Amber N. Pepper

Benralizumab for the treatment of asthma

ABSTRACT Introduction: The classification of asthma into phenotypes and endotoypes allows for the use of targeted therapies, including three biologics which target interleukin 5 (IL-5) signaling in eosinophilic asthma. Areas covered: As of December 2016, two monoclonal antibodies, mepolizumab and reslizumab, are approved by U.S. Food and Drug Administration and one, benralizumab, is in clinical development. Two phase 3 trials for benralizumab, SIROCCO and CALIMA, were published in September 2016. Although there are no direct comparisons among these three anti-IL-5 therapies, the goal of this review is to summarize the current data and discuss their potential similarities and differences, with a focus on benralizumab. Expert commentary: Compared to mepolizumab and reslizumab, the possible advantages of benralizumab are less frequent dosing and a potential to reduce exacerbations irrespective of the blood eosinophil count. Some improvements in asthma symptom scores and quality of life occur with all three biologics, but the clinical meaningfulness of these improvements is less clear. A more defined reference range for eosinophil levels is necessary to determine which subjects will best benefit from these medications. Until quality randomized controlled trials directly compare the three, choosing among them for the treatment of eosinophilic asthma remains difficult.

The High Cost of Epinephrine Autoinjectors and Possible Alternatives

Epinephrine autoinjectors provide potentially life-saving therapy for pediatric and adult subjects with systemic allergic reactions, including anaphylaxis. However, the cost of these devices, specifically the EpiPen (Mylan, Canonsburg, Pa), is increasing exponentially. Epinephrine autoinjectors are commonly prescribed in the United States but are not readily available worldwide. Alternatives for the self-administration of epinephrine exist and should be considered for patients who cannot afford or do not have access to these devices. The epinephrine prefilled syringe, stored in an eyeglass or pencil case, is a safe and viable option for the self-administration of epinephrine. Epinephrine prefilled syringes may not be as ideal as using autoinjectors but are superior to patients living without access to this medication.

Individualized Treatment of Allergic Rhinitis According to Nasal Cytology

Purpose Nasal cytology is important in the diagnosis and treatment of nasal inflammatory diseases. Treatment of allergic rhinitis (AR) according to nasal cytology has not been fully studied. We plan to explore the individualized treatment of AR according to nasal cytology. Methods Nasal cytology from 468 AR patients was examined for inflammatory cell quantity (grade 0-5) and the percentage of neutrophils and eosinophils. Results were subdivided into the following categories: AR(Eos), eosinophil ≥50% of the whole inflammatory cells; AR(Neu), neutrophils ≥90%; AR(Eos/Neu), 10%≤ eosinophil <50%; AR(Low), grade 0/1 inflammatory cell quantity. Nasal cytology-guided treatment was implemented: all AR(Eos) patients (n=22) and half of the AR(Neu) patients (AR[Neu1], n=22) were treated with mometasone furoate spray and oral loratadine. Another half of the AR(Neu) patients (AR[Neu2], n=22) were treated with oral clarithromycin. Visual analog scale (VAS), symptom scores, and nasal cytology were evaluated 2 weeks before and after treatment. Results There were 224/468 (47.86%) AR(Eos), 67/468 (14.32%) AR(Neu), 112/468 (23.93%) AR(Eos/Neu), and 65/468 (13.89%) AR(Low) of the AR patients studied. There were no significant differences in clinical characteristics among these subgroups, except that the nasal blockage score was higher in AR(Eos) patients than in AR(Neu) patients (1.99 vs 1.50, P=0.02). Comparing AR(Eos) patients with AR(Neu1) patients 2 weeks after treatment, nasal symptoms and VAS were significantly lower in AR(Eos) patients, except for nasal blockage symptoms (P<0.05 of nasal itching and sneezing; P<0.01 for nasal secretion, total scores, and VAS). Comparing AR(Neu1) with AR(Neu2) patients, nasal symptoms, and VAS were significantly lower in AR(Neu2), except for nasal blockage and nasal itching symptoms (P<0.05 for nasal secretions, sneezing, total score, and VAS). Conclusions Nasal cytology may have important value in subtyping AR and optimizing AR treatment. Treating neutrophils is very important in AR patients with locally predominant neutrophils.

Debunking myths about “allergy” to radiocontrast media in an academic institution

Abstract Purpose: Patients with “allergy” to iodine and shellfish often do not obtain necessary radiologic procedures due to anxiety about potential radiocontrast media reactions. This study assesses the impact of an educational intervention to dispel these myths. Methods: The authors surveyed 252 internal medicine, emergency medicine, pediatrics, radiology, obstetrics/gynecology, and surgery health professionals before and after an educational intervention. Pre- and posttest responses were analyzed to assess the impact of the intervention on beliefs about radiocontrast media reactions and their perceived relationship to shellfish allergy and iodine “allergy.” Results: The mean pre- and posttest correct response scores were 41% and 91%, respectively. The intervention had a greater impact on respondents’ knowledge about iodine allergy than shellfish allergy, most likely due to the difference in baseline knowledge (P < 0.005). Emergency medicine garnered the highest pretest correct response score (54%). Internal medicine earned the lowest pretest score (30%). There was a significant difference between the highest and lowest scoring specialties on the pretest (P = 0.037). There was no statistically significant correlation with training levels. There was a considerable decrease in the percentage of respondents who would withhold radiologic studies from patients suspected of shellfish or iodine allergy. The percentage of respondents who would premedicate patients with antihistamines or steroids also decreased significantly. Conclusion: An educational intervention helps rectify misconceptions among health care professionals about radiocontrast media reactions and their perceived relationship to shellfish or iodine allergy.

Nasal and ocular challenges

&NA; Nasal and ocular challenges facilitate the evaluation of subjective and objective responses to defined allergen or irritant exposure. Nasal and ocular allergen challenges are the gold standard to diagnose allergic rhinitis and conjunctivitis, respectively, and aid in the evaluation of novel therapies in clinical trials. Additionally, nasal and ocular allergen challenges might help identify medically relevant allergens in clinical practice. Nonspecific or irritant challenges evaluate mucosal hyperreactivity. Direct mucosal challenges, which can be performed in an office or research setting, expose the participant to higher allergen doses than common in the natural environment. Park studies and environmental chambers, which are most practical in clinical trials, more closely simulate natural allergen exposure. International consensus guidelines for nasal and ocular challenges do not exist. Therefore the positivity criteria, methodologies, and extract or allergen preparations used in challenges vary in the literature. Regardless of these limitations, nasal and ocular challenges are helpful clinical and research tools for nasal and ocular diseases.

Allergic Rhinitis: Diagnosis and Treatment

Rhinitis is a syndrome defined by the symptoms of nasal congestion, postnasal drip, rhinorrhea, sneezing, and nasal itching, usually with physical findings of turbinate edema and increased secretions. The term implies inflammation as an essential component of the pathophysiology, but inflammation may not always be evident or confirmed in the pathophysiology of all rhinitis syndromes. Nevertheless, rhinitis, rather than rhinopathy or another term, is generally used to describe the constellation of symptoms listed. Classification of severity is generally based on symptom intensity and duration rather than physical examination or laboratory findings. Rhinitis may be subdivided into more than nine groups based on probable etiology or associations. These include allergic, idiopathic perennial nonallergic (sometimes referred to as vasomotor rhinitis), infectious, medication related (rhinitis medicamentosa), hormonal, atrophic, polypoid or hyperplastic, and rhinitis associated with systemic diseases. Some authorities divide nonallergic rhinitis into subgroups based on triggers (e.g., weather, odor, alcohol ingestion, or irritants among others), but the symptoms and physical findings of these rhinitis subgroups tend to be more alike than dissimilar, prompting others to classify all into one category, perennial nonallergic rhinitis (PNAR). Occupational rhinitis is a classification sometimes used, referring to irritant, nonallergic rhinitis or allergic rhinitis related to work environments. This chapter focuses on allergic rhinitis and includes the differential diagnosis of other rhinitis syndromes (Table 6.1)

Asthma and chronic obstructive pulmonary disease inhalers: Techniques for proper use.

BACKGROUND Asthma and chronic obstructive pulmonary disease (COPD) affect millions of Americans. Inhalers are necessary to manage these diseases, but physicians and patients often struggle to use them correctly. OBJECTIVE To simplify inhaler use for patients and physicians. METHODS This article compares the various inhalers used to treat asthma and COPD, their techniques for use, and the steps necessary to prime the inhaler if required. The authors provide a suggested standardized technique for the use of metered-dose inhalers, dry powder inhalers, and soft-mist inhalers to provide for a more universal approach for the use of these medications and summarizes how each product is to be used per the U.S. Food and Drug Administration approved package insert. RESULTS AND CONCLUSIONS The simplified techniques proposed in this article for the use of metered-dose inhalers, dry powder inhalers, and soft mist inhalers used to treat asthma and COPD may limit inhaler misuse and aid in proper medication delivery and treatment.

Economic considerations in the treatment of systemic allergic reactions

Epinephrine is a life-saving medication used to treat systemic allergic reactions including anaphylaxis. Epinephrine autoinjectors (EAIs) are expensive and worldwide availability is limited. Epinephrine prefilled syringes and epinephrine kits are potentially lower-cost alternatives to EAIs. Advantages, disadvantages, and costs of available products are discussed. The socioeconomic factors impacting access to EAIs are described.

Effects of Exposure to New Car Interiors in Patients With Asthma and Allergic Rhinitis

Rationale Vehicle interiors are an important microenvironment for atopic subjects. This study evaluated the subjective and objective physiologic and clinical effects of exposing subjects with asthma and allergic rhinitis to new 2017 Mercedes vehicles during 90-minute rides. Methods Ten adult asthmatics with allergic rhinitis were assessed before and 45 and 90 minutes into rides in a 2017 Mercedes-Benz S-Class sedan and GLE-Class SUV on 2 separate days. Assessments included spirometry, fractional exhaled nitric oxide, peak nasal inspiratory flow, asthma symptom scores, and physical examinations. Results Of the 10 subjects, 6 were women, mean age was 32 years, and 6 and 4 were using chronic asthma controllers or intranasal corticosteroids, respectively. None of the subjects had worsening of asthma or rhinitis symptoms during the rides. There were no statistically significant changes from baseline in forced expiratory volume in 1 second, forced expiratory volume in 1 second:forced vital capacity ratio, forced expiratory flow at 25%–75% of vital capacity, fractional exhaled nitric oxide, or peak nasal inspiratory flow at 45 or 90 minutes into the rides with either Mercedes vehicle (all P values > .1 using generalized linear mixed model). Conclusion The interior environment of the tested Mercedes vehicles did not cause changes in subjective or objective measures of asthma and allergic rhinitis. We suggest that this model system can be used to test other vehicles for putatively adverse effects on patients with allergic respiratory disorders.