Ludger Klimek

Guideline for acute therapy and management of anaphylaxis

S2 Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Association of German Allergologists (AeDA), the Society of Pediatric Allergy and Environmental Medicine (GPA), the German Academy of Allergology and Environmental Medicine (DAAU), the German Professional Association of Pediatricians (BVKJ), the Austrian Society for Allergology and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), the German Society of Pharmacology (DGP), the German Society for Psychosomatic Medicine (DGPM), the German Working Group of Anaphylaxis Training and Education (AGATE) and the patient organization German Allergy and Asthma Association (DAAB)

Die spezifische Immuntherapie (Hyposensibilisierung) bei IgE-vermittelten allergischen Erkrankungen

The present guideline on allergen-specific immunotherapy (SIT) was established by the German allergy societies in conjunction with other scientific and medical societies (dermatology, ear-nose-throat, pediatrics, lung and airway diseases) and a patient support group according to criteria of the Association of the Scientific Medical Societies in Germany (AWMF). Subcutaneous immunotherapy (SCIT) is a unique causal treatment of IgE-mediated allergic diseases and induces longterm tolerance to the applied allergens due to numerous immunologic effects. Non-modified allergens are used as aqueous or physically coupled (depot) allergen extracts, chemically modified allergens (allergoids) are used as depot extracts for SCIT. Efficacy of SCIT has been demonstrated for pollen and house dust mite allergens in a large number of studies in patients with allergic rhinoconjunctivitis, and for animal dander (cat) and mold allergens (Alternaria, Cladosporium) in few studies. SCIT has been well-studied in intermittent and mild persisting IgE-mediated allergic asthma and is recommended as a therapeutic option besides allergen avoidance and pharmacotherapy. Preventive aspects, particularly reduced development of bronchial asthma and less novel allergic sensitizations, are increasingly considered during the decision for SCIT. In case of systemic reactions due to Hymenoptera (bee, wasp) venom allergy SCIT has excellent efficacy and should be continued for at least 3 - 5 years. An extended, sometimes lifelong SCIT, is necessary in a few patients. SCIT is indicated in patients with IgE-mediated sensitizations and corresponding clinical symptoms to allergens which do not permit allergen avoidance and which are available as suitable extracts. Diagnostic procedures, indication and selection of appropriate allergens for SCIT are made by a physician with certified training or qualified knowledge and skills in allergology. Contraindications have to be considered on an individual basis. Injections of SCIT are administered by a physician experienced in this therapy and who is able to perform emergency treatment in case of an allergic adverse event. Patients information and documentation are mandatory previous to the start of SCIT. Children tolerate SCIT very well and benefit especially from its immuno-modulatory effects. Systemic adverse reactions can occur due to SCIT, being rare in case of complete adherence to safety standards. Most adverse events are mild to moderate and easily treatable. Risk factors for and sequels of unwanted systemic effects can effectively be minimized by training the staff members involved, adhering to safety standards and immediate emergency treatment. Sublingual immunotherapy (SLIT) is an option for adults with allergic rhinoconjunctivitis due to pollen allergens, particularly if SCIT is not suitable. In house dust mite allergy and allergic asthma, SLIT does not substitute SCIT. Due to the present data, SLIT is not recommended for routine use in children and adolescents. A final conclusion on SLIT for children and adolescents is warranted if further study results are available. Various research fields like allergen characterization, routes of application, adjuvants, updosing regimen and preventive aspects demonstrate new developments in SIT being currently examined for clinical efficacy.

Pharmacological management of allergic rhinitis in the elderly : Safety issues with oral antihistamines

An increasing number of elderly persons in our society experience allergic rhinoconjunctivitis. Different agents are used in the pharmacological treatment of allergic rhinitis, with histamine H1 receptor antagonists (antihistamines) being the most frequently prescribed class. However, drug therapy of aged persons differs to a degree from that in other age groups primarily because of quantitative pharmacotherapeutic problems. The main problems are co-morbidities and polymedication, which may lead to drug-drug interactions.H1 receptor antagonists block the action of histamine at specific receptors and are available for both topical and systemic administration. First-generation H1 receptor antagonists are lipophilic and therefore may cross the blood-brain barrier; they also lack specificity for the H1 receptor. Second-generation H1 receptor antagonists have reduced capacity to cross the blood-brain barrier and greater specificity for the H1 receptor.Use of first-generation H1 receptor antagonists in the elderly should be considered carefully because of the large number of adverse effects and potential for interactions with these agents. Second-generation H1 receptor antagonists such as desloratadine, levocetirizine and ebastine provide good selective H1 receptor blockade without anticholinergic or α-adrenoceptor antagonist activity. Furthermore, they inhibit proinflammatory cytokines and are safe. Second-generation H1 receptor antagonists also offer therapeutic possibilities in patients with severe liver and/or renal dysfunction.

Effects of a structured educational intervention on knowledge and emergency management in patients at risk for anaphylaxis

Structured educational programmes for patients at risk for anaphylaxis have not yet been established. Patients and caregivers often lack adequate skills in managing the disease.

Depigmented–polymerized mixed grass/birch pollen extract immunotherapy is effective in polysensitized patients

Although many patients with allergic rhinoconjunctivitis have symptoms due to sensitization with more than one pollen allergen, and mixed pollen extracts are widely used for allergen immunotherapy in practice, there are few published trials.

Mites and other indoor allergens — from exposure to sensitization and treatment

House dust mites, cats and dogs are amongst the most frequent sources of indoor allergens in Europe. The fact that the allergens of house dust mites cause allergic disease through inhalation of house dust was discovered in 1964. The diagnosis of mite allergy is regularly complicated by its often nonspecific symptoms, which frequently develop insidiously and by no means always include attacks of paroxysmal sneezing and itching. Antibody-based immunological detection methods can be used to measure exposure to mite allergens. The structure and function of more than 20 allergens from Dermatophagoides pteronyssinus and D. farina are known. Other relevant indoor allergens come from mammals kept in households. Here again, allergens have been described and diagnostic as well as exposure-measurement tools are available. It is important to remember indoor pests and other „unwelcome lodgers“ as a possible cause in the case of unexplained symptoms experienced indoors. This short overview summarizes the current key points on the subject of „mites and other indoor allergens“. The present article provides an overview of several articles published in a special issue of the German journal Allergologie [February 2015; 38(2)] on the subject of „Mites and other indoor allergens“.

Immunological effects and tolerability of a new fast updosed immunologically enhanced subcutaneous immunotherapy formulation with optimized allergen/adjuvant ratio

Subcutaneous immunotherapy (SCIT) traditionally includes an updosing phase injecting increasing doses of allergen over a period of several weeks, followed by a maintenance phase. To establish shorter and more convenient updosing schedules, a fast updosed immunologically enhanced SCIT formulation has been developed by optimizing the allergen/adjuvant (aluminium hydroxide) ratio.

Die nasale Provokationstestung mit Allergenen

ZusammenfassungDer nasale Provoaktionstest ist ein standardisiertes Verfahren zum Nachweis der klinischen Relevanz einer allerigschen Rhinitis mit hoher Spezifität und Sensitivität. Zur Auswertung stehen neben subjektiven semiquantitativen Kriterien auch etablierte objektivierende Messverfahren zur Verfügung.

Anaphylaktische Reaktionen auf Lebensmittel nehmen zu

Nahrungsmittelallergien äußern sich mit einer großen Bandbreite von Symptomen, vom relativ harmlosen oralen Allergiesyndrom bis hin zur lebensbedrohlichen Anaphylaxie. In den letzten Jahren ist der Zahl der akuten, lebensbedrohlichen allergischen Reaktionen auf Nahrungsmittel angestiegen. Der Beitrag erläutert die verschiedenen Typen an Nahrungsmittelallergien, das diagnostische Vorgehen und die Therapie- bzw. Präventionsmöglichkeiten.

Situation frühzeitig erkennen

Der Begriff Anaphylaxie bezeichnet eine in der Regel IgE-vermittelte überschießende Reaktion des Immunsystems. Entscheidend für den Verlauf einer Anaphylaxie ist eine frühzeitige Behandlung, insbesondere bei Beteiligung des Herz-Kreislauf-Systems oder der unteren Atemwege. Aus diesem Grund ist die Kenntnis einer adäquaten Therapie für Nothelfer und Patienten essenziell.