for respiratory allergic diseases.

How strong is the evidence that immunotherapy in children prevents the progression of allergy and asthma?

PURPOSE OF REVIEW

The purpose of this review is to describe the scientific evidence that specific immunotherapy can prevent the development of asthma in patients suffering from rhinoconjunctivitis as well as reduce the number of new allergies developing.

RECENT FINDINGS

Proposed strategies for the prevention of the development of allergic rhinoconjunctivitis and asthma include allergen avoidance, pharmacological treatment (antihistamines and steroids) and specific immunotherapy. Long-term follow-up on immunotherapy studies demonstrates that specific immunotherapy for 3 years shows persistent long-term effects on clinical symptoms after termination of treatment and long-term, preventive effects on later development of asthma in children with seasonal rhinoconjunctivitis. It is so far the only treatment for allergic diseases that has been shown to be able to prevent worsening of disease and development of asthma. Also, specific immunotherapy seems to reduce the development of new allergic sensitivities as measured by the skin prick test as well as specific IgE measurements.

SUMMARY

Specific immunotherapy is the only treatment that interferes with the basic pathophysiological mechanisms of the allergic disease and thereby carries the potential for changes in the long-term prognosis of respiratory allergy. Specific immunotherapy should be recognized not only as first-line therapeutic treatment for allergic rhinoconjunctivitis, but also as secondary preventive treatment for respiratory allergic diseases.

Allergic rhinitis and asthma ad hoc survey: clinical and psychological perspectives

BACKGROUND

Several studies have provided evidence of a strong association between asthma and rhinitis, with consequences in terms of therapy and disease management.

OBJECTIVES

The aims of our study were to evaluate physicians' knowledge about rhinitis/asthma comorbidity, to note the patients' management behaviour and to assess the patients' experience about symptoms and expectations, and to investigate the clinical and psychological meaning of general practitioners' and patients' awareness.

METHODS

One hundred and one general practitioners and 504 asthmatic patients participated in the study. General practitioners and patients filled in two different multiple choice questionnaires concerning asthma-rhinitis link and impact.

RESULTS

34.7% of general practitioners are aware of the link between asthma and rhinitis, and 43.6% of them hypothesize the comorbidity on the basis of their clinical experience. 21.8% of physicians make the diagnosis autonomously. 27.8% of asthmatic patients experience three or less rhinitic symptoms, 41% from four to six symptoms and 31.2 more than six symptoms. These symptoms deeply interfere with daily life, causing sleep problems (87.3%), lack of concentration (78.9%), difficulties in spare time (71.8%) and sport (71.7%). Rhinitis symptoms are responsible for the worsening of asthma, with an increase in dyspnoea (86.3%), cough (73.9%), and wheezing (59%). Ninety-three percent of patients expressed an interest in a combination therapy approach.

CONCLUSIONS

Asthma and rhinitis interact in the development of clinical burden and impact on quality of life. The survey results showed different perspectives when evaluated from clinical and psychological points of view.

Burden of concomitant allergic rhinitis in adults with asthma

Asthma (A) and allergic rhinitis (AR) are common conditions with evidence of shared epidemiological and patho-physiological backgrounds. A systematic review of the literature in the last three decades was performed to summarize both the prevalence and the economic burden of concomitant AR in adult patients with asthma. The reported prevalence estimates of concomitant AR in patients with asthma in the United States and in Europe studies is in excess of 50%, with up to 100% prevalence reported in patients with allergic asthma. In these populations, asthma-related medical resource use, including asthma attacks, emergency room visits, physician visits, and prescription medication use, is higher among asthmatic patients with concomitant AR compared to those without AR. These patients also experience more frequent absence from work and decreased productivity. A low prevalence (6.2%) of comorbid AR in people with asthma has been reported in a single study from Asia. A combined treatment strategy as recommended by international guidelines may improve asthma outcomes in asthmatic patients with concomitant AR.

Increased risk of asthma attacks and emergency visits among asthma patients with allergic rhinitis: a subgroup analysis of the investigation of montelukast as a partner agent for complementary therapy [corrected]

BACKGROUND

Inadequately controlled allergic rhinitis (AR) in asthmatic patients can contribute towards increased asthma exacerbations and poorer symptom control, which may increase medical resource use. We assessed asthma-related medical resource use and attacks in asthmatic patients who did and did not have concomitant AR and were adding montelukast or salmeterol to baseline treatment with inhaled fluticasone.

METHODS

A post hoc resource use analysis of a 52-week, double-blind multicentre clinical trial (Investigation of Montelukast as a Partner Agent for Complementary Therapy) [corrected] including 1490 adults with chronic asthma, aged 15-72 years, with FEV(1) 50-90% of predicted and > or =12% increase in FEV(1) after salbutamol administration, treated with either montelukast 10 mg daily or salmeterol 50 microg twice daily in addition to fluticasone 200 microg, was undertaken. Asthma-related medical resource use included medical visits (defined as either an unscheduled visit [to a general practitioner, a specialist or a non-medical provider] or a specialist visit), emergency room visits and hospitalizations during follow-up. Asthma attacks were defined as the worsening of asthma requiring unscheduled visit, emergency visit, hospitalization or oral/intravenous/intramuscular corticosteroids.

RESULTS

A self-reported history of concomitant AR was identified in 60% of the patients (n=893). Univariate analysis suggests that significantly more patients with concomitant AR experienced emergency room visits (3.6% vs. 1.7%, P=0.029) and asthma attacks (21.3% vs. 17.1%, P=0.046). Multivariate analysis adjusting for treatment group, age and baseline asthma severity confirmed these results since the presence of concomitant AR in patients with asthma increases the likelihood of emergency room visit (odds ratio (OR)=2.35, 95% confidence interval (CI)=1.12-4.80) and asthma attack (OR=1.35, 95% CI=1.03-1.77). Patients with asthma alone compared with patients with both conditions did not differ in terms of unscheduled or specialist visits and hospitalizations.

CONCLUSIONS

Presence of self-reported concomitant AR in patients with asthma resulted in a higher rate of asthma attacks and more emergency room visits compared with asthma patients without concomitant AR.

Occupational upper airway disease

PURPOSE OF REVIEW

This article reviews recent findings concerning occupational upper airway diseases, which, although very frequent, are usually not considered serious. However, the concept of the 'united airway', evoked during recent years, should change our attitude regarding these diseases. Moreover, new agents in the occupational environment must be characterized. Furthermore, exposure to carcinogens has changed over the years, and in most cases risk should be reassessed.

RECENT FINDINGS

Recent findings concerning work-related upper airway diseases caused by allergens and irritants, and their relationship to lower airway diseases, are reviewed. Findings of studies aimed at characterizing occupational allergens of plant and animal origin are presented. Recognition of work-related upper airway diseases both in clinic and in epidemiological studies is discussed. Current evidence on occupational cancer of the upper airways, its risk factors and changes in them over the years resulting from preventative measures are also described.

SUMMARY

There is significant evidence that occupational allergic diseases of the upper airways can pose important health problems because they represent an early stage of allergy throughout the respiratory system. However, how to detect those rhinitic patients who will develop asthma remains unresolved. New occupational health problems due to irritants were recently reported, and both follow-up studies and evaluations of their implications for the lower airways are warranted. Although preventative measures have been effective to some extent, risk for occupational cancer of the upper airways persists and more targeted epidemiological studies in this area are needed.