Mast Cell Activation Profile and TFH13 Detection Discriminate Food Anaphylaxis Versus Sensitization

BACKGROUND AND OBJECTIVE

The prevalence of food allergy (FA) has increased significantly, and the risk of developing anaphylaxis is unpredictable. Thus, discriminating between sensitized patients and those at risk of having a severe reaction is of utmost interest. To explore mast cell activation pattern and T follicular helper (TFH) 13 presence in sensitized and food anaphylaxis patients.

METHODS

Patients sensitized to Lipid transfer protein (LTP) were classified as anaphylaxis or sensitized depending on the symptoms elicited by LTP-containing food. CD34+-derived MCs from patients and controls were obtained, sensitized with pooled sera, and challenged with Pru p 3 (peach LTP). Degranulation, PGD2, and cytokine/chemokine release were measured. The TFH13 population was examined by flow cytometry in the peripheral blood of all groups. In parallel, LAD2 cells were activated similarly to patients' MCs.

RESULTS

A distinguishable pattern of mast cell activation was found in anaphylaxis compared to sensitized patients. Robust degranulation, PGD2, and IL-8 and GM-CSF secretion were higher in anaphylaxis, whereas TFG- and CCL2 secretion increased in sensitized patients. Concomitantly, anaphylaxis patients had a larger TFH13 population. MC activation profile was dependent on the sera rather than the MC source. In agreement with that, LAD2 cells reproduce the same pattern as MCs from anaphylactic and sensitized patients.

CONCLUSION

The distinct profile of mast cell activation allows to discriminate between anaphylaxis and sensitized patients. Pooled sera may determine mast cell activation independently of mast cell origin. Besides, the presence of TFH13 cells in anaphylaxis patients points to an essential role of IgE affinity.

Low levels of miR-143-3p are associated with severe chronic rhinosinusitis with nasal polyps

microRNAs (miRNAs) are small, single-stranded, non-coding RNA molecules that regulate post-transcriptional gene expression. Accumulating evidence suggests their involvement in regulating various biological and pathological processes, including inflammation. Studies have revealed distinct expression patterns of miRNAs in Chronic Rhinosinusitis with (CRSwNP) and without (CRSsNP) nasal polyps (1). Specifically, miR-155 and miR-21 have been observed to be upregulated in CRSwNP, increasing and attenuating the expression of pro-inflammatory cytokines, respectively (2,3). Conversely, the downregulation of miR-34, miR-449, and members of the miR-200 family has been associated with impaired ciliogenesis and the regulation of epithelial-mesenchymal transition, respectively (4,5). Nonetheless, the direct role of miRNAs in CRSwNP is still being investigated.

Differences in molecular sensitization profiles between a Spanish and Latin American mite allergic patients

BACKGROUND AND OBJECTIVE

To analyze the sensitization pattern to Dermatophagoides pteronyssinus and to associate the diagnostic findings and clinical severity in 218 allergic patients from two different continents.

METHODS

Mite allergic patients were recruited by the Allergology departments from Latin America (n=88: Colombia, Costa Rica and Guatemala) and Spain (N=130). All patients had allergic rhinitis with or without asthma and positive skin prick test results to D. pteronyssinus. Specific IgE levels to D. pteronyssinus, D. farinae, Der p 1, Der p 2, and Der p 23 were quantified by ImmunoCAP system (ThermoFisher Scientific). Allergenic profile was also determined by western blot. Comparative Statistical analysis was performed by GraphPad software.

RESULTS

Patients recognized most frequently Der p 2 (79%) followed by Der p 1 (73%), and Der p 23 (69%) allergens. The percentage of asthmatic patients increases with the number of sensitizations however none statistically significant differences were found. Interestingly, asthmatic patients presented the highest median levels of total IgE and specific IgE levels of D. pteronyssinus and molecular allergens, mainly Der p 2. Analysing the two different populations, Spanish patients were predominantly sensitized to Der p 2 (88.46%) and Der p 1 (83.84%), whereas Latin American population were more sensitized to Der p 23.

CONCLUSION

Our data support the relevance of Der p 2 in mite allergy as the major allergen, with the high number of patients sensitized to it and its importance in the development of asthma. Sensitization to Der p 23 was more important in Latin America.

Consensus on the Definition of Control and Remission in Chronic Urticaria

The terms control and remission and other key terms used in chronic urticaria (CU) such as flare-up, relapse, exacerbation, and recurrence have not been fully defined in the literature. Disease monitoring and treatment goals in clinical practice are not well established. After a qualitative appraisal of available evidence, we aimed to find a consensus definition of control and remission, clarify key terminology, provide guidance on how to monitor the disease, and establish treatment goals in clinical practice. A modified Delphi consensus approach was used. Based on a literature review, a scientific committee provided 137 statements addressing controversial definitions and terms, available patient-reported outcomes (PROs), and recommendations on how to measure therapeutic objectives in CU. The questionnaire was evaluated by 138 expert allergists and dermatologists. A consensus was reached on 105 out of the 137 proposed items (76.6%). The experts agreed that complete control and remission of CU could be defined as the absence of signs or symptoms while on treatment and in the absence of treatment, respectively. Consensus was not reached on the definition of other key terms such as flare-up, exacerbation, and recurrence. The panel agreed that the objective of therapy in CU should be to achieve complete control. PROs that define the degree of control (complete, good, partial, or absence) were established. An algorithm for disease assessment is provided. In conclusion, this work offers consensus definitions and tools that may be useful in the management of patients with CU.

A Specialized Therapeutic Approach to Chronic Urticaria Refractory to H1-Antihistamines Improves Disease Burden: The Spanish AWARE Experience

OBJECTIVE

During its first year, the AWARE study assessed disease activity, patient quality of life (QOL), and treatment patterns in chronic urticaria (CU) refractory to H1-antihistamines (H1-AH) in clinical practice.

METHODS

We performed an observational, prospective (24 months), international, multicenter study. The inclusion criteria were age ≥18 years and H1-AH-refractory CU (>2 months). At each visit, patients completed questionnaires to assess disease burden (Urticaria Control Test [UCT]), disease activity (7 day-Urticaria Activity Score [UAS7]), and QOL (Dermatology Life Quality index [DLQI], Chronic Urticaria Quality of Life Questionnaire [CU-Q2oL], and Angioedema Quality of Life Questionnaire [AE-QoL]). We present data for Spain.

RESULTS

The study population comprised 270 evaluable patients (73.3% female, mean [SD] age, 48.9 [14.7] years). At baseline, 89.3% were prescribed a CU treatment. After 1 year, first- and second-line treatments became less frequent and third-line treatments became more frequent. At baseline, 47.0% of patients experienced angioedema; at 1 year, this percentage had fallen to 11.8%. The mean (SD) AE-QoL score decreased from 45.2 (28.7) to 24.0 (25.8). The mean (SD) UCT score decreased from 7.0 (4.5) to 12.1 (4.1). According to UAS7, 38.2% of patients reported absence of wheals and itch in the previous 7 days at 1 year compared with 8.3% at baseline. The mean (SD) DLQI score decreased from 8.0 (7.4) to 2.8 (4.6). At the 1-year visit, the percentage of patients reporting a high or very high impact on QOL fell from 29.9% to 9.6%.

CONCLUSION

H1-AH-refractory CU in Spain is characterized by absence of control of symptoms and a considerable impact on QOL. Continuous follow-up of CU patients and third-line therapies reduce disease burden and improve patients' QOL.

Usefulness of the Allergen Specific Nasal Provocation Test in the Diagnosis of Shellfish Allergy

BACKGROUND AND OBJECTIVE

Shellfish allergy is an important cause of food allergy and anaphylaxis worldwide. Several allergenic proteins have been described in the last few years, but the only diagnostic tool that allows discrimination between allergic and non-allergic sensitized subjects is still the oral food challenge (OFC). Objective: The aim of this study was to evaluate the usefulness of nasal allergen provocation test (NAPT) as a diagnostic tool in the diagnosis of shellfish allergy.

MATERIAL AND METHODS

Forty-five subjects with confirmed sensitization to shrimp by a positive skin prick test (SPT) to a commercial shrimp extract were recruited and classified as Sensitized-Allergic or non-Allergic based on current tolerance to shrimp intake, the result of an OFC with a freeze-dried cooked shrimp mixture extract, or recent history of anaphylaxis from shrimp ingestion. These subjects and ten controls without shrimp sensitization were subjected to a NAPT with a freeze-dried cooked shrimp mixture extract. The response was evaluated by means of acoustic rhinometry (AcRh) and visual analogue scale scores (VAS).

RESULTS

Significant differences (p=.001) were found between the Sensitized-Allergic group (18/20 positive NAPT, 90%) compared to both Sensitized-non-Allergic (2/18 positive NAPT, 11.1%) and Control (0/10 positive NAPT) groups. NAPT allows differentiation between allergic and non-allergic subjects with a S: 90%, E: 89%, PPV: 90% and NPV: 89%.

CONCLUSIONS

According to the study results NAPT may be a useful diagnostic tool that allows differentiating sensitized symptomatic subjects from sensitized tolerant. It could be a valuable test to consider when conducting a shrimp allergy study.

ARADyAL: The Spanish Multidisciplinary Research Network for Allergic Diseases

Thematic cooperative health research networks (RETICS) are organizational structures promoted by the Instituto de Salud Carlos III of the Spanish Ministry of Science with the objective of carrying out cooperative research projects addressing challenges of general interest for society as a whole in the field of health care. The RETICS of Asthma, Adverse Drug Reactions, and Allergy (ARADyAL) received funding in 2016 for a 5-year program (2017-2021). ARADyAL integrates basic and clinical research in the areas of allergy, immunology, genetics, nanomedicine, pharmacology, and chemistry, with special interest in research on new biomarkers and the design and evaluation of new interventions for allergic patients with severe phenotypes. The consortium comprises 28 groups across Spain, including 171 clinical and basic researchers, 17 clinical groups that cover more than 10 000 000 patients of all ages from urban and rural areas and 11 basic groups active mostly at universities and research institutes. ARADyAL has proposed a research program organized into 3 different areas focusing on precision medicine, as follows: Program 1, Mechanisms and prediction of adverse drug reactions and allergic diseases; Program 2, Toward a precise diagnosis of allergic diseases; and Program 3, Predicting interventions in allergic diseases. There is also 1 common program dedicated to training. The network has a Steering Committee and an External Advisory Scientific Committee, which advise the global network coordinator, who has recognized expertise in the field. ARADyAL is a unique meeting point for clinicians and basic scientists who are already working in allergy.

Allergy rhinitis: similarities and differences between children and adults

BACKGROUND

Allergic rhinitis (AR) is a highly prevalent disease worldwide. Although a number of studies have described AR, no studies compared children and adult AR populations. The objective was to compare the AR characteristics between two AR cohorts of children and adults.

METHODS

Two AR cohorts (children and adults) from Spain were studied through observational cross-sectional multicentre studies. AR was classified based on classical (allergen exposure), original (o-ARIA), and modified (m-ARIA) ARIA criteria. AR was evaluated by Total 4-Symptoms Score (T4SS), and disease severity by Visual Analogue Scale (VAS, 0-100 mm). AR comorbidities were also evaluated.

RESULTS

A total of 5,405 patients (1,275 children, 4,130 adults) were studied. According to symptoms duration, intermittent AR was more frequent in children than in adults. Using o-ARIA severity, more children than adults had moderate/severe AR while, using m-ARIA, more children than adults had severe AR. T4SS was higher in adults than in children. Moreover, VAS was also higher in adults than in children. In addition, asthma atopic dermatitis and conjunctivitis were more associated to children than adults with AR, the frequency of this comorbidities increasing according to higher severity.

CONCLUSIONS

AR in children was more intermittent, severe, with less symptoms but with more comorbidities than in adults. These results suggest AR has similarities but also significant differences between children and adults.

Molecular cloning of plane pollen allergen Pla a 3 and its utility as diagnostic marker for peach associated plane pollen allergy

BACKGROUND

Non-specific lipid transfer proteins (nsLTP) are considered to provoke allergic symptoms to plane tree pollen, which are frequently associated with peach allergy.

OBJECTIVE

The objective was to clone the cDNA of plane pollen nsLTP Pla a 3, to characterize IgE-binding and allergenic potency of recombinant Pla a 3 in comparison to its natural counterpart and peach nsLTP Pru p 3.

METHODS

Natural Pla a 3 was purified from plane pollen and analysed by mass spectrometry (MS). Recombinant Pla a 3 was characterized by SDS-PAGE and CD spectroscopy. Specific IgE to extract, components of plane pollen and Pru p 3 was measured by ImmunoCAP in sera of patients allergic to either plane pollen (n = 10), peach (n = 15) or both (n = 15). Biological potency of the proteins was investigated by in vitro mediator release assays and IgE cross-reactivity by competitive ELISA.

RESULTS

Two Pla a 3 isoforms were identified. Recombinant Pla a 3 showed high purity, structural integrity, IgE-binding capacity comparable to nPla a 3 and biological potency. Sensitization to plane pollen extract was confirmed in 24/25 plane pollen allergics. The frequency of sensitization to Pla a 3 was 53% among patients allergic to both plane pollen and peach and 10% among plane pollen allergics tolerating peach where most patients were sensitized to Pla a 1. Pla a 3 and Pru p 3 showed strong bi-directional IgE cross-reactivity in patients allergic to peach and plane pollen, but not in peach allergics tolerating plane pollen. Levels of IgE-binding were generally higher to Pru p 3 than to Pla a 3.

CONCLUSION

Sensitization to Pla a 3 is relevant in a subgroup of plane pollen allergics with concomitant peach allergy. IgE testing with Pla a 3 may serve as a marker to identify plane pollen allergic patients at risk of LTP-mediated food reactions and thereby improve in vitro diagnostic procedures.

Allergic rhinitis severity can be assessed using a visual analogue scale in mild, moderate and severe

BACKGROUND

Allergic rhinitis is a global healthcare problem due to its high prevalence, impact on individuals and socioeconomic burden for the nations. Allergic rhinitis severity evaluation is the key to a correct treatment, prevention of comorbidities and improving the quality of life of patients. This evaluation should be made with a simple, easy, fast but accurate and reliable methodology, both in a primary care and specialist setting. The visual analogue scale (VAS) meets all requirements to be the ideal tool to assess allergic rhinitis severity and has already been validated by using a single cut-off point, but this classification in two degrees of severity suffer from not allocating the patients uniformly and from giving a blind interval to classify the patients when the score is between 5 to 6 cm.

METHODOLOGY

The main objective of our study is to describe the optimal cut-off points by using a VAS to discriminate between three degrees of allergic rhinitis severity (mild, moderate, and severe) following the ARIA modified severity criteria that has been previously validated. Sensitivity, specificity, positive and negative predictive values just like receiver operating characteristic curves were used to select the best cut-off values.

RESULTS

In a cross-sectional multicentre study with 3,572 patients included we have found that VAS has a significant correlation with nasal symptom score and quality of life and that the best cut-off points to differentiate between mild, moderate an severe allergic rhinitis are a VAS score of 4 and 7, respectively.

CONCLUSIONS

Allergic rhinitis severity could be assessed in three degrees by using VAS in a simple, easy, and accurate method.

Immediate Reactions to More Than 1 NSAID Must Not Be Considered Cross-Hypersensitivity Unless Tolerance to ASA Is Verified

BACKGROUND AND OBJECTIVES

Individuals who develop drug hypersensitivity reactions (DHRs) to chemically unrelated nonsteroidal anti-inflammatory drugs (NSAIDs) are considered cross-hypersensitive. The hallmark for this classification is that the patient presents a reaction after intake of or challenge with acetylsalicylic acid (ASA). Whether patients react to 2 or more NSAIDs while tolerating ASA remains to be studied (selective reactions, SRs). Objective: To identify patients with SRs to 2 or more NSAIDs including strong COX-1 inhibitors.

METHODS

Patients who attended the Allergy Service of Hospital Infanta Leonor, Madrid, Spain with DHRs to NSAIDs between January 2011 and December 2014 were evaluated. Those with 2 or more immediate reactions occurring in less than 1 hour after intake were included. After confirming tolerance to ASA, the selectivity of the response to 2 or more NSAIDs was demonstrated by in vivo and/or in vitro testing or by controlled administration.

RESULTS

From a total of 203 patients with immediate DHRs to NSAIDs, 16 (7.9%) met the inclusion criteria. The patients presented a total of 68 anaphylactic or cutaneous reactions (mean [SD], 4.2 [2.1]). Most reactions were to ibuprofen and other arylpropionic acid derivatives and to metamizole. Two different NSAIDs were involved in 11 patients and 3 in 5 patients.

CONCLUSIONS

Patients with NSAID-induced anaphylaxis or urticaria/angioedema should not be considered cross-hypersensitive unless tolerance to ASA is verified.

Effects of Rupatadine on Platelet- Activating Factor-Induced Human Mast Cell Degranulation Compared With Desloratadine and Levocetirizine (The MASPAF Study)

BACKGROUND AND OBJECTIVE

Platelet-activating factor (PAF) is a lipid mediator involved in the pathophysiology of several allergic diseases, for example, in the amplification of mast cell (MC) activation in anaphylaxis. Rupatadine is an antihistamine with a demonstrated anti-PAF effect, although its capacity to inhibit PAF-induced MC degranulation has not been fully evaluated. Objectives: To compare the ability of rupatadine to inhibit PAF-induced MC degranulation with that of desloratadine and levocetirizine and to confirm the dual anti-H1 and anti-PAF activity of rupatadine.

METHODS

The human MC line LAD2 and primary MCs (human lung tissue MCs [hLMCs]) were used. MC mediator release was evaluated using the b-hexosaminidase and histamine release assay. The effects of rupatadine (H1 antagonist + PAF receptor antagonist), desloratadine, and levocetirizine (H1 antagonists) on LAD2 and hLMCs were compared. The PAF receptor antagonists WEB2086, BN52021, and CV6209 were also tested. PAF receptor protein expression was evaluated in both LAD2 and hLMCs.

RESULTS

CV6209 and rupatadine inhibited PAF-induced MC degranulation in both LAD2 and hLMCs. In LAD2, rupatadine (5 and 10 µM) and levocetirizine (5 µM), but not desloratadine, inhibited PAF-induced b-hexosaminidase release. Rupatadine (1-10 µM), levocetirizine (1-10 µM), and desloratadine (10 µM) inhibited PAF-induced histamine release. Rupatadine at 10 µM had an inhibitory effect on hLMC degranulation, but levocetirizine and desloratadine did not.

CONCLUSIONS

This study shows that rupatadine and, to a lesser extent, levocetirizine, but not desloratadine, inhibit PAF-induced degranulation in both LAD2 and hLMCs. These findings support the dual antihistamine and anti-PAF effect of rupatadine in allergic disorders.

Comparable actions of omalizumab on mast cells and basophils

BACKGROUND

Omalizumab (OmAb) has recently been approved for the treatment of diseases other than allergic asthma, including chronic urticaria. The exploration of the use of OmAb in chronic urticaria was based on the presence of IgE autoantibodies against autoantigens such as anti-IgE, anti-FcεRI, and IgE antibodies against thyroid peroxidase in certain patients with chronic urticaria. OmAb recognizes and sequesters free IgE to prevent its interaction with FcεRI. However, OmAb is equally and rapidly effective against autoimmune and non-autoimmune urticaria, suggesting the possible involvement of additional mechanisms of IgE.

OBJECTIVES

We sought to investigate the in vitro mechanism of action of OmAb in mast cells and basophils.

METHODS

Both LAD2 human mast cell line, previously sensitized with IgE, and ex vivo basophils were incubated with OmAb at different doses, analysing its effect on IgE-dependent events (e.g., degranulation, phosphorylation-mediated signalling, and eicosanoid release).

RESULTS

We found that OmAb dissociates pre-bound IgE from mast cells and basophils, resulting in a reduction of proximal phosphorylation-mediated signalling events (Syk, PLCγ, and LAT) and in a decrease in degranulation and leukotriene synthesis.

CONCLUSION

Our data prove the existence of common mechanisms of action of OmAb in mast cells and basophils that would explain its effectiveness and rapid effect in chronic urticaria and provide a basis for its use in other diseases mediated by these cells.

Mechanisms of Anaphylaxis Beyond IgE

Anaphylaxis is an acute, life-threatening, multisystem syndrome resulting from the sudden release of mediators derived from mast cells and basophils. Food allergens are the main triggers of anaphylaxis, accounting for 33%-56% of all cases and up to 81% of cases of anaphylaxis in children. Human anaphylaxis is generally thought to be mediated by IgE, with mast cells and basophils as key players, although alternative mechanisms have been proposed. Neutrophils and macrophages have also been implicated in anaphylactic reactions, as have IgG-dependent, complement, and contact system activation. Not all allergic reactions are anaphylactic, and the presence of the so-called accompanying factors (cofactors or augmenting factors) may explain why some conditions lead to anaphylaxis, while in other cases the allergen elicits a milder reaction or is even tolerated. In the presence of these factors, allergic reactions may be induced at lower doses of allergen or become more severe. Cofactors are reported to be relevant in up to 30% of anaphylactic episodes. Nonsteroidal anti-inflammatory drugs and exercise are the best-documented cofactors, although estrogens, angiotensin-converting enzyme inhibitors, β-blockers, lipid-lowering drugs, and alcohol have also been involved. The mechanisms underlying anaphylaxis are complex and involve several interrelated pathways. Some of these pathways may be key to the development of anaphylaxis, while others may only modulate the severity of the reaction. An understanding of predisposing and augmenting factors could lead to the development of new prophylactic and therapeutic approaches.

Is Microarray Analysis Really Useful and Sufficient to Diagnose Nut Allergy in the Mediterranean Area?

BACKGROUND

Component-based diagnosis on multiplex platforms is widely used in food allergy but its clinical performance has not been evaluated in nut allergy.

OBJECTIVE

To assess the diagnostic performance of a commercial protein microarray in the determination of specific IgE (sIgE) in peanut, hazelnut, and walnut allergy.

METHODS

sIgE was measured in 36 peanut-allergic, 36 hazelnut-allergic, and 44 walnut-allergic patients by ISAC 112, and subsequently, sIgE against available components was determined by ImmunoCAP in patients with negative ISAC results. ImmunoCAP was also used to measure sIgE to Ara h 9, Cora 8, and Jug r 3 in a subgroup of lipid transfer protein (LTP)-sensitized nut-allergic patients (positive skin prick test to LTP-enriched extract). sIgE levels by ImmunoCAP were compared with ISAC ranges.

RESULTS

Most peanut-, hazelnut-, and walnut-allergic patients were sensitized to the corresponding nut LTP (Ara h 9, 66.7%; Cor a 8, 80.5%; Jug r 3, 84% respectively). However, ISAC did not detect sIgE in 33.3% of peanut-allergic patients, 13.9% of hazelnut-allergic patients, or 13.6% of walnut-allergic patients. sIgE determination by ImmunoCAP detected sensitization to Ara h 9, Cor a 8, and Jug r 3 in, respectively, 61.5% of peanut-allergic patients, 60% of hazelnut-allergic patients, and 88.3% of walnut-allergic patients with negative ISAC results. In the subgroup of peach LTP-sensitized patients, Ara h 9 sIgE was detected in more cases by ImmunoCAP than by ISAC (94.4% vs 72.2%, P < .05). Similar rates of Cora 8 and Jug r 3 sensitization were detected by both techniques.

CONCLUSIONS

The diagnostic performance of ISAC was adequate for hazelnut and walnut allergy but not for peanut allergy. sIgE sensitivity against Ara h 9 in ISAC needs to be improved.

Management of urticaria: not too complicated, not too simple

In spite of being an old disease and apparently easy to diagnose, chronic spontaneous urticaria (CSU) is still perceived as an uncontrollable and difficult to manage disease. The perception of the patient is that his/her condition is not well understood and that is suffering from a disorder with hidden causes that doctors are not able to tackle. Sometimes patients go through a number of clinicians until they found some CSU expert who is familiar with the disease. It is surprising that myths and believes with no scientific support still persist. Guidelines are not widely implemented, and recent tools to assess severity are infrequently used. European and American recent guidelines do not agree in several key points related to diagnosis and treatment, which further contributes to confusion. With the aim to clarify some aspects of the CSU picture, a group of allergists and dermatologists from the Spanish Dermatology and Allergy societies developed a Frequent Asked Questions leaflet that could facilitate physicians work in daily practice and contribute to a better knowledge of common clinical scenarios related to patients with CSU.

Specialist-based treatment reduces the severity of allergic rhinitis

BACKGROUND

Although the treatment of allergic rhinitis (AR) is now well established, its impact on severity has not yet been evaluated.

OBJECTIVE

The aim was to analyse specialist-based treatment on AR severity, nasal symptoms and quality of life.

METHODS

A longitudinal observational, prospective, multi-centre study with 4 weeks of follow-up was carried out by 141 allergologists and ENT specialists in Spain. Selection criteria were adult patients with AR, clinically diagnosed at least 2 years before, with a total nasal symptom score (TNSS) ≥5, not receiving either antihistamines within the previous week or nasal corticosteroids during the 2 previous weeks. Disease severity using both original Allergic Rhinitis and its Impact on Asthma (o-ARIA) and modified (m-ARIA) classifications, nasal symptoms, and Quality of Life (ESPRINT-15), were measured at baseline and after 4 weeks of treatment.

RESULTS

Among the recruited AR patients (n = 707, 58% women), 39.3% were intermittent and 60.7% persistent, 40.2% had asthma and 61.4% conjunctivitis. Most patients were treated with second generation antihistamines in monotherapy (63.2%) or in combination with intranasal corticosteroids (31.5%). While using o-ARIA, 96.9% of patients had 'moderate/severe' AR, the m-ARIA discriminated between 'moderate' (55.4%) and severe (41.5%) AR, at baseline. After 4 weeks of treatment, improvement was found on disease severity (P < 0.0001), TNSS (8.2 ± 1.8 vs. 3.5 ± 2.3, P < 0.0001) and Quality of Life (ESPRINT-15 global score: 3.0 ± 1.2 vs. 1.1 ± 1.0, P < 0.0001).

CONCLUSIONS

Specialist-based treatment reduces AR severity, evaluated using the m-ARIA classification for the first time, in addition to the improvement of nasal symptoms and quality of life.

CLINICAL RELEVANCE

Specialist-based treatment improves AR severity, in addition to nasal symptoms and quality of life. However, no matter the treatment option some AR patients remain severe and need further follow-up.

The allergenic structure of the thaumatin-like protein Ole e 13 is degraded by processing of raw olive fruits

BACKGROUND

The thaumatin-like protein (TLP) Ole e 13 in raw olive fruit is responsible for occupational allergy in olive oil mill workers. However, these workers do not experience allergic symptoms after ingestion of edible olive.

OBJECTIVES

To analyze the presence of IgE-reactive TLP in raw and edible olive fruit and to assess the allergenic potency of both sources.

METHODS

The content of TLP in raw and edible olive fruit protein extracts was analyzed using immunoblotting with sera from allergic patients and with olive TLP-specific IgG. The structural and immunological stability of TLP were assayed using immunoblotting after treatment of both raw olive and purified TLP with 0.25 M NaOH solution for 24 hours. Olive pollen extract was investigated by immunoblotting for TLP content.

RESULTS

The TLP contained in raw olive fruit was not present in edible olives as a result of maceration before human consumption. No TLP was detected in olive pollen using specific IgG or sera from patients allergic to olive fruit. Sera from patients allergic to olive pollen did not react with purified TLP.

CONCLUSIONS

IgE-reactive TLP is not present in edible olive, thus explaining the low number of patients allergic to this highly consumed fruit. Patients allergic to olive pollen are not sensitized toTLP and, therefore, not expected to be at risk of food allergy to olive fruit or TLP plant sources.

Assessment of severity and quality of life in chronic urticaria

Chronic urticaria (CU) is very prevalent in the general population and, despite its low mortality, can have devastating effects on the quality of life (QoL) of those who experience it.Therefore, consensus documents on its classification, diagnosis, and treatment have become a necessity. The intensity of urticaria is currently evaluated using indices such as the Urticaria Activity Score and visual analog scales to assess itch or the degree of itch associated with the use of antihistamines. QoL is evaluated using various generic questionnaires and specific tools for skin disease and for CU. In recent years, attempts have been made to combine these evaluations to create a specific tool that would enable us to simultaneously evaluate the severity of the condition and the impact of symptoms on QoL. One such tool is the Urticaria Severity Score, which also allows us to compare global changes brought about by different treatments.

Assessment of nasal obstruction: correlation between subjective and objective techniques

BACKGROUND

Nasal sensation of airflow describes the perception of the passage of air through the nose. Nasal obstruction can be assessed using subjective techniques (symptom scores and visual analogue scales [VAS]) and objective techniques (anterior rhinomanometry [RMN], acoustic rhinometry [AR], and peak nasal inspiratory flow [PNIF]). Few studies have evaluated the correlation between these techniques.

OBJECTIVE

The primary objective of our study was to determine the degree of correlation between subjective and objective techniques to assess nasal obstruction.

MATERIALS AND METHODS

Nasal obstruction was assessed using a symptom score, VAS, RMN, AR (minimal cross-sectional area [MCSA] and volume), and PNIF in 184 volunteer physicians. Spearman's rho was recorded. Correlations were considered weak if r ≤ 0.4, moderate if 0.4 < r < 0.8, and strong if r > 0.8.

RESULTS

Mean (SD) age was 37.1 (6.9) years (range, 25-56 years); 61% were women. We found a strong correlation (r > 0.8; p = 0.001) between the different parameters of RMN and a moderate correlation between symptom score and VAS (r = 0.686; p = 0.001) and between MCSA and RMN (resistance) (r = 0.496; p = 0.001) and PNIF (r = 0.459; p = 0.001). The correlations were weak or non-significant for the remaining comparisons.

CONCLUSION

Nasal obstruction can be assessed using subjective and objective approaches. The correlations between objective techniques were moderate to strong. In addition, between subjective techniques we reported a moderate correlation. Finally, the correlations between the subjective and objective techniques were weak and absent. These findings suggest that each of the techniques assesses different aspects of nasal obstruction, thus making them complementary.

Lipid transfer protein syndrome: clinical pattern, cofactor effect and profile of molecular sensitization to plant-foods and pollens

BACKGROUND

Multiple plant-food sensitizations with a complex pattern of clinical manifestations are a common feature of lipid transfer protein (LTP)-allergic patients. Component-resolved diagnosis permits the diagnosis of the allergen sensitization profile.

OBJECTIVE

We sought to clinically characterize and describe the plant-food and pollen molecular sensitization profile in patients with LTP syndrome.

METHODS

Forty-five subjects were recruited, after being diagnosed with multiple plant-food allergies sensitized to LTP, but not to any other plant-food allergen, according to the molecular allergen panel tested (Pru p 3 (LTP), Pru p 1 (Bet v 1-like), Pru p 4 (profilin) and those included in a commercial microarray of 103 allergenic components). IgE-mediated food-allergy symptoms and pollinosis were collected. Patients were skin prick tested with a plant-food and pollens panel, and specific IgE to Tri a 14 was evaluated.

RESULTS

A heterogeneous group of plant-foods was involved in local and systemic symptoms: oral allergy syndrome (75.6%), urticaria (66.7%), gastrointestinal disorders (55.6%) and anaphylaxis (75.6%), 32.4% of which were cofactor dependent (Non-Steroidal Anti-inflammatory Drugs, exercise). All tested subjects were positive to peach and Pru p 3, Tri a 14 and to some of the LTPs included in the microarray. Pollinosis was diagnosed in 75.6% of subjects, with a broad spectrum of pollen and pollen-allergen sensitization. Plane tree and mugwort were the statistically significant pollens associated with Pru p 3.

CONCLUSIONS AND CLINICAL RELEVANCE

Several plant-foods, taxonomically unrelated, independent of peach involvement, are implicated in LTP syndrome. Local symptoms should be evaluated as a risk marker for anaphylaxis because they are frequently associated with cofactor-dependent anaphylaxis. The association of these symptoms with pollinosis, especially plane tree pollinosis, could be part of this syndrome in our area.

Use of second generation H1 antihistamines in special situations

Antihistamine drugs are one of the therapeutic classes most used at world level, at all ages and in multiple situations. Although in general they have a good safety profile, only the more recent drugs (second generation antihistamines) have been studied specifically with regard to the more important safety aspects. Given the variety of antihistamine drugs, they cannot all be considered equivalent in application to various special clinical situations, so that the documented clinical experience must be assessed in each case or, in the absence of such, the particular pharmacological characteristics of each molecule for the purpose of recommendation in these special situations. In general, there are few clinical studies published for groups of patients with kidney or liver failure, with concomitant multiple pathologies (such as cardiac pathology), in extremes of age (paediatrics or geriatrics) and in natural stages such as pregnancy or lactation, but these are normal situations and it is more and more frequent (among the elderly) for antihistamine drugs to be recommended. This review sets out the more relevant details compiled on the use of antihistamines in these special situations.

Antihistamines in drivers, aircrew and occupations of risk

The most commonly occurring allergic diseases can involve a daytime drowsiness associated with the condition itself. The antihistamines used in their treatment can also have central effects and affect certain occupations concerned with risk, road safety and maritime and air navigation. Cognitive tests, experimental studies and epidemiological data recommend avoiding 1st generation antihistamines for people who must drive regularly and/or professions concerned with safety. Although there are no comparative studies on real driving between 1st and 2nd generation antihistamines, in this type of patients there should be a preference for prescribing those with least possible central effect, especially those which are a good substrate for transmembrane transporter pumps such as P-glycoprotein and therefore have a low capacity for crossing the hematoencephalic barrier, thus allowing a broader window for therapy. In this sense, bilastine is a good P-glycoprotein substrate and shows good tolerance at CNS level, in both psychometric trials and real driving test protocols, even at double the dose recommended in the technical file.

H1 antihistamines and benzodiazepines. Pharmacological interactions and their impact on cerebral function

Antihistamines (AH) have been classified into first and second generation according to their pharmacokinetic properties, structural characteristics and adverse effects. The effects on the central nervous system (CNS) are determined basically by their capacity to cross the hematoencephalic barrier and attach to central H1 receptors. Benzodiazepines (BZD) are drugs with effects on the CNS following their union to the specific location of GABA receptors type A. At low doses, the BZD have sedative and anticonvulsive effects, and as the dose increases it leads to sedation, amnesia and finally unconsciousness. Various studies have been made on the possible interaction between the BZD and the AH H1 with special attention to their effect on the CNS. In some cases these were studies to assess the safety of this association and in others, the aim was different: to see if their joint administration gives a better therapeutic result in pathology related with anxiety syndrome or insomnia. In general it can be said that first generation AH interact with the BZD increasing the sedative effects of the latter. However, second generation AH do not increase these sedative effects, which makes them the chosen drugs to treat allergic rhinitis/rhino-conjunctivitis and urticaria in patients also receiving BZD.

Prevalence of asthma and severity of allergic rhinitis comparing 2 perennial allergens: house dust mites and Parietaria judaica pollen

BACKGROUND

Allergic rhinitis (AR) is an increasingly prevalent worldwide disease that has a considerable impact on quality of life and health care costs. Asthma and AR may be part of the same disease, with AR leading to an increased risk of asthma.

OBJECTIVES

To assess the prevalence of asthma in patients with AR due to house dust mites (HDMs) or Parietaria judaica and analyze the characteristics of asthma and AR in each group.

METHODS

Cross-sectional, multicenter study with recording of demographic and clinical characteristics. All patients had AR confirmed by symptoms and a positive skin prick test to HDMs or P judaica. They were classified according to the severity and frequency ofAR following the Allergic Rhinitis and its Impact on Asthma (ARIA) and modified ARIA criteria and according to the severity of asthma following the Global Initiative for Asthma criteria.

RESULTS

We studied 395 patients (226 in the HDM group and 169 in the Pjudaica group) with a mean (SD) age of 43 (15.3) years. Using the modified ARIA criteria, we detected more severe and persistent AR in the P judaica group than in the HDM group (44.5% vs 24.8%, P < .001). Nevertheless, there were no statistically significant differences between the groups in terms of the severity or prevalence (50% in HDM vs 47.9% in P judaica, P = .685) of asthma.

CONCLUSION

AR due to P judaica pollen, which behaves like a perennial allergen, is associated with the same prevalence of asthma and with more severe rhinitis than AR due to HDMs.

Validation of the modified allergic rhinitis and its impact on asthma (ARIA) severity classification in allergic rhinitis children: the PEDRIAL study

BACKGROUND

A modified allergic rhinitis and its impact on asthma (ARIA) (m-ARIA) criterion to classify the severity of allergic rhinitis (AR) has recently been validated in both treated and untreated adult patients; however, such information in children is lacking. The aim of this study was to validate this m-ARIA severity criterion, which allows for discrimination between moderate and severe AR, in a large pediatric patient sample population.

METHODS

The m-ARIA classification categorizes AR severity into mild (no affected items), moderate (1-3 affected items), and severe (all four affected items). We applied this modified criterion to untreated AR pediatric patients aged 6-12 years, through an observational, cross-sectional, and multicenter study. AR symptoms were assessed using the Total Four Symptom Score (T4SS), and the severity was evaluated by both ARIA severity items and visual analogue scale (VAS).

RESULTS

Allergic rhinitis pediatric patients (N = 1269) from 271 centers were included. Among them, 59.5% had intermittent and 40.5% persistent disease; 89.9% had moderate/severe AR using the original ARIA (o-ARIA) classification and 59.5% had moderate, while 30.5% had severe AR using the m-ARIA criterion. Using the m-ARIA, significantly higher T4SS and VAS scores were obtained when comparing severe with moderate AR.

CONCLUSIONS

The m-ARIA severity classification is a useful clinical tool to discriminate moderate from severe AR among untreated pediatric patients.

Acoustic rhinometry and aspirin nasal challenge in the diagnosis of aspirin-intolerant asthma: clinical finding and safety aspects

BACKGROUND

The safety and utility of nasal provocation tests with lysine-aspirin (L-ASA) in the diagnosis of aspirin-intolerant asthma (AIA) have previously been described in a short series of patients.

OBJECTIVES

To describe the clinical features and safety of an L-ASA challenge test in patients with AIA.

METHODS

We evaluated 72 patients (79% women), with a mean ± SD age of 47.9 ± 14.5 years. All patients were submitted to an L-ASA nasal provocation test (29 mg in each nostril) under acoustic rhinometry (AcR) control. Symptom score (0-3), visual analogical scale and nitric oxide determinations were performed at baseline and at 15, 30, 60 and 90 min. A decrease in nasal volume of at least 25% was considered a positive test. Nasal nitric oxide (nNO) and forced expiratory volume in 1 s were measured.

RESULTS

Nasal congestion and rhinorrhea represented 51 and 32%, respectively, of total symptoms. According to AcR data, the L-ASA challenge test was positive in 20% of patients at 15 min, an additional 36% were positive at 30 min, 18% at 60 min, and the remaining 26% at 90 min. nNO nasal values decreased but did not reach statistical significance. No pulmonary or systemic reactions were observed.

CONCLUSIONS

Symptoms of nasal congestion associated with the reduction in nasal volume measured by AcR are the most useful parameters for establishing the diagnosis of AIA using the L-ASA nasal challenge. The method is very well tolerated and can be safely used even in patients with severe asthma.

Nasal and bronchial inflammation after nasal allergen challenge: assessment using noninvasive methods

BACKGROUND

Links between the upper and lower airways have been demonstrated in recent years. However, few studies have evaluated inflammation using noninvasive methods.

METHODS

A nasal allergen challenge was performed with pollen outside the pollen season in 30 patients with allergic rhinitis due to pollen but no asthma. Clinical and inflammatory nasal and bronchial responses to nasal allergen challenge were evaluated using the nasal symptoms score (NSS), visual analog scale (VAS), nasal geometry (volume between 2 and 5 cm [Vol2-5]) by acoustic rhinometry, lung function by spirometry, nasal nitric oxide (nNO), and exhaled nitric oxide (eNO). Values were recorded at baseline, 15 minutes, and 2 and 24 hours after challenge. Nasal lavage and exhaled breath condensate (EBC) samples were collected at 2 and 24 hours to assess 8-isoprostane, cys-leukotrienes, eosinophil cationic protein (ECP), tryptase, granulocyte-macrophage colony-stimulating factor, and interleukin (IL) 5.

RESULTS

NSS and VAS increased significantly at 15 minutes and 2 and 24 hours after challenge. Vol2-5 decreased significantly at 15 minutes and 2 hours, while nNO decreased at 15 minutes. All inflammatory mediators except ECP increased significantly at 2 hours in nasal lavage samples, while ECP, 8-isoprostane, and cys-leukotrienes increased at 24 hours (P < .01). In EBC, 8-isoprostane and cys-leukotrienes increased at 2 and 24 hours (P < .01). No significant changes were found at any time in lung function or eNO.

CONCLUSION

Nasal allergen challenge induces clinical and inflammatory responses in the nose and bronchi that can be assessed using noninvasive methods such as nasal lavage, EBC, and nNO.

Effect of antihistamine up-dosing in chronic urticaria

Chronic urticaria has an important impact upon patient quality of life, and no treatment has yet been developed capable of effectively controlling the disease. The most recent guidelines recommend the use of non-sedating antihistamines at high doses as second-step therapy before resorting to other treatments. The present review examines the studies published to date on the use of H1 antihistamines at doses higher than those indicated as therapeutic doses in chronic urticaria. Most of the studies report no significant differences among the studied doses-only a tendency towards increased response on elevating the dose. There are no clinically well designed, randomized double-blind trials comparing efficacy between therapeutic doses and doses higher than those indicated in the corresponding Summary of Product Characteristics. Likewise, there are insufficient data to conduct a meta-analysis and thus classify the degree of evidence of the few available studies, which moreover present contradictory results. At present, the prescription of high-dose H1 antihistamines is based only on experts opinion. However, considering the high safety profile of these drugs, it would be a good option to evaluate their efficacy at high doses, before moving on to other therapeutic steps.