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Larenas-Linnemann DES, Mayorga-Butrón JL, Maza-Solano J, Emelyanov AV, Dolci RLL, Miyake MM, Okamoto Y. Global expert views on the diagnosis, classification and pharmacotherapy of allergic rhinitis in clinical practice using a modified Delphi panel technique. World Allergy Organ J 2023; 16:100800. [PMID: 37520611 PMCID: PMC10372170 DOI: 10.1016/j.waojou.2023.100800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 04/26/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023] Open
Abstract
Background Diagnosis, classification, and treatment of allergic rhinitis (AR) varies considerably despite the availability of treatment guidelines. Objectives We aimed to carry out a two-part modified Delphi panel study to elucidate global expert management of AR in real life. Methods The modified Delphi panel study was composed of two ten-minute online questionnaires sent to global AR experts, aiming to identify areas of consensus (defined as >75% respondent agreement) on aspects of their real-world daily practice related to AR diagnosis, classification, and pharmacotherapy. A workshop discussion with respondents held after the first-round questionnaire informed the development of the second-round questionnaire. Results Eighteen experts (from 7 countries across 3 continents) completed both questionnaires in September-October 2021 and January 2022, respectively. The majority of respondents agreed that diagnosis of AR is best confirmed using a mixture of observation and testing (n = 15) and collaborating with colleagues across other specialties (n = 14). Experts agreed that severity (n = 18), upper/lower respiratory tract involvement (n = 15) and symptom frequency (n = 14) are important factors when classifying AR, however consensus was not reached on which classification tool should be used. Although there were mixed opinions on the preferred pharmacotherapy treatment in the presented case studies, respondents largely agreed on which treatments require less monitoring (intranasal corticosteroid therapies [INCS]) and when treatments should be stepped down (≤3 months). Although opinions varied across respondents, some respondents considered as-needed INCS treatment and surgery to be viable treatment options. Conclusion We identified clear differences between real-world practice and treatment guidelines related to the management of AR. Furthermore, we recognized differences among physicians concerning their clinical practice in the pharmacological treatment of AR. These findings highlight the need for greater research into the management of AR and further indicate there is still a major gap between treatment guidelines and daily practice, even among specialists, suggesting a need for local guideline adaptation and implementation plans.
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Affiliation(s)
| | | | - Juan Maza-Solano
- Rhinology/Skull Base Surgery Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Alexander V. Emelyanov
- North-Western State Medical University named after I.I. Mechnikov, St. Petersburg, Russia
| | - Ricardo LL. Dolci
- Department of Otolaryngology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Marcel M. Miyake
- Department of Otolaryngology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Yoshitaka Okamoto
- Chiba Rosai Hospital, Ichihara, Japan
- Chiba University, Inage Ward, Chiba, Japan
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Larenas-Linnemann D, Morfin Maciel BM. How can we improve our use of allergen immunotherapy as a treatment option for asthma and severe asthma? Expert Rev Respir Med 2023; 17:717-725. [PMID: 37642332 DOI: 10.1080/17476348.2023.2251403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION In patients suffering from allergic asthma, especially in the pediatric age-group, allergen immunotherapy (AIT) could be of benefit and has the potential of long-term disease modification. AREAS COVERED We reviewed the evidence for a beneficial effect of AIT in allergic asthma. A correct selection of the possible candidates for AIT is crucial. We define the comprehensive allergic asthma diagnosis: confirming asthma, confirming allergic sensitization and having symptoms on exposure to the relevant allergens.We analyze why the first trials on AIT for asthma were contradictory; we consider the results of systematic reviews and discuss the high degree of heterogeneity often found in meta-analysis. We assess recent, double-blind, placebo-controlled trials in sublingual AIT that provide robust evidence for a reduction in acute asthma exacerbations and a decrease in the use of inhaled corticosteroids. Further, we demonstrate how real-world trials and large pharmacy data-based analyses confirm these findings for SLIT and SCIT. Finally, we explore the option of AIT in severe asthma patients, once well-controlled on biologic therapy. EXPERT OPINION Clear indications for AIT in asthma guidelines would benefit allergic asthmatics. AIT is a therapeutic option in appropriately selected asthmatics. Three years treatment has the potential for long-term tolerance, with persisting benefits years after discontinuation.
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Grigorieva IN, Manina IV, Sergeev AY, Popadyuk VI. [Etiopathophysiological mechanism of systemic and local allergic sensitization in the development of chronic rhinitis and chronic rhinosinusitis]. Vestn Otorinolaringol 2022; 87:85-91. [PMID: 35818951 DOI: 10.17116/otorino20228703185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The persistence, development and exacerbation of chronic rhinitis and chronic rhinosinusitis all involve sensitization to respiratory allergens. The allergic response in question is the IgE-mediated mechanism of rhinitis, which often leads to a complex of etiopathophysiological malfunctions in various organs and systems. For clinical classification and further management of patients, it is important not to miss the detection of both systemic allergic sensitization to aeroallergens (which is achieved by conducting skin prick test or detecting the allergen-specific immunoglobulin E in the blood) and local sensitization (which can be confirmed by conducting nasal provocation test or detecting the nasal-specific immunoglobulin E in nasal mucosa). Before a full examination is conducted and both systemic and local sensitization are ruled out, the diagnosis of non-allergic rhinitis and the management of a patient with non-allergic nasal inflammation may be premature.
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Affiliation(s)
- I N Grigorieva
- Institute of Allergology and Clinical Immunology, Moscow, Russia
| | - I V Manina
- Institute of Allergology and Clinical Immunology, Moscow, Russia
| | - A Yu Sergeev
- Institute of Allergology and Clinical Immunology, Moscow, Russia
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - V I Popadyuk
- Peoples' Friendship University of Russia, Moscow, Russia
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Larenas-Linnemann D, Rodríguez-Pérez N, Luna-Pech JA, Rodríguez-González M, Blandón-Vijil MV, Del-Río-Navarro BE, Costa-Domínguez MDC, Navarrete-Rodríguez EM, Macouzet-Sánchez C, Ortega-Martell JA, Pozo-Beltrán CF, Estrada-Cardona A, Arias-Cruz A, Rodríguez Galván KG, Brito-Díaz H, Canseco-Raymundo MDR, Castelán-Chávez EE, Escalante-Domínguez AJ, Gálvez-Romero JL, Gómez-Vera J, González-Díaz SN, Guerrero-Núñez MGB, Hernández-Colín DD, Macías-Weinmann A, Mendoza-Hernández DA, Meneses-Sánchez NA, Mogica-Martínez MD, Moncayo-Coello CV, Montiel-Herrera JM, O'Farril-Romanillos PM, Onuma-Takane E, Ortega-Cisneros M, Rangel-Garza L, Stone-Aguilar H, Torres-Lozano C, Venegas-Montoya E, Wakida-Kusunoki G, Partida-Gaytán A, López-García AI, Macías-Robles AP, Ambriz-Moreno MDJ, Azamar-Jácome AA, Beltrán-De Paz CY, Caballero-López C, Fernández de Córdova-Aguirre JC, Fernández-Soto JR, Lozano-Sáenz JS, Oyoqui-Flores JJ, Osorio-Escamilla RE, Ramírez-Jiménez F, Rivero-Yeverino D, Martínez Infante E, Medina-Ávalos MA. Compromising between European and US allergen immunotherapy schools: Discussions from GUIMIT, the Mexican immunotherapy guidelines. World Allergy Organ J 2020; 13:100444. [PMID: 32884611 PMCID: PMC7451623 DOI: 10.1016/j.waojou.2020.100444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/15/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background Allergen immunotherapy (AIT) has a longstanding history and still remains the only disease-changing treatment for allergic rhinitis and asthma. Over the years 2 different schools have developed their strategies: the United States (US) and the European. Allergen extracts available in these regions are adapted to local practice. In other parts of the world, extracts from both regions and local ones are commercialized, as in Mexico. Here, local experts developed a national AIT guideline (GUIMIT 2019) searching for compromises between both schools. Methods Using ADAPTE methodology for transculturizing guidelines and AGREE-II for evaluating guideline quality, GUIMIT selected 3 high-quality Main Reference Guidelines (MRGs): the European Academy of Allergy, Asthma and Immunology (EAACI) guideines, the S2k guideline of various German-speaking medical societies (2014), and the US Practice Parameters on Allergen Immunotherapy 2011. We formulated clinical questions and based responses on the fused evidence available in the MRGs, combined with local possibilities, patient's preference, and costs. We came across several issues on which the MRGs disagreed. These are presented here along with arguments of GUIMIT members to resolve them. GUIMIT (for a complete English version, Supplementary data) concluded the following. Results Related to the diagnosis of IgE-mediated respiratory allergy, apart from skin prick testing complementary tests (challenges, in vitro testing and molecular such as species-specific allergens) might be useful in selected cases to inform AIT composition. AIT is indicated in allergic rhinitis and suggested in allergic asthma (once controlled) and IgE-mediated atopic dermatitis. Concerning the correct subcutaneous AIT dose for compounding vials according to the US school: dosing tables and formula are given; up to 4 non-related allergens can be mixed, refraining from mixing high with low protease extracts. When using European extracts: the manufacturer's indications should be followed; in multi-allergic patients 2 simultaneous injections can be given (100% consensus); mixing is discouraged. In Mexico only allergoid tablets are available; based on doses used in all sublingual immunotherapy (SLIT) publications referenced in MRGs, GUIMIT suggests a probable effective dose related to subcutaneous immunotherapy (SCIT) might be: 50-200% of the monthly SCIT dose given daily, maximum mixing 4 allergens. Also, a table with practical suggestions on non-evidence-existing issues, developed with a simplified Delphi method, is added. Finally, dissemination and implementation of guidelines is briefly discussed, explaining how we used online tools for this in Mexico. Conclusions Countries where European and American AIT extracts are available should adjust AIT according to which school is followed.
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Key Words
- AGREE-II, Appraisal of Guidelines for Research & Evaluation Instrument
- AIT, Allergen immunotherapy
- Allergen extract
- Allergen immunotherapy
- Asthma and Immunology, DBPC
- CMICA, Colegio Mexicano de Inmunología Clínica y Alergia
- COMPEDIA, Colegio Mexicano de Pediatras Especialistas in Inmunología Clínica y Alergia
- EAACI, European Academy of Allergy
- FASIT, Future of the Allergists and Specific Immunotherapy
- GIN, Guidelines International Network
- GINA, Global Initiative for Asthma
- GP, grass pollen
- GRADE, grading of recommendations assessment development and evaluation
- GUIMIT, by its Spanish initials of Guía Mexicana de Inmunoterapia
- Guideline
- HDM, house dust mite
- Ig, immunoglobulin
- MRG, main reference guidelines
- PICO, Patient-Intervention-Comparator-Outcome
- SCIT, subcutaneous allergen immunotherapy
- SLIT, sublingual allergen immunotherapy
- Subcutaneous immunotherapy
- Sublingual immunotherapy
- US, United States of North America
- double-blind, placebo controlled
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Affiliation(s)
- Désirée Larenas-Linnemann
- Médica Sur, Clinical Foundation and Hospital, Mexico City, Mexico
- Corresponding author. Médica Sur, Fundación clínica y hospital, Puente de piedra 150, T2Toriello Guerra, Tlalpan, 14050, Ciudad de México, Mexico
| | | | - Jorge A. Luna-Pech
- Departamento de Disciplinas Filosóficas, Metodológicas e Instrumentales (CUCS), Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | | | | | | | | | | | - Carlos Macouzet-Sánchez
- State University of Nuevo León, School of Medicine and University Hospital “Dr. José Eleuterio González”, Monterrey, Nuevo León, Mexico
| | | | | | | | - Alfredo Arias-Cruz
- State University of Nuevo León, School of Medicine and University Hospital “Dr. José Eleuterio González”, Monterrey, Nuevo León, Mexico
| | | | | | | | | | | | | | - Javier Gómez-Vera
- Institute of Security and Social Services of State Workers, López Mateos Regional Hospital, Mexico City, Mexico
| | - Sandra Nora González-Díaz
- State University of Nuevo León, School of Medicine and University Hospital “Dr. José Eleuterio González”, Monterrey, Nuevo León, Mexico
| | | | | | - Alejandra Macías-Weinmann
- State University of Nuevo León, School of Medicine and University Hospital “Dr. José Eleuterio González”, Monterrey, Nuevo León, Mexico
| | | | - Néstor Alejandro Meneses-Sánchez
- Centro Médico Nacional Siglo Xxi. Unidad Médica De Alta Especialidad. Hospital De Pediatria Dr. Silvestre Frenk Freund., Mexico City, Mexico
| | | | | | | | | | | | | | | | | | | | - Edna Venegas-Montoya
- Mexican Social Security Institute, High Specialty Medical Unit 25, Department of Clinical Immunology and Allergy, Monterrey, Nuevo León, Mexico
| | | | | | | | - Ana Paola Macías-Robles
- Instituto Mexicano del Seguro Social, Centro Medico Nacional de Occidente Unidad de Alta Especialidad Hospital de Pediatria, Guadalajara, Jalisco, Mexico
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Dykewicz MS, Wallace DV, Amrol DJ, Baroody FM, Bernstein JA, Craig TJ, Dinakar C, Ellis AK, Finegold I, Golden DBK, Greenhawt MJ, Hagan JB, Horner CC, Khan DA, Lang DM, Larenas-Linnemann DES, Lieberman JA, Meltzer EO, Oppenheimer JJ, Rank MA, Shaker MS, Shaw JL, Steven GC, Stukus DR, Wang J, Dykewicz MS, Wallace DV, Dinakar C, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Khan DA, Lang DM, Lieberman JA, Oppenheimer JJ, Rank MA, Shaker MS, Stukus DR, Wang J, Dykewicz MS, Wallace DV, Amrol DJ, Baroody FM, Bernstein JA, Craig TJ, Finegold I, Hagan JB, Larenas-Linnemann DES, Meltzer EO, Shaw JL, Steven GC. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol 2020; 146:721-767. [PMID: 32707227 DOI: 10.1016/j.jaci.2020.07.007] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022]
Abstract
This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.
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Affiliation(s)
- Mark S Dykewicz
- Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, School of Medicine, Saint Louis University, St Louis, Mo.
| | - Dana V Wallace
- Department of Medicine, Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - David J Amrol
- Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC
| | - Fuad M Baroody
- Department of Otolaryngology-Head and Neck Surgery, Pritzker School of Medicine, University of Chicago, Chicago, Ill
| | - Jonathan A Bernstein
- Allergy Section, Division of Immunology, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Timothy J Craig
- Departments of Medicine and Pediatrics, Penn State University, Hershey, Pa
| | - Chitra Dinakar
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, Stanford University, Stanford, Calif
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ira Finegold
- Division of Allergy and Immunology, Department of Medicine, Mount Sinai West, New York, NY
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Department of Medicine, School of Medicine, John Hopkins University, Baltimore, Md
| | - Matthew J Greenhawt
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, School of Medicine, University of Colorado, Aurora, Colo
| | - John B Hagan
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Caroline C Horner
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, School of Medicine, Washington University, St Louis, Mo
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Tex
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | - Jay A Lieberman
- Division of Pulmonology Allergy and Immunology, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tenn
| | - Eli O Meltzer
- Division of Allergy and Immunology, Department of Pediatrics, School of Medicine, University of California, San Diego, Calif; Allergy and Asthma Medical Group and Research Center, San Diego, Calif
| | - John J Oppenheimer
- Division of Pulmonary & Critical Care Medicine and Allergic & Immunologic Diseases, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, New Brunswick, NJ; Pulmonary and Allergy Associates, Morristown, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Larenas-Linnemann D. How does the efficacy and safety of Oralair(®) compare to other products on the market? Ther Clin Risk Manag 2016; 12:831-50. [PMID: 27313458 PMCID: PMC4892828 DOI: 10.2147/tcrm.s70363] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Due to differences between allergen immunotherapy (AIT) trials in patient populations, trial design (including primary efficacy variables), the definition of a pollen season, data analysis, and comparisons between AIT products with existing data, is not possible nor valid. The efficacy of two grass pollen AIT tablets, Oralair® and Grazax®/Grastek®, should not be compared by looking at the percentage of score improvement in their respective trials. However, the evidence available concerning the efficacy and safety in trials can be compared by paying close attention to the scientific quality of the trials, details in the administration schedules, and safety issues. It can be concluded due to the high level of evidence available, that Oralair® is effective in a pre (2-months)-coseasonal schedule to reduce symptoms and medication use, and improve a patients’ quality of life during the treatment season. For the long-term, where the quality of efficacy evidence is moderate at 2-year posttreatment due to a high dropout rate, the pre (4-months)-coseasonal schedule should be used. No clinical efficacy data exists for starting treatment in-season, but the clinical onset of action of Oralair® is detectable after only 1 month of treatment. In the pivotal trials in Europe and the USA, no tablet-related epinephrine was needed, though some rare severe local reactions have been reported. Research for Grazax®/Grastek® showed that the long-term efficacy needs a continuous 3-year administration (moderate-low quality evidence available), and in two patients, tablet-related epinephrine was given. Further details on the comparative efficacy of both tablets would only be possible if both were evaluated in the same, adequately powered trial.
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Affiliation(s)
- Désirée Larenas-Linnemann
- Pediatric Allergy and Asthma Clinic, Department of Investigation, Hospital Médica Sur, México City, México
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Peters AT. The pathophysiology of sinonasal conditions and novel therapeutic options. Am J Rhinol Allergy 2015; 28:185-6. [PMID: 24980228 DOI: 10.2500/ajra.2014.28.4070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Allergic Sensitization and Rhinitis in Children: What Is New? CURRENT TREATMENT OPTIONS IN ALLERGY 2015. [DOI: 10.1007/s40521-015-0044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Larenas-Linnemann D, Michels A, Dinger H, Shah-Hosseini K, Mösges R, Arias-Cruz A, Ambriz-Moreno M, Barajas MB, Javier RC, de la Luz Cid Del Prado M, Moreno MAC, Almaráz RG, García-Cobas CY, Garcia Imperial DA, Muñoz RG, Hernández-Colín D, Linares-Zapien FJ, Luna-Pech JA, Matta-Campos JJ, Jiménez NM, Medina-Ávalos MA, Hernández AM, Maldonado AM, López DN, Pizano Nazara LJ, Sanchez ER, Ramos-López JD, Rodríguez-Pérez N, Rodríguez-Ortiz PG. Allergen sensitization linked to climate and age, not to intermittent-persistent rhinitis in a cross-sectional cohort study in the (sub)tropics. Clin Transl Allergy 2014; 4:20. [PMID: 24976949 PMCID: PMC4073512 DOI: 10.1186/2045-7022-4-20] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 05/05/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Allergen exposure leads to allergen sensitization in susceptible individuals and this might influence allergic rhinitis (AR) phenotype expression. We investigated whether sensitization patterns vary in a country with subtropical and tropical regions and if sensitization patterns relate to AR phenotypes or age. METHODS In a national, cross-sectional study AR patients (2-70 y) seen by allergists underwent blinded skin prick testing with a panel of 18 allergens and completed a validated questionnaire on AR phenotypes. RESULTS 628 patients were recruited. The major sensitizing allergen was house dust mite (HDM) (56%), followed by Bermuda grass (26%), ash (24%), oak (23%) and mesquite (21%) pollen, cat (22%) and cockroach (21%). Patients living in the tropical region were almost exclusively sensitized to HDM (87%). In the central agricultural zones sensitization is primarily to grass and tree pollen. Nationwide, most study subjects had perennial (82.2%), intermittent (56.5%) and moderate-severe (84.7%) AR. Sensitization was not related to the intermittent-persistent AR classification or to AR severity; seasonal AR was associated with tree (p < 0.05) and grass pollen sensitization (p < 0.01). HDM sensitization was more frequent in children (0-11 y) and adolescents (12-17 y) (subtropical region: p < 0.0005; tropical region p < 0.05), but pollen sensitization becomes more important in the adult patients visiting allergists (Adults vs children + adolescents for tree pollen: p < 0.0001, weeds: p < 0.0005). CONCLUSIONS In a country with (sub)tropical climate zones SPT sensitization patterns varied according to climatological zones; they were different from those found in Europe, HDM sensitization far outweighing pollen allergies and Bermuda grass and Ash pollen being the main grass and tree allergens, respectively. Pollen sensitization was related to SAR, but no relation between sensitization and intermittent-persistent AR or AR severity could be detected. Sensitization patterns vary with age (child HDM, adult pollen). Clinical implications of our findings are dual: only a few allergens -some region specific- cover the majority of sensitizations in (sub)tropical climate zones. This is of major importance for allergen manufacturers and immunotherapy planning. Secondly, patient selection in clinical trials should be based on the intermittent-persistent and severity classifications, rather than on the seasonal-perennial AR subtypes, especially when conducted in (sub)tropical countries.
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Affiliation(s)
- Désirée Larenas-Linnemann
- Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico
| | - Alexandra Michels
- Institute of Medical Statistics, Informatics and Epidemiology (IMSIE), University of Cologne, Cologne, Germany ; University of Cologne, Cologne, Germany
| | - Hanna Dinger
- Institute of Medical Statistics, Informatics and Epidemiology (IMSIE), University of Cologne, Cologne, Germany ; University of Cologne, Cologne, Germany
| | - Kijawasch Shah-Hosseini
- Institute of Medical Statistics, Informatics and Epidemiology (IMSIE), University of Cologne, Cologne, Germany ; University of Cologne, Cologne, Germany
| | - Ralph Mösges
- Institute of Medical Statistics, Informatics and Epidemiology (IMSIE), University of Cologne, Cologne, Germany ; University of Cologne, Cologne, Germany
| | - Alfredo Arias-Cruz
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Centro Regional de Alergia e Inmunología Clínica, Hospital Universitario "Dr. José Eleuterio González" de la Universidad Autónoma de Nuevo León, Monterrey, Nuevo León
| | - Marichuy Ambriz-Moreno
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico
| | - Martín Bedolla Barajas
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Servicio de Alergia e Inmunología Clínica, División de Medicina Interna, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca" Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Ruth Cerino Javier
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; CEINTAP (centro de investigación y tratamiento del asma pediátrico), Hospital Regional de Alta Especialidad del Niño. Dr. Rodolfo Nieto Padrón, Villahermosa, Tabasco, Mexico
| | - María de la Luz Cid Del Prado
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico
| | - Manuel Alejandro Cruz Moreno
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Clinica Santa Cruz, Villahermosa, Tabasco
| | - Roberto García Almaráz
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Allergy Department, Hospital Infantil de Tamaulipas, Cd.Victoria, Tamaulipas, Mexico
| | - Cecilia Y García-Cobas
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Inmunología y Alergia, UMAE Hospital de Especialidades, CMNO, IMSS, Guadalajara, Jalisco, Mexico
| | - Daniel A Garcia Imperial
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Allergy Department, Hospital Médica Tec 100, Querétaro, Querétaro, Mexico
| | - Rosa Garcia Muñoz
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico
| | - Dante Hernández-Colín
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Servicio de Alergia e Inmunología Clínica, División de Medicina Interna, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca" Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Francisco J Linares-Zapien
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Centro de Diagnostico y Tratamiento de Enfermedades Alérgicas y Asma de Toluca, Toluca, Estado de México
| | - Jorge A Luna-Pech
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Inmunología y Alergia, UMAE Hospital de Especialidades, CMNO, IMSS, Guadalajara, Jalisco, Mexico
| | - Juan J Matta-Campos
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Allergy and Clinical Immunology Department, Hospital of specializations CMN 'Siglo XXI', Mexico, DF, Mexico
| | - Norma Martinez Jiménez
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico
| | - Miguel A Medina-Ávalos
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico
| | - Alejandra Medina Hernández
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Coordination of evidence based medicine (EBM), Facultad de medicina. Universidad Autonoma de Queretaro, Querétaro, Querétaro, Mexico
| | - Alberto Monteverde Maldonado
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico
| | - Doris N López
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico
| | - Luis J Pizano Nazara
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Clinical immunology & allergy department, Clínica Hospital San Jose, Cd.Obregón, Sonora, Mexico
| | - Emmanuel Ramirez Sanchez
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Allergy and immunology department, General Hospital of Cancun "Dr. Jesus Kumate Rodriguez', Cancun, Quintana Roo, Mexico
| | - José D Ramos-López
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Servicio de Alergia e Inmunología Clínic, Seguro Social, Hospital General de Zona No2, Potosí, Potosí, Mexico
| | - Noel Rodríguez-Pérez
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Pediatrics and Immunology, Autonomous university of Tamaulipas, H.Matamoros, Tamaulipas, Mexico
| | - Pablo G Rodríguez-Ortiz
- Mexican Study Group on Allergic Rhinitis and Skin Sensitivity. Hospital Médica Sur, Torre 2, cons.602, Puente de Piedra 150, Colonia Toriello Guerra; Delegación Tlalpan, México, DF 14050, Mexico ; Hospital Star Médica Mérida, Mérida, Yucatan, Mexico
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