Low incidence of pneumonia in COPD patients treated with inhaled corticosteroids undergoing pulmonary rehabilitation

Background

Based on meta-analyses results, it is currently acknowledged that there is an increased risk of pneumonia in patients with chronic obstructive pulmonary disease (COPD) undergoing inhaled corticosteroids (ICS) treatment. However, this is not found to be true in those with asthma. No data on this risk are available for COPD patients involved in pulmonary rehabilitation program (PR).

Methods

For 1 year, we prospectively studied 2 cohorts of COPD patients—undergoing PR and not undergoing PR. The first group included 438 patients undergoing PR of which 353 were treated with ICS, and 85 were treated with bronchodilators only. The second group was comprised of 76 COPD patients who were treated with ICS, but not PR. The control group consisted of 49 ICS-treated patients with asthma. The diagnosis of pneumonia, when suspected, had to be confirmed with a chest x-ray.

Results

Overall, 6 cases of pneumonia were diagnosed in the first study group: 5 ICS-treated patients and 1 patient treated only with bronchodilators. This corresponded to a rate of 1.41 and 1.17%, respectively, compared to a rate of 6.6% in COPD patients not treated with PR, which was significantly higher (p = 0.029) than that in the first study group. No case of pneumonia was registered among patients with asthma.

Conclusions

These findings suggest that a significantly lower incidence of pneumonia is found in COPD patients treated with ICS and PR than in patients treated with ICS but not with PR. This observation deserves to be investigated in large populations of PR-treated COPD patients, possibly in multi-centric cohort studies.

Allergen immunotherapy in atopic dermatitis

INTRODUCTION

Atopic dermatitis (AD) is a chronic relapsing skin disease, characterized by flare-up due to the exposure to allergens in patients sensitized to them. Currently, therapy of AD is mainly based on symptomatic treatment and avoidance of irritating/allergenic factors, house dust mites being particularly important. Allergen immunotherapy (AIT) is suggested to be the only etiologic treatment, to modify the natural history of the disease. Areas covered: The aim of this review is investigating the putative role of AIT in AD through the evaluation of the most recent scientific literature. Several studies have been conducted since 1970, with promising results in improving the clinical outcome of AD, but they often lack the necessary scientific rigorousness. Moreover, heterogeneity of the studies makes it very difficult to compare and to analyze data in a systematic review or meta-analysis. Expert commentary: As a result of the above-mentioned limitations, the treatment of AD with causative aeroallergen can nowadays be suggested only as an add-on therapy in selected patients who are non-responsive to the traditional therapy.

[Risk of pneumonia in patients with chronic obstructive pulmonary disease treated with inhaled corticosteroids: evidence and uncertainties]

A large number of studies, evaluated by several meta-analyses, indicate that patients with chronic obstructive pulmonary disease (COPD) treated with inhaled corticosteroids have a significantly increased risk of pneumonia which, however, is not associated with a corresponding increase in mortality. The increased risk seems to be exclusive of COPD, since meta-analyses involving patients with asthma treated with inhaled corticosteroids did not show a risk of pneumonia higher than that of the general population. Possible interventions to reduce this risk are to improve adherence to guidelines for prescribing inhaled corticosteroids in COPD (often used even in mild to moderate disease, for which they are not indicated), and using lower doses.

Comparing the compliance to a short schedule of subcutaneous immunotherapy and to sublingual immunotherapy during three years of treatment

BACKGROUND

Allergen immunotherapy (AIT) in its two forms of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) is an effective treatment of respiratory allergy, but is particularly concerned by the issue of compliance.

OBJECTIVE

We aimed a real-life study at evaluating the compliance to SLIT and to SCIT administered by a short-course of four injections during a 3-year period of observation.

METHODS

A group of 145 patients (79 males, 66 females, age ranging from 14 to 69 years), suffering from pollen-induced rhino-conjunctivitis with or without asthma, were included in the study. Following adequate education on AIT and according to patient's preference, 72 patients chose to be treated with short-course SCIT and 73 chose to be treated with SLIT. The latter was performed by allergen extracts from different manufacturers according to the suggested schedules.

RESULTS

The rate of withdrawal was as follows: after one year, 15.6% for SCIT and 33.4 for SLIT; after two years, 25.6% for SCIT and 44.8% for SLIT; after three years, 26.7 for SCIT and 46% for SLIT. There was no significant difference in the rate of withdrawal between males and females. Regarding the safety, no systemic reaction requiring medical treatment was observed either in SCIT or SLIT group.

CONCLUSION

The findings of this study confirm that involving the patient in the choice of the route of administration is associated to a satisfactory compliance to AIT. In particular, more than 70% of patients treated with a short schedule of SCIT completed the three-years course of treatment that is recommended for AIT, while this goal was reached by 54% of SLIT treated patients.

Striving for optimal bronchodilation: focus on olodaterol

β2-agonists were introduced in the 1940s as bronchodilators to be used in obstructive respiratory diseases. Long-acting β2-agonists have been a mainstay of bronchodilating treatment for decades. Recently, agents extending their effect to 24 hours and thus allowing the once-daily administration were introduced, defined as very-long-acting β2-agonists. Olodaterol is a new very-long-acting β2-agonist that has been shown, in controlled trials, to improve lung function as well as clinical outcomes and quality of life. Most of these trials included patients with moderate, severe, or very severe chronic obstructive pulmonary disease (COPD). Olodaterol has a rapid onset of action (comparable to formoterol) and provides bronchodilation over 24 hours. In controlled trials, olodaterol was shown to be as effective as formoterol twice daily, but significantly superior in terms of quality of life in patients with COPD. The safety profile of olodaterol was very good, with a rate of adverse events, including the cardiac events that are particularly important for β2-agonists, comparable to placebo. Also, the efficiency of the Respimat(®) device concurs to the effectiveness of treatment.

Combination therapy with indacaterol and glycopyrronium bromide in the management of COPD: an update on the evidence for efficacy and safety

The international guidelines on chronic obstructive pulmonary disease (COPD) recommend inhaled bronchodilators for maintenance treatment of the disease. These drugs include β2-agonists and muscarinic antagonists, which are both available as short-acting agents (to be used as needed for dyspnea) and long-acting agents. To the latter belong salmeterol and formoterol (long-acting β2-agonists) and indacaterol, vilanterol and olodaterol (very long-acting β2-agonist) as β2-agonists, and tiotropium, aclidinium and glycopyrronium bromide as long-acting muscarinic antagonists. The efficacy and safety of indacaterol and glycopyrronium as monotherapies has been demonstrated in several controlled trials. However, in some patients with moderate-to-severe COPD, symptoms are poorly controlled by bronchodilator monotherapy; in these cases the addition of a second bronchodilator from a different pharmacological class may be beneficial. Here we review the evidence from published randomized trials concerning the efficacy and safety of the once-daily fixed-dose dual bronchodilator combining indacaterol and glycopyrronium.

Effects of pulmonary rehabilitation on lung function in chronic obstructive pulmonary disease: the FIRST study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) causes an impairment of respiratory function, well reflected by the progressive decrease in forced expiratory volume in 1 second (FEV1). The only interventions able to slow down the FEV1 decline are smoking cessation and drug treatment. Pulmonary rehabilitation (PR), is claimed to improve exercise tolerance, symptoms and quality of life, but its effects on lung function have been scantly investigated.

AIM

The aim of this paper was to evaluate, by the study named "FEV1 as an Index of Rehabilitation Success over Time" (FIRST), the effects of PR on lung function in patients with COPD, under drug treatment with inhaled corticosteroids or long-acting β2-agonists and/or tiotropium in various combinations, according to guidelines, during a 3-year period.

DESIGN

Observational, prospective, with two parallel groups study.

SETTING

PR setting in an urban hospital.

POPULATION

Two hundred fifty-seven COPD patients, 190 (103 males, mean age 71.1 ± 7.1 years range 57-86 years) underwent PR and 67 (49 males, mean age 67.9 ± 7.9 years, range 58-79 years) were treated only with drugs.

METHODS

Lung function was measured at baseline and at one-year intervals up to 3 years. The postbronchodilator FEV1 was used for statistical analysis.

RESULTS

In the PR group, FEV1 increased from 1240 mL (57.3% of predicted value) to 1252.4 mL (60.8%) after 3 years, whereas in the controls the values were 1367 mL (55% of predicted) at baseline and 1150 mL (51%) after 3 years. This difference was statistically significant (P<0.001).

CONCLUSION

In patients with COPD on standard pharmacotherapy, PR significantly affected the decline of FEV1 over time.

CLINICAL REHABILITATION IMPACT

The ability to substantially stop the FEV1 decline seems exclusive of PR when added to drug treatment. This finding warrants confirmation from randomized trials.

Omalizumab, an anti-immunoglobulin E antibody: state of the art

A large number of trials show that the anti-immunoglobulin (Ig) E antibody omalizumab is very effective in patients with severe allergic asthma. This is acknowledged in consensus documents. The drug also has a good safety profile and a pharmacoeconomic advantage due to a reduction in the number of hospitalizations for asthma attacks. In recent years, some studies have shown that omalizumab is effective also in nonallergic asthma. Effects on the complex signaling mechanisms leading to activation of effector cells and to mediator release may account for this outcome. Indeed, omalizumab has been reported to be effective in a number of IgE-mediated and non-IgE-mediated disorders. Concerning the former, clinical efficacy has been observed in rhinitis, allergic bronchopulmonary aspergillosis, latex allergy, atopic dermatitis, allergic urticaria, and anaphylaxis. In addition, omalizumab has been demonstrated to be able to prevent systemic reactions to allergen immunotherapy, thus enabling completion of treatment in patients who otherwise would have to stop it. Concerning non-IgE-mediated disorders, omalizumab has been reported to be effective in nasal polyposis, autoimmune urticaria, chronic idiopathic urticaria, physical urticaria, idiopathic angioedema, and mastocytosis. Current indications for treatment with omalizumab are confined to severe allergic asthma. Consequently, any other prescription can only be off-label. However, it is reasonable to expect that the use of omalizumab will be approved for particularly important indications, such as anaphylaxis, in the near future.

Role of indacaterol and the newer very long-acting β2-agonists in patients with stable COPD: a review

Bronchodilators are central drugs in the management of patients with chronic obstructive pulmonary disease (COPD). Indacaterol was the first agent of the novel family of very long-acting β2-agonists to be used as an inhaled bronchodilator for COPD and provides 24-hour therapeutic action, thus allowing once-daily administration. Data from clinical trials show that indacaterol has a bronchodilator effect similar to that of the anticholinergic tiotropium bromide and slightly higher efficacy compared with the long-acting β2-agonists, salmeterol and formoterol. Moreover, the safety profile is excellent and comparable with that of placebo. Concerning adherence with drug treatment and real-life management in respect to long-acting β2-agonists, once-daily dosing makes indacaterol more convenient for COPD patients and is likely to enhance patient adherence. Other very long-acting β2-agonists currently in development include vilanterol, olodaterol, and carmoterol, and these have shown good characteristics for clinical use in the studies reported thus far.

Ultra short pre-seasonal subcutaneous immunotherapy and pre-coseasonal sublingual immunotherapy for pollen allergy: an evaluation of patient's preference in real life

BACKGROUND

Specific immunotherapy (SIT) efficacy and safety by subcutaneous (SCIT) and sublingual (SLIT) route is supported by literature data. Pre-coseasonal treatment is currently the more accepted option for pollen immunotherapy in terms of costs and patient's compliance. This retrospective study evaluated the patient's preference concerning subcutaneous or sublingual route in pre-coseasonal treatment.

MATERIALS AND METHODS

We evaluated 145 patients (79 males, 66 females, age ranging from 14 to 69 years), suffering from moderate-severe rhino-conjunctivitis or mild bronchial asthma and with homogeneous characteristic according to allergic disease severity. We proposed either SLIT, with extracts by different producers, or SCIT with Pollinex 4 (Allergy Therapeutics, Worthing, UK), a product designed for ultra-short administration in 4 injections, highlighting for each kind of SIT the major practical advantages or burdens.

RESULTS

Of 145 patients, 72 chose Pollinex 4 SCIT and 73 chose SLIT. SCIT-treated patients received a total of 90 vaccines (18 patients had double course of SCIT). SLIT-treated patients received a total of 87 vaccines (14 patients had double course of SLIT). In the SCIT group, there were 49 males and 23 females; in the SLIT group, there were 30 males and 43 females. Mean age was 36.5 years in SCIT group and 28.5 years in SLIT group. Males preferred SCIT (49 of 72 patients) and females preferred SLIT (43 of 73 patients). No severe reaction was observed either in SCIT or SLIT group.

CONCLUSION

Patients are active subjects in decisional process. Trying to apply in real life the indications coming from guidelines about patient's preference is an important matter. In our patients SCIT with ultra short schedule and SLIT are similarly preferred.

Shrinking the room for invasive ventilation in hypercapnic respiratory failure

Noninvasive ventilation (NIV) was introduced as an alternative to invasive mechanical ventilation for acute respiratory failure caused from exacerbations of chronic obstructive pulmonary disease in the 1980s, and its use gradually rose worldwide. Seventy-eight patients (57 males, mean age 78.3 ± 9.2 years) undergoing NIV were evaluated. Of them, 48 (62.3%) had acute hypercapnic respiratory failure because of a chronic obstructive pulmonary disease exacerbation, and the remaining 30 had acute hypercapnic respiratory failure from other causes, mainly cardiac failure. All patients were treated by NIV using the bi-level positive airway pressure set up at high pressure/high backup rate. NIV was successful in 67 subjects (85.9%) and the patients were discharged, 57 of whom continued NIV at home and ten had spontaneous breathing. NIV was unsuccessful in eleven patients, ten of whom died and one was successfully treated by invasive mechanical ventilation. Significant differences were detected for a higher basal Glasgow Coma Scale score in successfully treated patients (P = 0.007), a higher basal Acute Physiology and Chronic Health Evaluation score in unsuccessfully treated patients (P = 0.004), and a lower pH after 1 hour in unsuccessfully treated patients (P = 0.015). These findings show a very high rate of success of NIV in patients with acute hypercapnic respiratory failure not only from chronic obstructive pulmonary disease but also from cardiac failure. This suggests that the use of invasive mechanical ventilation may be further reduced, with a decrease in its known complications as well.

The clinical stage of allergic rhinitis is correlated to inflammation as detected by nasal cytology

Allergic rhinitis (AR) is the most common allergic disease. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines classify AR according to its duration and severity and suggest recommended treatments, but there is evidence that these guidelines are insufficiently followed. Considering the validity of histopathological data, physicians are more likely to be persuaded by such information on AR. Thus, we attempted to define the severity of AR by nasal cytology on the basis of the ARIA classification. We examined 64 patients with AR caused by sensitization to grass pollen. We clinically defined AR according to the ARIA classification and performed nasal cytology by Rhino-probe sampling, staining and reading by optical microscopic observation. Clinically, 22 (34.4%), 21 (32.8%), 10 (15.6%), and 11 (17.2%) patients had mild intermittent, moderate-to-severe intermittent, mild persistent, and moderate-to-severe persistent AR, respectively. Nasal cytology detected neutrophils in 49 patients, eosinophils in 41 patients, mast cells in 21 patients, and lymphocytes or plasma cells in 28 patients. The patients with moderate-to-severe AR had significantly more mast cells and lymphocytes/ plasma cells than those with mild AR. Our findings demonstrate that the ARIA classification of AR severity is associated with different cell counts in nasal cytology; especially, moderate-to-severe AR shows significantly increased counts of mast cells and lymphocyte or plasma cells. The ease of performing nasal cytology ensures is feasibility as an office AR diagnostic procedure for primary care physicians, able to indicate when anti-inflammatory treatments, such as intranasal corticosteroids and subcutaneous or sublingual allergen immunotherapy, are needed.

Role of noninvasive ventilation in elderly patients with hypercapnic respiratory failure

The effectiveness of non-invasive ventilation (NIV) in treating patients with acute respiratory failure (ARF) is showed by its ability to diminish the recurrence to endotracheal intubation (ETI), the occurrence of ETI-associated lung infections as well as related mortality. A specific issue is the outcome of NIV in patients referring to Emergency Department for ARF who receive a do-not-intubate (DNI) order because of too critical conditions or advanced age. Recent data show that elderly patients (mean age 81 years) with ARF who have a DNI order can be successfully treated by NIV, as demonstrated by a survival rate of 83%. The positive outcome was confirmed by a subsequent 3-year observation, that demonstrated an overall survival rate of 54%. These findings clearly suggest to treat by NIV elderly patients also in presence of a DNI order.

Skin reaction to inhaled tiotropium bromide: a case report

Introduction

Systemic reactions to inhaled drugs are rare. To the best of our knowledge, we report the first case of generalized itching related to the use of tiotropium bromide, a long acting inhaled anti-cholinergic agent commonly used to treat chronic obstructive pulmonary disease.

Case presentation

A 78-year-old Caucasian woman was referred to our facility for allergological evaluation. Our patient had been treated twice with tiotropium for chronic obstructive pulmonary disease and had experienced an allergic reaction with itching. We performed a double-blind placebo-controlled inhalation challenge for our patient with tiotropium and a placebo. Inhalation tests yielded positive results for tiotropium and negative results for the placebo. The results of a skin prick test with tiotropium were negative.

Conclusions

These findings reveal that tiotropium may elicit immediate skin allergic reactions. The negative result from the skin test suggests that such a reaction is not immunoglobulin E-mediated.

Sublingual immunotherapy in allergic asthma: Current evidence and needs to meet

Allergen-specific immunotherapy is aimed at modifying the natural history of allergy by inducing tolerance to the causative allergen. In its traditional, subcutaneous form, immunotherapy has complete evidence of efficacy in allergic asthma. However, subcutaneous immunotherapy (SCIT) has a major flaw in side effects, and especially in possible anaphylactic reactions, and this prompted the search for safer ways of administration of allergen extracts. Sublingual immunotherapy (SLIT) has met such need while maintaining a clinical efficacy comparable to SCIT. In fact, the safety profile, as outlined by a systematic revision of the available literature, was substantially free from serious systemic reactions. A number of meta-analyses clearly showed that SLIT is effective in allergic rhinitis by significantly reducing the clinical symptoms and the use of anti-allergic drugs, while the efficacy in allergic asthma is still debated, with some meta-analyses showing clear effectiveness but other giving contrasting results. Besides the efficacy on symptoms, the preventive activity and the cost-effectiveness are important outcomes of SLIT in asthma. The needs to meet include more data on efficacy in house dust mite asthma, optimal techniques of administration and, as previously done with SCIT, introduction of adjuvants able to enhance the immunologic response and use of recombinant allergens.

Current and future applications of the anti-IgE antibody omalizumab

IgE antibodies are a pivotal factor in pathophysiology of allergic diseases, and the possibility of reducing their level by anti-IgE has long been envisioned. Following several attempts, an effective biologic agent was obtained with the recombinant humanized mono-clonal antibody (rhuMAb)-E25, known as omalizumab. A number of controlled clinical trials demonstrated its efficacy and safety in the treatment of severe allergic asthma uncontrolled by standard drug treatment with maximal recommended doses, and treatment with omalizumab is currently included in international guidelines on asthma management. Other studies reported a clear effectiveness also in allergic rhinitis, but the cost of the anti-IgE treatment suggests its use in patients with rhinitis concomitant with asthma. Other indications to be further investigated are skin disorders such as atopic dermatitis and IgE-mediated urticaria, as well as adverse reactions to foods, with a particularly important role in preventing food-induced anaphylaxis. Finally, there are data indicating the usefulness of omalizumab when used in combination with allergen specific immunotherapy, in terms of reducing the adverse reactions to treatment and increasing the clinical efficacy.

Long-term survival in elderly patients with a do-not-intubate order treated with noninvasive mechanical ventilation

Background:

Noninvasive mechanical ventilation (NIMV) is an effective tool in treating patients with acute respiratory failure (ARF), since it reduces both the need for endotracheal intubation and the mortality in comparison with nonventilated patients. A particular issue is represented by the outcome of NIMV in patients referred to the emergency department for ARF and with a do-not-intubate (DNI) status because of advanced age or excessively critical conditions. This study evaluated long-term survival in a group of elderly patients with acute hypercapnic ARF who had a DNI order and who were successfully treated by NIMV.

Methods:

The population consisted of 54 patients with a favorable outcome after NIMV for ARF. They were followed up for 3 years by regular control visits, with at least one visit every 4 months, or as needed according to the patient’s condition. Of these, 31 continued NIMV at home and 23 were on long-term oxygen therapy (LTOT) alone.

Results:

A total of 16 of the 52 patients had not survived at the 1-year follow-up, and another eight patients died during the 3-year observation, with an overall mortality rate of 30.8% after 1 year and 46.2% after 3 years. Comparing patients who continued NIMV at home with those who were on LTOT alone, 9 of the 29 patients on home NIMV died (6 after 1 year and 3 after 3 years) and 15 of the 23 patients on LTOT alone died (10 after 1 year and 5 after 3 years).

Conclusion:

These results show that elderly patients with ARF successfully treated by NIMV following a DNI order have a satisfactory long-term survival.

[Update on eosinophilic airway disorders]

Eosinophilic disorders of the airways affect the nose and paranasal sinuses, the bronchi and the lungs. Involvement of the nose includes the well known non allergic rhinitis with eosinophilia syndrome and new disorders characterized by co-participation of mast cells and neutrophils. Eosinophilic bronchitis must be distinguished from asthma, on the basis of some functional findings and a different cytokine profile. Eosinophilic pneumonia comprises acute and chronic forms, Churg-Strauss syndrome, hypereosinophilic syndrome, and eosinophilic granuloma, as well as secondary pneumonia such as Loeffler's syndrome.The treatment is mainly based on corticosteroids and the prognosis is variable, depending upon the development of acute respiratory failure (acute eosinophilic pneumonia, eosinophilic granuloma) or of vasculitis with multi-organ organ involvement in Churg-Strauss syndrome.

Pulmonary rehabilitation as evaluated by clinical trials: an overview

During the 80' and the 90's, the role of pulmonary rehabilitation (PR) was still not clearly demonstrated. The following development of PR was mainly due to the increasing number of clinical studies providing proofs of its effectiveness, and convincing physicians, institutions, and regulatory agencies about its additional value to conventional pharmacological therapies. In the later years, PR has become an evidence-based non pharmacological treatment, designed for patients suffering from chronic obstructive lung disease (COPD). In the pulmonary rehabilitation programs (PRPs), exercise is essential for improving muscular tone and thus reducing disability. This later is due to chronic breathlessness, fatigue, and impairment of daily activities, that cause a reduction in functional performance and quality of life (QoL) in COPD patients. PRPs include also educational, psychosocial and nutritional interventions, so that it becomes a multifaceted approach. Despite the existing consciousness that PR results in improvement of exercise tolerance, dyspnea, and QoL, it is under prescribed by most health professionals, and only about 2% of COPD patients undergo PRPs. An appropriate consideration of the PR is essential to ensure optimal management of COPD, in particular when patients have respiratory symptoms that lead to a decrease in physical activity.

Sublingual immunotherapy in polysensitized patients: effect on quality of life

BACKGROUND

Quality of life (QOL) is an important issue in allergic rhinitis and has been evaluated in a number of studies that have shown how it is impaired in untreated patients and improved by effective treatment. However, there are no data concerning QOL after sublingual immunotherapy (SLIT) in polysensitized patients.

OBJECTIVE

To evaluate the effect, in real-life clinical practice, of SLIT on QOL in a population of polysensitized patients with allergic rhinitis.

METHODS

We prospectively evaluated 167 consecutively enrolled polysensitized patients with allergic rhinitis. QOL was measured in all cases with the Rhinoconjunctivitis Quality of Life Questionnaire at baseline and after 1 year of SLIT (performed in approximately 70% of cases using single allergen extracts provided by the same manufacturer).

RESULTS

The most frequent causes of sensitization were grass pollen, Parietaria, and house dust mites. The mean number of sensitizations per patient was 3.65. SLIT was performed with 1 extract in 123 patients (73.6%), with 2 extracts in 31 patients (18.6%), and with more than 2 extracts in 13 patients (7.8%). The mean values of all the QOL items improved significantly (P < .01 in all cases), with the following reductions noted: activities, 3.96 to 2.89; sleep, 2.07 to 1.56; general problems, 2.16 to 1.5; practical problems, 3.69 to 2.58; nasal symptoms, 3.57 to 2.50; eye symptoms, 2.92 to 1.83; and emotional aspects, 2.2 to 1.44.

CONCLUSIONS

This study provides evidence that QOL can be improved in polysensitized patients treated with SLIT, and that the use of just 1 or 2 allergen extracts seems to be sufficient and effective in terms of improving QOL.

Sublingual immunotherapy: administration, dosages, use

Allergen extracts for sublingual immunotherapy (SLIT) are currently marketed by several manufacturers, with administration schedules and amount of allergen(s) quite variable in the different products, although almost all are standardized biologically or immunologically. The allergen extracts for SLIT are available in two main pharmaceutical forms: solution to be delivered by drop-counters, pre-dosed actuators (mini-pumps) or disposable single-dose vials; tablets with appropriate composition that allows a slow (1-2 minutes) dissolution in the mouth in contact with saliva. In Europe, SLIT is prescribed in general for one or a few allergens, and mixtures are less used, though there is no immunological contraindication to give multiple allergens. SLIT traditionally involves a build-up phase and a maintenance phase with the top dose. The build-up phase has usually the duration of 4 - 6 weeks. The patient must start with the lowest concentration and gradually increase, using the different dosage preparations, until the maintenance dose is reached. Rush and ultra-rush inductions have been introduced, based on the safety profile of SLIT that is very favorable. For these reasons it has been suggested that an updosing phase maybe even not necessary. The no-updosing approach would result in a treatment that is more patient-friendly and convenient to manage. Indeed, the most recent randomized trials were performed with the no-updosing regimen and their results in term of safety were as favorable as the studies performed with the traditional updosing approach. The currently recommended duration of SLIT is comprised between 3 and 4 years depending on the clinical response in single patients.

Effects of pulmonary rehabilitation on exercise capacity in patients with COPD: a number needed to treat study

Background

Pulmonary rehabilitation (PR) is recognized as an evidence-based treatment in improving dyspnea and quality of life in patients with COPD. We evaluated the number needed to treat (NNT) to achieve an increase in physical capacity, as defined by a significant improvement in the six-minute walk test (6MWT) in patients with COPD undergoing PR.

Methods

The study enrolled 284 patients aged 41 to 86 years (mean age 69.4 years) divided into two groups: a study group (222 patients) undergoing a PR program, and a control group (62 patients) treated only with drugs. The study group included patients with COPD divided in four subgroups according to GOLD stages.

Results

In the study group, 142 out of 222 patients (64%) had an increase of at least 54 m in the 6MWT following PR versus 8 out of 62 patients (13%) in the control group after the same time interval. The NNT in the overall study group was 2; the same NNT was obtained in GOLD stages 2, 3, and 4, but was 8 in stage 1.

Conclusions

PR is highly effective in improving the exercise capacity of patients with COPD, as demonstrated by a valuable NNT, with better results in patients with a more severe disease.

Effect of noninvasive mechanical ventilation in elderly patients with hypercapnic acute-on-chronic respiratory failure and a do-not-intubate order

Noninvasive mechanical ventilation (NIMV) is effective in the treatment of patients with acute respiratory failure (ARF). It proved to reduce the need of endotracheal intubation (ETI), the incidence of ETI-associated pneumonia, and mortality compared to nonventilated patients. A particular aspect concerns the outcome of NIMV in patients referring to an emergency room (ER) for ARF, and with a do-not-intubate (DNI) status due to advanced age or critical conditions. The aim of our study is to assess the outcome of NIMV in a group of elderly patients with acute hypercapnic ARF who had a DNI status. An overall number of 62 subjects (30 males, 32 females, mean age 81 ± 4.8 years, range 79–91 years) referred to our semi-intensive respiratory department were enrolled in the study. The underlying diseases were severe chronic obstructive pulmonary disease (COPD) in 50/62 subjects, restrictive thoracic disorders in 7/62 subjects, and multiorgan failure in 5/62 subjects. Fifty-four/62 patients were successfully treated with NIMV while 2/62 did not respond to NIMV and were therefore submitted to ETI (one survived). Among NIMV-treated patients, death occurred in 6 patients after a mean of 9.9 days; the overall rate of NIMV failure was 12.9%. Negative prognostic factors for NIMV response proved to be: an older age, a low Glasgow Coma Score, a high APACHE score at admission, a high PaCO₂ after 12 hours and a low pH both after 1 and 12 hours of NIMV. We conclude that elderly patients with acute hypercapnic ARF with a DNI status can be successfully treated by NIMV.

Effectiveness of omalizumab in a patient with severe asthma and atopic dermatitis

The anti-IgE antibody omalizumab is currently indicated in severe asthma not controlled by standard drug therapy. Recently, new indications for omalizumab were suggested, which include atopic dermatitis (AD), a skin disorder characterized by elevated levels of IgE. We report the case of a 39-year old woman with severe asthma and severe AD, both resistant to conventional drug treatment. The patient had a IgE level of 1304 kU/L, which exceeded the recommended maximum level for treating asthma with omalizumab (stated in 700 Ku/L) but was far lower than previously reported in cases of AD treated with anti-IgE. The treatment consisted of a dose of omalizumab 375 mg every two weeks, and induced a rapid improvement of asthma, with no need of other drugs after three months, along with a progressive decline of severity of AD, which after five months was completely cured. These findings suggest the usefulness of omalizumab in patients with concomitant severe asthma and AD, also considering the pharmaco-economic balance obtained by withdrawing the multiple drugs used to treat both diseases.

Characteristics of patients with allergic polysensitization: the POLISMAIL study

BACKGROUND

The natural history of respiratory allergy is commonly characterized by a worsening of symptom severity, frequent comorbidity of rhinitis and asthma, and polysensitization to aeroallergens. The polysensitization phenomenon starts since childhood and is rare to find monosensitized adult patients. However, there are few studies investigating the characteristics of polysensitized patients.

METHODS

This study was performed on a large cohort of patients with allergic rhinitis (assessed by ARIA criteria) and/or mild to moderate asthma (assessed by GINA). The kind and the number of sensitizations, their patterns, and the relation with quality of life (QoL) measured by the Juniper's RQLQ guestionnaire, were evaluated.

RESULTS

Globally 418 patients (50.2% males, 49.8% females, mean age 26.4 years, range 3.5-65 years, 64 smokers, 371 non-smokers) were enrolled: 220 had allergic rhinitis alone, and 198 allergic rhinitis and asthma. The mean number ofsensitizations was 2.6. Three hundred-five patients (73%) had persistent rhinitis (PER), 220 of them with moderate-severe form. There was no significant derence in rate of rhinitis and asthma in monosensitized or polysensitized patients. Most patients were sensitized to pollens, whereas only 24.2% of them were sensitized to perennial allergens. Polysensitization was significantly associated with some issues of QoL, confirming previous findings, but not with number ofsensitizations.

CONCLUSIONS

This study provides data confirming for poly-sensitized patients the relevance of ARIA classification of AR. PER is the most common form of AR in this cohort, symptoms are frequently moderate-severe, and asthma is present in about the half of patients with AR.

Impairment of small airways in COPD patients with frequent exacerbations and effects of treatment with tiotropium

Disease exacerbations are an important aspect of COPD, because they affect its course and are associated with higher lung function decline. On the other hand, data obtained by biopsies have demonstrated that the progression of COPD is related to an increasing impairment of small airways. We sought to evaluate the small airway impairment (FEF25-75) in two groups of COPD patients (each group had 37 subjects) in relation to the frequency of exacerbations and the effectiveness of treatment with tiotropium bromide on the small airway impairment. The mean number of exacerbations was 3.6/year and 1.38/year in frequent and in infrequent exacerbators, respectively (p < 0.001). The mean value of FEF25-75 at baseline was 624 mL and 865 mL in frequent and in infrequent exacerbators respectively (p = 0.002). The changes in respiratory parameters versus baseline showed increases in mean FEV1, FVC, and FEF25-75 in both groups but only the increase in FEF25-75 in frequent exacerbators was statistically significantly (p = 0.013). During the 3-month period of the study the mean number of exacerbations was 0.66 in frequent and 0.12 in infrequent exacerbators. These findings indicate that COPD patients with frequent exacerbations have a higher impairment of small airways. Treatment with tiotropium in COPD subjects with frequent exacerbations proved to be effective in improving small airway impairment.

[A survey on current attitudes to smoking in health care workers in Italy]

BACKGROUND

Prevalence of smoking among healthcare workers has been steadily decreasing in recent years but is still higher than in the general population. This may have a negative impact in the process of recognizing smoking as the major avoidable cause of morbidity and mortality.

OBJECTIVES

In this study we evaluated the prevalence and the attitudes to smoking in healthcare workers, divided into inpatient and outpatient staff in order to assess the possible role of stress in favouring smoking.

METHODS

A standardized questionnaire on smoking was submitted to all employees of the "Istituti Clinici di Perfezionamento", a public hospital in Milan, Italy, covering 1597 subjects.

RESULTS

An overall number of 383 subject (24%) answered the questionnaire. Thirty (7.8%) were non-smokers and not exposed to second-hand smoking, 175 (45.7%) were non-smokers but exposed to second-hand smoking, 79 (20.6%) were ex-smokers, and 99 (25.8%) were current smokers. The comparison between inpatient and outpatient staff did not reveal any significant diferences. As to smoking attitudes, 29 subjects (29.3%) were not interested in quitting, 26 (26.3%) tried unsuccessfully to quit, 27 (27.3%) believed they could succeed in quitting, and 17 (17.2%) wanted to quit but did not know how. Also in this case there were no significant differences between inpatient and outpatient staff.

CONCLUSION

These findings confirm the decrease in the prevalence of smoking observed in recent years in healthcare professionals but suggest the need to continue information, counselling and medical support campaigns aimed at achieving cessation of smoking.

Incidence and characteristics of hospital-acquired pneumonia in a pulmonary rehabilitation setting

BACKGROUND

The incidence of Hospital Acquired Pneumonia (HAP) varies according to the setting. It is estimated to be approximately 0.5% to 1% in hospitalized subjects but higher in mechanically ventilated patients in intensive care units. The incidence of HAP in a pulmonary rehabilitation unit has not been investigated.

MATERIAL/METHODS

Patients with chronic obstructive pulmonary disease (COPD), admitted for pulmonary rehabilitation between January 1 and December 31, 2006, were included. HAP was defined by symptoms, signs, and radiograph imaging of pulmonary infiltrate. Chest radiography allowed us to distinguish HAP from COPD exacerbations. The disease course also was evaluated.

RESULTS

In total, 143 subjects (85 men, 58 women; mean age, 74.2 years) were enrolled. Nine of them (6.3%; 6 men, 3 women; mean age, 72.8+/-3.2 years) developed HAP. Twenty-four (16.8%) had pneumonia signs and symptoms but no radiologic findings. In these patients, a diagnosis of COPD exacerbation was made. Seven of 9 patients with HAP were successfully treated with empiric antibiotic therapy, while the other 2 required a modification of the antibiotic regimen after resistant Klebsiella pneumoniae and Pseudomonas aeruginosa had been detected in sputum culture.

CONCLUSIONS

The incidence of HAP in a pulmonary rehabilitation setting was approximately 6%, higher than that previously described in hospitalized subjects. The clinical course of HAP was favorable, no mortality occurred. This could be explained either by patient-related or by environment-related factors.

Anaphylaxis to honey in pollinosis to mugwort: a case report

A case of anaphylaxis to honey in a 19 year old female sensitized to Compositae pollen is described. The patient suffered from summer rhinoconjunctivitis since seven years; in January 2006, ten minutes after eating bread and honey she developed angioedema of the lips and tongue, runny nose, cough, dyspnoea, and collapse, requiring hospitalization and treatment with high dose corticosteroids and anti-histamines. After two weeks, skin prick tests (SPT) with a standard panel of inhalant allergens and prick + prick with a number of kinds of honey were performed. SPTs were positive to mugwort, ragweed, dandelion, and goldenrod. Concerning honey, the prick + prick was positive to "Millefiori" (obtained from bees foraging on Compositae) and also to sunflower, limetree, and gum tree honey, while was negative for other kinds of honey, including the frequently used chestnut honey and acacia honey. The allergenic component responsible of anaphylaxis in this case seems to be a molecule occurring in Compositae pollens, as previously reported for other three reports, but also in pollen from plants of different families. Honey contains a large number of components derived from bees, such as gland secretions and wax, as well as from substances related to their foraging activity, such flower nectar and pollens (1, 2). Honey as a food has been associated to allergic reactions and particularly to anaphylaxis (3-6). Among the pollens, the role of Compositae is somewhat controversial, since its responsibility is clear in some studies (3, 5, 6) but considered negligible in others (7). Here we present the case of a patient sensitized to Compositae pollen who had an anaphylactic reaction to the ingestion of honey obtained from bees foraging on Compositae flowers and was tested with a number of different varieties of honey.

Effects of replacing oxitropium with tiotropium on pulmonary function in patients with COPD: a randomized study

BACKGROUND

Inhaled bronchodilators are first line drugs in the treatment of chronic obstructive pulmonary disease (COPD). Tiotropium bromide is a recently introduced long-acting anticholinergic agent able to reduce dyspnoea and COPD exacerbations and to improve pulmonary function and quality of life. We designed a study to compare the short-term efficacy of tiotropium bromide with that of oxitropium bromide in improving pulmonary function in patients with COPD.

METHODS

Eighty patients were randomized either to continue oxitropium 800 mcg/day or to receive tiotropium 18 mcg/day. Seventy-six (39 in the tiotropium and 37 in the oxitropium group) completed the study. Plethysmography was performed at baseline and after 72 h in all patients. The changes in functional parameters in the two groups were compared by the Mann-Whitney U-test.

RESULTS

There were no differences between the two groups regarding age (72.5 vs. 74.2 years), male/female ratio (25/14 vs. 23/14) and pulmonary function at baseline. The changes in spirometric parameters were significantly greater in tiotropium- than in oxitropium-treated patients: mean forced expiratory volume in 1s (FEV(1)) increased significantly by 15% vs. 3% (P=0.017), mean FVC by 10.5% vs. 2.2% (P=0.044), and FEF 25, 50, and 75 by 34% vs. 14% (P<0.05), 33% vs. 7% (P<0.05), and 50% vs. 6% (P<0.0001), respectively; mean FRC and RV decreased nonsignificantly by 7.5% and 10% with tiotropium vs. 4.3% and 6.5% with oxitropium, respectively.

CONCLUSION

The replacement of oxitropium with tiotropium significantly increases pulmonary function in patients with COPD. The improvement involves also small airways that have not been investigated thus far.

Dose dependence of efficacy and safety of subcutaneous immunotherapy

A number of experimental and clinical evidence has shown that exposure to high amounts of allergen molecules favours the development of tolerance. This is true also for subcutaneous immunotherapy (SCIT), for which a dose dependence of clinical efficacy was clearly demonstrated. The effective doses, measured as microg of major allergens, to be administered during maintenance treatment were established for the main allergens. Regarding pollens, the range of effectiveness corresponds to 25-41 and 13-20 microg of major allergens Phl p 5 and Phl p 6 for grasses, to 10-47 microg of Amb a 1 for ragweed, to 12 microg of Bet v 1 for birch, and to 6.2 microg of Par j 1 for Parietaria. With house dust mites, a maintenance dose of 5-11.5 microg of the major allergen from Dermatophagoides pteronyssinus Der p 1 is associated to clinically relevant effects, and with cat epithelium the clinical success is observed using a dose of 13-15 microg of Fel d 1. Nevertheless, there are adverse reactions facing SCIT, which are related to the amount of injected allergen. In fact, the safety decreases when the administered doses increase. This has led to "optimal doses" being defined which show a good balance between efficacy and safety (corresponding for example to a dose of 7 microg for Der p 1 and of 13 microg for Fel d 1). The dose dependency with respect to both efficacy and safety makes essential to accurately consider the risk/benefit ratio in each patient eligible for SCIT.

Different outcomes of pulmonary rehabilitation in patients with COPD with or without exacerbations

BACKGROUND

Pulmonary rehabilitation is recognised as an effective treatment in reducing disability and improving the quality of life in patients with COPD. We evaluated the effects of a course of pulmonary rehabilitation in improving the physical performance and lung function in patients with or without COPD exacerbations.

METHODS

74 patients with COPD were enrolled, 37 (24 males and 13 females, mean age 74.6 years) without exacerbations (group A), and 37 (23 males, 14 females, mean age 73.9 years) with exacerbations (group B). The latter must have had the latest exacerbation at least one month before the inclusion. All patients underwent to a rehabilitation programme of 8 visits in 4 weeks in a day-hospital setting, with exercise training, respiratory muscle training and education on COPD. The changes in physical performance and lung function in respect to baseline were measured by a 6-minute walking test, using phethysmography, and by an analogic manometer measuring maximal inspiratory and expiratory pressures (MIP, MEP).

RESULTS

Patients of group A showed a mean increase in timed walk distance of 58.38 +/- 57.46 m, compared to a mean increase of 31.38 +/- 44.78 m in group B patients (p = 0.028). As to lung function, a mean increase of 178.92 +/- 132.28 ml in FEV1 in group A versus 67.84 +/- 102.04 ml in group B (p < 0.0001) and a mean increase of 22.36 +/- 25.06 cm H2O in MEP in group A versus 7.70 +/- 12.28 cm H2O in group B (p = 0.002) was found.

CONCLUSIONS

These findings indicate that patients with COPD with exacerbations achieve a less favourable outcome of pulmonary rehabilitation, with a significantly lower improvement of physical performance, respiratory muscle strength and lung function in respect to subjects without exacerbations.

Determination of cut-off positivity values in nasal challenge testing of patients with allergic rhinitis

Nasal challenge testing with allergen extracts is currently used to diagnose nasal allergy and, to a greater extent, in studies of pathophysiology of allergic rhinitis. The resulting nasal obstruction, measured as nasal airway resistance (NAR), is determined by rhinomanometry (RMM). The aim of this study was to define a cut-off NAR value for a positive response in a nasal allergen challenge test. Forty-two, grass-allergic adult patients and 40 nonallergic adults were challenged out of the grass pollen season under standard conditions with timothy grass extract administered intranasally in doses increasing from 10 to 1500 IU/mL. Inspiratory NAR was determined by computerized anterior active RMM. The cut-off value for a positive test was determined from receiver operating characteristic curves plotted from these data with the LABROC1 computer program. In addition, the subjects' nasal cycle was recorded during the four hours preceding the allergen challenge. The patients' mean NAR value at baseline (0.33 Pa/cc/sec) and when challenged with normal saline solution did not differ from those of the control subjects. The patients, but not the control subjects, experienced typical nasal allergic symptoms when challenged with the grass extract. The control subjects had no symptoms and their NAR did not change significantly when they were challenged with the same extract. All 42 allergic patients had measurable increases in NAR at the 800 IU/mL allergen dose; 19/42 patients had complete obstruction (i.e., NAR unmeasurable) when challenged with the 1500 IU/mL dose. The maximum diagnostic value (= sensitivity + specificity at the discriminator position on the receiver operating characteristic curves) was 1.96 with the 800 IU/mL dose. At that dose, the NAR cut-off value was 0.91 Pa/cc/sec, which was 2.7 times greater than their mean value at baseline. NAR varied less than 1-fold between the maximum and minimum points of the normal nasal cycle in both groups of subjects. An increase of NAR of nearly three-fold during nasal allergen challenge compared to the baseline value determined by computerized anterior active RMM discriminates best patients with allergic rhinitis from nonallergic adults.

Atopy and intolerance of antimicrobial drugs increase the risk of reactions to acetaminophen and nimesulide in patients allergic to nonsteroidal anti-inflammatory drugs

This study evaluated the risk factors for developing allergic reactions to alternative drugs such as acetaminophen and nimesulide in 367 patients intolerant of nonsteroidal anti-inflammatory drugs (NSAID) compared to 243 healthy controls. All subjects were given test doses (TD) of acetaminophen and nimesulide, and age, sex, atopy, and history of reactions also to unrelated drugs were compared in those who reacted and those who were tolerant of the challenge. TD was positive in 49 of 367 (14%) NSAID-allergic patients and in one (0.4%) of the controls (P<0.001). No difference was found in age and sex between the TD-positive and TD-negative subjects, although a significantly larger number of females were NSAID allergic (P<0.01). Of the 367 patients, 208 had a history of reactions only to NSAID, and 148 to NSAID and antimicrobial drugs (AMD). TD with acetaminophen or nimesulide was positive in 6% of patients intolerant only of NSAID and in 24% of those intolerant of both NSAID and AMD, with an odds ratio of 4.82. Atopy was more frequent among patients (36%) than controls (23%) (P=0.004), among TD-positive (51%) than TD-negative patients (33.5%) (P<0.02), and among patients intolerant of NSAID and AMD (48%) than those intolerant only of NSAID (P=0.006). The odds ratios were, respectively, 1.87, 2.57, and 3.16. This study provides evidence that atopy and history of allergic reactions to AMD increase the likelihood of intolerance of usually well-tolerated alternative drugs such as acetaminophen and nimesulide in subjects allergic to NSAID.

Sensitization to cockroach in Italy: a multicentric study

The prevalence of sensitization to cockroach (CR) was evaluated by skin prick test (SPT) in 1299 patients consecutively referred for rhinitis and asthma to five allergy centers in northern, central, and southern Italy. In patients with positive SPT to CR, an SPT with D. pteronyssinus extract was made. RAST inhibition was performed with pooled sera of subjects with positive SPT and RAST of at least Class 3 for CR and D. Pteronyssinus, to assess the cross-reactivity between these two allergenic sources. The protein content of allergen extracts was assayed by isoelectric focusing (IEF). A total of 170 patients (13%) had a positive SPT with CR extract, and 133 of them (78.2%) were also positive for D. pteronyssinus. RAST inhibition showed a cross-reactivity between CR and D. pteronyssinus, and IEF detected in the extracts employed a series of bands focusing at the same pI of CR and D. pteronyssinus relevant allergens. Therefore, the prevalence of sensitization to CR in the population studied, corresponding to 13%, suggests that CR extract might be added to standard SPT panels for respiratory allergy. However, the cross-reactivity with D. pteronyssinus calls for careful evaluation of the clinical importance of this sensitization.

Cut off values of bone mineral density defining postmenopausal women with bone fractures

OBJECTIVES

To define cut off values of bone mineral density (BMD), measured at different forearm sites by single photon absorptiometry, that discriminated postmenopausal women who have had fractures from those who have not, in order to provide an index of fracture risk for screening purposes.

METHODS

BMD values were measured at distal third radius (DTR) and ultradistal radius (UDR) sites in two groups of postmenopausal women. Group 1 (n = 398) had not suffered fractures, and group 2 (n = 354) had appendicular fractures. Results were evaluated using receiver operating characteristic (ROC) curves.

RESULTS

BMD values were significantly greater (p < 0.001) at both sites in group 1. Weight was lower in group 2 than in group 1 (p < 0.001). The BMD cut off value was 0.596 g/cm2 at DTR (sensitivity 63%, specificity 72%), and 0.310 g/cm2 at UDR (sensitivity 80%, specificity 80%). Values of area under ROC curves estimated for UDR were greater than for those DTR (p < 0.001).

CONCLUSION

For screening purposes the BMD cut off value of 0.310 g/cm2 at the UDR may be useful in identifying women at high risk of fracture in an unselected postmenopausal population. BMD measured at UDR appeared to have a better predictive value than that at DTR.

Importance of allergic etiology in nasal polyposis

Sensitization to environmental allergens in nasal polyposis was evaluated in an in vitro study conducted on 90 patients undergoing polypectomy by measuring total and specific IgE for a panel of common allergens and levels of IgG, IgA and albumin in serum, and nasal secretions (NSe). Fifty healthy individuals were chosen as a control group. Total IgE concentrations were higher in patients with nasal polyps than in controls. RAST was positive in serum in 34 (38%), in NSe in 29 (32%), and exclusively in NSe in 10 patients (11%). Allergens most frequently involved were mites and cat dander. No differences were found between the study and control groups for serum and NSe IgA, albumin, and serum IgG, whereas IgG in NSe were significantly higher in patients with nasal polyps. Subjects with positive RAST only in NSe had significantly lower secretory IgA than did controls. Our data indicate that in nasal polyposis: 1) sensitization to aeroallergens is relatively common; 2) a local production of specific IgE may occur, especially for perennial allergens; 3) prolonged exposure to these allergens gives rise to chronic nasal inflammation, with altered local production of immunoglobulins.

Comparison of rhinomanometry, symptom score, and inflammatory cell counts in assessing the nasal late-phase reaction to allergen challenge

Inspiratory nasal resistance, symptom score, and influx of inflammatory cells into the nose were evaluated before and after a nasal challenge in 15 patients with grass pollen rhinitis and in six nonallergic control subjects, to study the nasal late-phase reaction and its relationship with nasal cytology. All patients had an immediate positive reaction to specific nasal challenge. In seven allergic subjects we observed a later inspiratory nasal resistance increase, but only two had a significant late symptom score. Inflammatory cells increased by 8 hours in all the patients; the higher the cell influx, the higher the symptom score. Close correlations were found between the inspiratory nasal resistance increase, nasal obstruction at hours 8 and 24, and all cell counts. In control challenges there were no significant increases of symptom score or inspiratory nasal resistance either during the challenge or in the next 24 hours. A weakly significant increase was found only for neutrophil counts at 8 hours. These results indicate that an inflammatory reaction constantly occurs after a specific nasal challenge; its extent is closely related to inspiratory nasal resistance and to the intensity of nasal obstruction. Moreover, our data outline the pivotal role played by eosinophils and basophils in the genesis of an allergic late-phase reaction in the nose.