Patient-Reported Outcome Measures in Atopic Dermatitis and Chronic Urticaria are Underused in Clinical Practice

BACKGROUND

Patient-reported outcome measures (PROMs) are validated and standardized tools that complement physician evaluations and guide treatment decisions. PROMs are crucial for monitoring atopic dermatitis (AD) and chronic urticaria (CU) in clinical practice, but there are unmet needs and knowledge gaps regarding their use in clinical practice.

OBJECTIVE

We investigated the global real-world use of AD and CU PROMs in allergology and dermatology clinics as well as their associated local and regional networks.

METHODS

Across 72 specialized allergy and dermatology centers and their local and regional networks, 2,534 physicians in 73 countries completed a 53-item questionnaire on the use of PROMs for AD and CU.

RESULTS

Of 2,534 physicians, 1,308 were aware of PROMs. Of these, 14% and 15% used PROMs for AD and CU, respectively. Half of physicians who use PROMs do so only "rarely" or "sometimes". AD and CU PROM usage is associated with being female, younger, and a dermatologist. POSCORAD and UAS were the most utilized PROMs for AD and CU, respectively. Monitoring disease control and activity are the main drivers of the use of PROMs. Time constraints were the primary obstacle to using PROMs, followed by the impression that patients dislike PROMs. AD and CU PROM users would like training in selecting the proper PROM.

CONCLUSION

Even though PROMs offer several benefits, their use in routine practice is suboptimal, and physicians perceive barriers to their use. It is essential to attain higher levels of PROM implementation in accordance with national and international standards.

Urticaria exacerbations and adverse reactions in patients with chronic urticaria receiving COVID-19 vaccination: Results of the UCARE COVAC-CU study

BACKGROUND

Concern about disease exacerbations and fear of reactions after coronavirus disease 2019 (COVID-19) vaccinations are common in chronic urticaria (CU) patients and may lead to vaccine hesitancy.

OBJECTIVE

We assessed the frequency and risk factors of CU exacerbation and adverse reactions in CU patients after COVID-19 vaccination.

METHODS

COVAC-CU is an international multicenter study of Urticaria Centers of Reference and Excellence (UCAREs) that retrospectively evaluated the effects of COVID-19 vaccination in CU patients aged ≥18 years and vaccinated with ≥1 dose of any COVID-19 vaccine. We evaluated CU exacerbations and severe allergic reactions as well as other adverse events associated with COVID-19 vaccinations and their association with various CU parameters.

RESULTS

Across 2769 COVID-19-vaccinated CU patients, most (90%) received at least 2 COVID-19 vaccine doses, and most patients received CU treatment and had well-controlled disease. The rate of COVID-19 vaccination-induced CU exacerbation was 9%. Of 223 patients with CU exacerbation after the first dose, 53.4% experienced recurrence of CU exacerbation after the second dose. CU exacerbation most often started <48 hours after vaccination (59.2%), lasted for a few weeks or less (70%), and was treated mainly with antihistamines (70.3%). Factors that increased the risk for COVID-19 vaccination-induced CU exacerbation included female sex, disease duration shorter than 24 months, having chronic spontaneous versus inducible urticaria, receipt of adenovirus viral vector vaccine, having nonsteroidal anti-inflammatory drug/aspirin intolerance, and having concerns about getting vaccinated; receiving omalizumab treatment and Latino/Hispanic ethnicity lowered the risk. First-dose vaccine-related adverse effects, most commonly local reactions, fever, fatigue, and muscle pain, were reported by 43.5% of CU patients. Seven patients reported severe allergic reactions.

CONCLUSIONS

COVID-19 vaccination leads to disease exacerbation in only a small number of CU patients and is generally well tolerated.

Hypereosinophilic syndrome with central nervous system involvement treated with anti-IL-5 therapy

Hypereosinophilic syndrome (HES) is a rare disorder characterized by a persistent eosinophilia with a multi-organ involvement including neurological manifestation. A 59-year-old man was referred from a neurosurgery unit with a spastic triparesis with predominant left side involvement, dissociated sensory loss to Th7, and metastasis-like lesions in a brain CT. MRI examination of the thoracic spine revealed an intraspinal T2-hyperintensive lesion with a subtle central gadolinium enhancement at Th4-Th8 level. MRI of the cervical spine showed a C1-Th1 long T2-hyperintensive lesion with a partial gadolinium enhancement and MRI of the brain revealed a large tumefactive T2-hyperintensive lesion in the right hemisphere. Blood tests showed an increased number of eosinophils (1790 cells/µl; 18.3%). Common causes of the eosinophilia were excluded. After corticosteroid treatment moderate neurological improvement was observed however in the brain MRI new T2-hyperintensive lesions were revealed. The patient was referred to the Department of Allergology and qualified for a treatment with mepolizumab, a monoclonal antibody against IL-5, with subsequent clinical and radiological improvement. To the best of our knowledge, this is the first case of hypereosinophilic syndrome with brain and spinal cord involvement treated with mepolizumab.

New approach to intermittent and mild asthma therapy: evolution or revolution in the GINA guidelines?

New recommendations from the Global Initiative for Asthma (GINA) were released in a pocket guide form on April 12, 2019. These recommendations provide very important changes to the management of asthma, especially regarding the treatment of intermittent and mild asthma. Due to safety concerns, GINA experts no longer recommend treatment with a short-acting β2 agonist alone. Henceforth, all adults and adolescents (but not yet children) with mild asthma should receive either symptom-driven or daily low-dose ICS. The main goal of this new approach is to reduce the risk of serious asthma exacerbations and asthma-related deaths in the population of patients with mild asthma. Herein, the authors present the epidemiological and clinical data regarding the risks of excessive SABA use and the benefits of regular treatment with inhaled corticosteroids. The authors deliver a critical review on the evolution of the changes in the GINA experts’ standpoint and provide evidence-based background for the new approach to asthma treatment. Moreover, the authors identify gaps and unmet needs still present in the current asthma management recommendations and discuss them thoroughly.

The whole-genome expression analysis of peripheral blood mononuclear cells from aspirin sensitive asthmatics versus aspirin tolerant patients and healthy donors after in vitro aspirin challenge

Background

Up to 30 % of adults with severe asthma are hypersensitive to aspirin and no unambiguous theory exists which provides a satisfactory explanation for the occurrence of aspirin-induced asthma (AIA) in some asthmatic patients. Therefore, the aim of this study was to compare the AIA expression profile against aspirin tolerant asthma (ATA) and healthy volunteers (HV) profile in peripheral blood mononuclear cells (PBMCs) after in vitro aspirin challenge in Caucasian population.

Methods

PBMCs were separated from blood of three groups of subjects - 11 AIA, 7 ATA and 15 HV and then stimulated by either 2 μM lysine aspirin or 20 μM lysine as a control. Subsequently, RNA was isolated, transcribed into cDNA and subjected to microarray and qPCR studies. Simultaneously, protein was extracted from PBMCs and used in further immunoblotting analysis.

Results

The validation of results at mRNA level has shown only three genes, whose expression was significantly altered between comprising groups. mRNA expression of CNPY3 in PBMCs in AIA was significantly lower (-0.41 ± 2.67) than in HV (1.04 ± 2.69), (p = 0.02); mRNA expression of FOSL1 in PBMCs in AIA was also significantly decreased (-0.66 ± 2.97) as opposed to HV (0.31 ± 4.83), (p = 0.02). While mRNA expression of ERAS in PBMCs was increased (1.15 ± 0.23) in AIA in comparison to HV (-1.32 ± 0.41), (p = 0.03). At protein level the changed expression of one protein was confirmed. Protein expression of FOSL1 in PBMCs in AIA was both significantly lower (-0.86 ± 0.08) than in ATA (0.39 ± 0.42), (p = 0.046) and in HV (0.9 ± 0.27), (p = 0.007).

Conclusions

This pilot study implies a positive association between CNPY3, ERAS, FOSL1 and aspirin-intolerant asthma, suggesting that these findings would be useful for further investigations of NSAIDs mechanism.

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-015-0305-4) contains supplementary material, which is available to authorized users.

Perennial is more effective than preseasonal subcutaneous immunotherapy in the treatment of seasonal allergic rhinoconjunctivitis

BACKGROUND

Two different regimens of subcutaneous immunotherapy (IT), perennial or preseasonal, may be used in the treatment of seasonal allergy. The aim of this study was to compare the efficacy and safety of perennial IT (PIT) and preseasonal IT (PSIT) in patients suffering from seasonal rhinoconjunctivitis.

METHODS

The study was planned as a randomized, double-blind, comparative study on the efficacy and safety of PIT and PSIT. The study group comprised 120 patients allergic to grass and rye pollen. After the observational season they were randomized to receive PIT or PSIT for 3 years. The effect of IT was assessed based on symptom severity and medication use recorded in diaries.

RESULTS

Ninety-nine patients completed the study. No difference was seen between the groups regarding combined symptom medication score (SMS) in the first season of IT. During the second season, the difference between PIT and PSIT regarding combined SMS was 27.9% (p = 0.063) and reached 42.7% (p = 0.012) in favor of PIT in the third season. Both treatments had a similar safety profile.

CONCLUSION

PIT was more effective than PSIT in the treatment of rhinoconjunctivitis in patients allergic to grass and rye pollens.

Two patterns of changes in nasal nitric oxide after lysine aspirin nasal challenge in patients with aspirin-exacerbated respiratory disease

BACKGROUND

Nasal nitric oxide (nNO) levels after nasal lysine acetylsalicylic acid (lys-ASA) challenge have not been determined. This study was designed to determine a pattern of changes after lys-ASA challenge in aspirin-exacerbated respiratory disease (AERD) patients and to evaluate the usefulness of nNO measurements in the assessment of lys-ASA nasal challenge outcome.

METHODS

Eighteen patients with aspirin hypersensitivity, nasal polyps, and asthma were included. Aspirin-tolerant control groups consisted of 10 healthy volunteers without asthma and nasal polyps and 10 patients with nasal polyps without asthma. All subjects underwent nasal challenge with lys-ASA. nNO was measured before and 1, 2, 4, and 24 hours after control solution and lys-ASA administration.

RESULTS

A significant fall in nNO levels was noted in AERD patients with a positive result to challenges at time points 1 hour (p = 0.0033), 2 hours (p = 0.0033), and 3 hours (p = 0.026) after lys-ASA. A trend toward higher nNO concentrations was observed after lys-ASA challenge at the 2-hour (p = 0.018) and 4-hour (p = 0.018) time points compared with baseline in subjects with AERD and a clinically negative result to the challenge. No significant changes in nNO levels after the challenge were observed in control groups. The combined increase and decrease in nNO levels gave the sensitivity as 0.94 and specificity 1.00 at best.

CONCLUSION

nNO levels decrease after lys-ASA nasal challenge in subjects with AERD and a clinically positive result of the challenge. An unexpected trend toward an increase in nNO levels is observed in subjects with AERD and a clinically negative result of the challenge.

287 Nasal Nitric Oxide Levels after Lysine Aspirin Nasal Challenge in Subjects with Aspirin Induced Asthma

Background

Changes in nasal nitric oxide (nNO) levels after nasal lysine aspirin (lys-ASA) challenge have not been determined.

Methods

Fourteen patients with aspirin induced asthma (AIA) with or without nasal polyps with aspirin were included to the study. Hypersensitivity had to be confirmed by positive result of oral aspirin challenge Ten healthy subjects served as the control group. 12 mg of lys-ASA were applied unilaterally. Nasal symptoms were assessed using visual analogue scale (VAS) and nNO and peak nasal inspiratory flow (PNIF) measurements were performed before and 1, 2, 4 and 24 hours after the challenge. The result of the challenge was considered as positive when at least 20% fall of PNIF as well as 20% increase of total VAS score were observed.

Results

Ten patients (71.4%) had clinically positive result of the challenge. We observed significant fall in nNO levels in AIA patients after 1 and 2 hours after the challenge (653. 1 ± 420. 2 at baseline versus 490. 3 ± 456. 0; P = 0.0029 and 439. 9 ± 556. 4 ppb; P = 0.0076; respectively). The decrease in nNO level was more pronounced in patients with clinically positive result of the challenge (510. 1 ± 212. 5 at baseline versus 283. 3 ± 173. 4; P = 0.005; 159, 6 ± 166,1; P = 0.005 and 331. 0 ± 312.0 ppb; P = 0.037 after 1, 2 and 3 hours, respectively). In 4 subjects with clinically negative result of the challenge we noticed a trend towards higher nNO concentrations after lys-ASA challenge (1010. 8 ± 625. 2 at baseline vs 1341. 3 ± 670. 5 ppb after 4 hours). No significant changes in nNO levels after the challenge were observed in healthy controls.

Conclusions

NO levels decrease after lys-ASA nasal challenge in subjects with AIA and clinically positive nasal provocation. An unexpected trend towards increase in nNO levels was observed in subjects with AIA and clinically negative provocation Potential usefulness of nNO measurement in aspirin nasal provocation needs further evaluation.

Frequencies of Bcl I, E22E, and N363S of h-GR/NR3C1 restriction fragment length polymorphisms of glucocorticoid receptor gene in Polish adult population

BACKGROUND

Polymorphism of the gene encoding the glucocorticoid receptor - h-GR/NR3C1 demonstrates close genetic and biochemical correlation with etiopathogenesis of metabolic, cardiovascular, hematologic, and mental disorders. The natural variability of DNA sequence within the h-GR gene affects both the conformation and the activity of glucocorticoid receptors. Modifications of the amino acid receptor structure give rise to disturbances of the receptor-hormone complex interaction with many genes responsible for normal cellular function. Transactivation, or transrepression, of the genes encoding proteins synthesized within the framework of cellular response to glucocorticosteroids is 1 among many molecular pathways leading to the development of resistance to anti-inflammatory drugs.

MATERIAL/METHODS

A group of 70 healthy participants, with no history of asthma or atopic conditions, qualified for the study. Genotyping was accomplished using PCR-RFLP method.

RESULTS

In healthy, nonatopic population, within the h-GR gene promoter, a polymorphism of Bcl I: GG, GC, and CC occurring with 0.129/0.471/0.40 frequency, were identified. Two polymorphisms were identified in exon 2 at 1220 and 198 position in the h-GR gene: N363S (AA, AG occurring with 0.9/0.1 frequency) and ER22/23EK (GG, GC occurring with 0.843/0.157 frequency).

CONCLUSIONS

The frequency of polymorphisms occurring within the h-GR gene has not been assessed to date in the Polish population. The present study is the first attempt of such estimation. The study is an introduction to more-detailed analysis of the correlation between the occurrence of h-GR gene polymorphisms, and the development of severe, steroid-resistant bronchial asthma.

Lipoxin A4 generation is decreased in aspirin-sensitive patients in lysine-aspirin nasal challenge in vivo model

BACKGROUND

Lipoxins represent a group of lipoxygenase derived eicosanoids which, in contrast to leukotrienes, are potent anti-inflammatory mediators. The aim of our study was to determine lipoxin A(4) (LXA(4)) and leukotriene C(4) (LTC(4)) levels in nasal lavages after intranasal challenge with aspirin in aspirin intolerant (AIA) in comparison to aspirin tolerant (ATA) asthmatics and after allergen challenge in patients suffering from allergic rhinitis.

METHODS

Twelve AIA, 8 ATA and 20 allergic patients were challenged with placebo, 16 mg of lysine-aspirin (Lys-ASA) or allergen (grasses). Nasal lavages were collected and eicosanoids' levels were determined using ELISA.

RESULTS

Clinically positive Lys-ASA challenge in AIA resulted in influx of leukocytes (eosinophils and basophils) to nasal secretions and increase of LTC(4) to 106.82 pg/ml (P < 0.05 vs baseline (26.58 pg/ml)) on first hour after the challenge. We did not observe any differences in LTC(4) level before and after ASA challenge in ATA. In AIA group the mean level of LXA(4) was 43 +/- 21.5 pg/ml after placebo and decreased in 2 h after Lys-ASA challenge (29 +/- 17 pg/ml, P = 0.015). We found an increase in LXA(4) in ATA after ASA provocation as compared to placebo (33 +/- 16 pg/ml vs 52 +/- 31 pg/ml, P = 0.046). In atopic patients baseline level of LXA(4) was 33.49 +/- 16.95 pg/ml with no difference after the clinically positive allergen challenge (36.22 +/- 13.26 pg/ml, P = 0.23).

CONCLUSIONS

Results of our study confirm that AIA have diminished LXs' biosynthesis capacities in vivo after ASA challenge. Taking into consideration anti-inflammatory properties of lipoxins this phenomenon may be partially responsible for the development of chronic inflammation in AIA patients.