Mepolizumab para el tratamiento de asma grave eosinofílica

El asma grave es una enfermedad heterogénea y compleja que afecta aproximadamente al 5% de los pacientes con asma y se asocia a una importante carga de síntomas, exacerbaciones graves frecuentes e impactos negativos en la funcionalidad y calidad de vida. Diferentes estrategias de innovación han actualizado las opciones terapéuticas disponibles para estos pacientes, pero los anticuerpos monoclonales representan las alternativas con mayor relevancia clínica. Como especialistas en asma es importante mantenernos actualizados para poder identificar correctamente a aquellos pacientes que pueden beneficiarse del tratamiento con estos medicamentos. Este artículo ofrece una revisión actualizada y práctica enfocada en mepolizumab, un anticuerpo monoclonal humanizado anti-IL5 aprobado como tratamiento complementario en pacientes con asma grave eosinofílica. Los autores hemos realizado una síntesis de las evidencias de eficacia, seguridad y efectividad de mepolizumab con el objetivo de proveer una herramienta de consulta y apoyo en la toma de decisiones para el especialista que evalúa, diagnostica y trata pacientes con asma grave. Mepolizumab ha documentado en condiciones controladas de ensayos clínicos, y en estudios de vida real reducir consistente y significativamente las exacerbaciones de asma, mejorar el control de la enfermedad, mejorar la calidad de vida de los pacientes, y disminuir la dosis o retirar la exposición a corticoesteroides sistémicos.

Reference values for bone mineral density in healthy Mexican children and adolescents

INTRODUCTION

Clinical assessment of bone health by Dual-Energy X-ray Absorptiometry (DXA) in the paediatric population requires robust reference values. The International Society for Clinical Densitometry (ISCD) recommends that country/regional reference values ideally should be used to improve precision in bone health assessment.

OBJECTIVE

The aim of this study was to provide reference values for relevant bone health variables for healthy Mexican children and adolescents aged 5 to 18 years.

METHODS

This was a cross-sectional, stratified and population-based study, that measured a representative sample of healthy Mexican children and adolescents with DXA. We constructed age- and sex-smoothed reference values for areal bone mineral density (aBMD) of total body less head (TBLH), total body (TB), lumbar spine (LS), and bone mineral apparent density (BMAD) for LS, by means of Generalized Additive Models for Location, Scale and Shape (GAMLSS).

RESULTS

Reference data including the 3th, 5th, 10th, 25th, 50th, 75th, 90th, 95th and 97th centiles, along with lambda (L), mu (M) and sigma (S) values, are given for each variable of interest for each sex at 0.25 years intervals. Reference values relative to height and Tanner-stage for both sexes are also provided. Finally, formulas to enable Z score estimation for clinical use are also presented CONCLUSIONS: The sex, age, height, Tanner-stage and ethnic-specific reference data provided in this study should enable more precise assessment of bone health in the Mexican paediatric population. The data presented may also allow for future evaluation of potential similarities and differences across different ethnic groups.

Compromising between European and US allergen immunotherapy schools: Discussions from GUIMIT, the Mexican immunotherapy guidelines

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.

[GUIMIT 2019, Mexican Guideline on Immunotherapy. Guideline on the diagnosis of IgE-mediated allergic disease and immunotherapy following the ADAPTE approach]

BACKGROUND

In Mexico, allergen immunotherapy (AIT) and immunotherapy with hymenoptera venom (VIT) is traditionally practiced combining aspects of the European and American school. In addition, both types of extracts (European and American) are commercially available in Mexico. Moreover, for an adequate AIT/VIT a timely diagnosis is crucial. Therefore, there is a need for a widely accepted, up-to-date national immunotherapy guideline that covers diagnostic issues, indications, dosage, mechanisms, adverse effects and future expectations of AIT (GUIMIT 2019).

METHOD

With nationwide groups of allergists participating, including delegates from postgraduate training-programs in Allergy/Immunology-forming, the guideline document was developed according to the ADAPTE methodology: the immunotherapy guidelines from European Academy of Allergy and Clinical Immunology, German Society for Allergology and Clinical Immunology, The American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma, and Immunology were selected as mother guidelines, as they received the highest AGREE-II score among international guidelines available; their evidence conforms the scientific basis for this document.

RESULTS

GUIMIT emanates strong or weak (suggestions) recommendations about practical issues directly related to in vivo or in vitro diagnosis of IgE mediated allergic diseases and the preparation and application of AIT/VIT and its adverse effects. GUIMIT finishes with a perspective on AIT modalities for the future. All the statements were discussed and voted on until > 80 % consensus was reached.

CONCLUSIONS

A wide and diverse group of AIT/VIT experts issued transculturized, evidence-based recommendations and reached consensus that might improve and standardize AIT practice in Mexico.

Preescolar masculino con Síndrome Prader-Willi y tromboembolia pulmonar

<p>El síndrome de Prader-Willi es un trastorno genético raro, originalmente descrito en 1956 por<br />Prader, Labhart y Willi. Su prevalencia es variable pero se estima entre 1:10 000-25 000 nacidos vivos.1-3 La causa genética es la ausencia de la expresión de genes heredados del padre en la región cromosómica 15q11-q13, ya sea por deleción, disomía uniparental materna, defecto de impronta genética o translocación balanceada.2</p>