Michael S. Blaiss

Allergic Rhinitis and its Impact on Asthma (ARIA) 2008

J. Bousquet, N. Khaltaev, A. A. Cruz, J. Denburg, W. J. Fokkens, A. Togias, T. Zuberbier, C. E. Baena-Cagnani, G. W. Canonica, C. van Weel, I. Agache, N. A t-Khaled, C. Bachert, M. S. Blaiss, S. Bonini, L.-P. Boulet, P.-J. Bousquet, P. Camargos, K.-H. Carlsen, Y. Chen, A. Custovic, R. Dahl, P. Demoly, H. Douagui, S. R. Durham, R. Gerth van Wijk, O. Kalayci, M. A. Kaliner, Y.-Y. Kim, M. L. Kowalski, P. Kuna, L. T. T. Le, C. Lemiere, J. Li, R. F. Lockey, S. Mavale-Manuel , E. O. Meltzer, Y. Mohammad, J. Mullol, R. Naclerio, R. E. O Hehir, K. Ohta, S. Ouedraogo, S. Palkonen, N. Papadopoulos, G. Passalacqua, R. Pawankar, T. A. Popov, K. F. Rabe, J. Rosado-Pinto, G. K. Scadding, F. E. R. Simons, E. Toskala, E. Valovirta, P. van Cauwenberge, D.-Y. Wang, M. Wickman, B. P. Yawn, A. Yorgancioglu, O. M. Yusuf, H. Zar Review Group: I. Annesi-Maesano, E. D. Bateman, A. Ben Kheder, D. A. Boakye, J. Bouchard, P. Burney, W. W. Busse, M. Chan-Yeung, N. H. Chavannes, A. Chuchalin, W. K. Dolen, R. Emuzyte, L. Grouse, M. Humbert, C. Jackson, S. L. Johnston, P. K. Keith, J. P. Kemp, J.-M. Klossek, D. Larenas-Linnemann, B. Lipworth, J.-L. Malo, G. D. Marshall, C. Naspitz, K. Nekam, B. Niggemann, E. Nizankowska-Mogilnicka, Y. Okamoto, M. P. Orru, P. Potter, D. Price, S. W. Stoloff, O. Vandenplas, G. Viegi, D. Williams

Efficacy and safety of timothy grass allergy immunotherapy tablets in North American children and adolescents

BACKGROUND Allergy immunotherapy tablet (AIT) treatment might be a safe and convenient form of specific immunotherapy but it has not been investigated in North American children and adolescents. OBJECTIVE We sought to investigate the efficacy and safety of timothy grass AIT treatment in North American children/adolescents with grass pollen-induced allergic rhinoconjunctivitis (ARC) with or without asthma. METHODS Three hundred forty-five subjects (5-17 years old) were randomized to once-daily grass AIT treatment (2,800 bioequivalent allergen units, 75,000 standardized quality tablet, approximately 15 μg of Phl p 5) or placebo approximately 16 weeks before the 2009 grass pollen season (GPS). Treatment continued through the GPS. Daily symptoms and allergy rescue medication use were recorded. The primary end point was the total combined score (TCS) of the daily symptom score (DSS) and daily medication score (DMS) for the entire GPS. DSS, DMS, Rhinoconjunctivitis Quality of Life Questionnaire score, and Phl p 5-specific IgG4 and IgE-blocking factor levels were secondary end points. Safety was assessed through adverse events. RESULTS Eighty-nine percent of subjects were multisensitized. TCS, DSS, DMS, and Rhinoconjunctivitis Quality of Life Questionnaire score versus placebo improved 26% (P = .001), 25% (P = .005), 81% (P = .006), and 18% (P = .04). Phl p 5-specific IgG4 and IgE-blocking factor levels were significantly higher at the peak and end of the GPS (P < .001). Treatment was well tolerated. Adverse events were generally mild and transient. Although no investigator-assessed systemic allergic reactions were reported, 1 grass AIT-treated subject experienced an event indicating a systemic reaction (lip angioedema, dysphagia, and cough). CONCLUSIONS Use of once-daily timothy grass AIT treatment effectively treats timothy grass (cross-reactive with Festucoideae grasses) pollen-induced ARC in North American children 5 years and older. Given its convenient administration, lack of dose build-up requirement, safety profile, and efficacy, AIT treatment might become an important addition to the North American ARC treatment armamentarium.

Allergic rhinitis and impairment issues in schoolchildren: a consensus report

BACKGROUND Allergic rhinitis (AR) can have substantial negative impact on children. Most notably, it can impede learning during the school-age years. Other consequences include adverse behavioral and psychosocial effects, poor quality of life, and potential impact on serious comorbidities, such as asthma. CONSENSUS PANEL In February 2004, in a conference sponsored by Aventis Pharmaceuticals, a multidisciplinary group convened to review relevant clinical data for the purposes of developing consensus recommendations for the management of AR in children. The consensus panel consisted of academic, school health, and medical providers, who were identified based on previous work and publications. CONSENSUS FINDS The focus of discussions was to assess the degree of impact of AR in schoolchildren and, based on this information, to determine how to improve screening, diagnosis, prevention, and treatment, to help ensure quality of life and maximal school performance in this population. The group considered the most critical factor in successful management ot be communication and collaboration among parents, educators, and healthcare professionals. Knowledge of the common signs and symptoms of AR in children can help to ensure early diagnosis, appropriate intervention, and clinically favorable outcomes. Importantly, both uncontrolled symptoms of AR, as well as adverse effects from medications, can diminish cognitive function and learning. When choosing treatment for children with AR, consideration must be given to the side effects of medications. All first-generation and some second-generation antihistamines can be associated with adverse effects on cognitive function and learning, as a result of their sedative properties. Treatment with non-sedating second-generation antihistamine has been shown to improve learning potential and is an ideal choice for treatment in this population. CONCLUSION Existing data indicate that further studies using objective measures of impairment in children taking antihistamine medications should be conducted to evaluate the impact of disease and treatment.SUMMARY Background: Allergic rhinitis (AR) can have a substantial negative impact on children. Most notably, it can impede learning during the school-age years. Other consequences include adverse behavioral and psychosocial effects, poor quality of life, and potential impact on serious comorbidities, such as asthma. Consensus panel: In February 2004, in a conference sponsored by Aventis Pharmaceuticals, a multidisciplinary group convened to review relevant clinical data for the purposes of developing consensus recommendations for the management of AR in children. The consensus panel consisted of academic, school health, and medical providers, who were identified based on previous work and publications. Consensus findings: The focus of discussions was to assess the degree of impact of AR in schoolchildren and, based on this information, to determine how to improve screening, diagnosis, prevention, and treatment, to help ensure quality of life and maximal school performance in this population. The group considered the most critical factor in successful management to be communication and collaboration among parents, educators, and healthcare professionals. Knowledge of the common signs and symptoms of AR in children can help to ensure early diagnosis, appropriate intervention, and clinically favorable outcomes. Importantly, both uncontrolled symptoms of AR, as well as adverse effects from medications, can diminish cognitive function and learning. When choosing treatment for children with AR, consideration must be given to the side effects of medications. All first-generation and some second-generation antihistamines can be associated with adverse effects on cognitive function and learning, as a result of their sedative properties. Treatment with a non-sedating second-generation antihistamine has been shown to improve learning potential and is an ideal choice for treatment in this population. Conclusion: Existing data indicate that further studies using objective measures of impairment in children taking antihistamine medications should be conducted to evaluate the impact of disease and treatment.

Evaluating approved medications to treat allergic rhinitis in the United States: an evidence-based review of efficacy for nasal symptoms by class

OBJECTIVE To evaluate how well the medications currently approved in the United States for allergic rhinitis (AR) treat nasal symptoms when examined according to Food and Drug Administration-indicated uses and dosages. DATA SOURCES MEDLINE (1966 onward), EMBASE (1974 onward), and the Cochrane Library (2007) were systematically searched according to the following criteria defined at a roundtable meeting of the authors: randomized controlled trial, at least a 2-week duration, and approved indication and dosage in the United States. STUDY SELECTION Data from studies that met the inclusion criteria were extracted into evidence tables, which were reviewed twice by the full panel of authors. Individual panel members also were asked to comment on abstracts, articles, and summary tables based on their known expertise. The entire faculty approved the selection of studies included in this review. RESULTS Fifty-four randomized, placebo-controlled studies involving more than 14,000 adults and 1,580 children with AR met the criteria for review: 38 studies of seasonal allergic rhinitis (SAR; n = 11,980 adults and 946 children) and 12 studies of perennial allergic rhinitis (PAR; n = 3,800 adults and 366 children). The median percentage changes from baseline for total nasal symptom score for SAR were as follows: nasal antihistamines, -22.2%; oral antihistamines, -23.5%; intranasal steroids (INSs), -40.7%; and placebo, -15.0%. For PAR, the changes were as follows: oral antihistamines, -51.4%; INSs, -37.3%; and placebo, -24.8%. Data for mediator antagonists were limited. CONCLUSIONS The data, although limited, confirm that INSs produce the greatest improvements in nasal symptoms in patients with SAR. In addition, INSs are effective for PAR, but the data were of variable quality, and oral antihistamines may be equally effective for some patients. The reporting of published data should be standardized to permit better comparisons in future studies.

Unmet needs in asthma: Global Asthma Physician and Patient (GAPP) Survey: global adult findings

Background:  The Global Asthma Physician and Patient (GAPP) Survey is the first global quantitative survey designed to uncover asthma attitudes and treatment practices among separate groups of physicians and patients, with the goal of identifying barriers to optimal management.

Management of Rhinitis: Allergic and Non-Allergic

Rhinitis is a global problem and is defined as the presence of at least one of the following: congestion, rhinorrhea, sneezing, nasal itching, and nasal obstruction. The two major classifications are allergic and nonallergic rhinitis (NAR). Allergic rhinitis occurs when an allergen is the trigger for the nasal symptoms. NAR is when obstruction and rhinorrhea occurs in relation to nonallergic, noninfectious triggers such as change in the weather, exposure to caustic odors or cigarette smoke, barometric pressure differences, etc. There is a lack of concomitant allergic disease, determined by negative skin prick test for relevant allergens and/or negative allergen-specific antibody tests. Both are highly prevalent diseases that have a significant economic burden on society and negative impact on patient quality of life. Treatment of allergic rhinitis includes allergen avoidance, antihistamines (oral and intranasal), intranasal corticosteroids, intranasal cromones, leukotriene receptor antagonists, and immunotherapy. Occasional systemic corticosteroids and decongestants (oral and topical) are also used. NAR has 8 major subtypes which includes nonallergic rhinopathy (previously known as vasomotor rhinitis), nonallergic rhinitis with eosinophilia, atrophic rhinitis, senile rhinitis, gustatory rhinitis, drug-induced rhinitis, hormonal-induced rhinitis, and cerebral spinal fluid leak. The mainstay of treatment for NAR are intranasal corticosteroids. Topical antihistamines have also been found to be efficacious. Topical anticholinergics such as ipratropium bromide (0.03%) nasal spray are effective in treating rhinorrhea symptoms. Adjunct therapy includes decongestants and nasal saline. Investigational therapies in the treatment of NAR discussed include capsaicin, silver nitrate, and acupuncture.

Pediatric allergic rhinitis : Physical and mental complications

Allergic rhinitis (AR) affects up to 40% of children in the United States and its prevalence continues to increase. Most AR develops during the pediatric years and it is the most common chronic allergic disorder seen in children. It is important to note that AR is more than just sneezing and a nuisance for the children. There are numerous complications that can lead to significant problems both physically and mentally in the child who suffers with AR. Under physical complications, otitis media with effusion, recurrent and/or chronic sinusitis, asthma, and snoring impact children with AR. Sleep disturbances, poor school performance, and hyperactivity are all mental complications seen in many children related to their nasal allergies. It is important for the clinician to take AR in the child seriously to prevent or control complications that can have a detrimental effect on the child.

Selecting the Optimal Oral Antihistamine for Patients with Allergic Rhinitis

Allergic rhinitis (AR) is now recognised as a global health problem that affects 10–30% of adults and up to 40% of children. Each year, millions of patients seek treatment from their healthcare provider. However, the prevalence of AR maybe significantly underestimated because of misdiagnosis, under diagnosis and failure of patients to seek medical attention. In addition to the classical symptoms such as sneezing, nasal pruritus, congestion and rhinorrhoea, it is now recognised that AR has a significant impact on quality of life (QOL). This condition can lead to sleep disturbance as a result of nasal congestion, which leads to significant impairment in daily activities such as work and school. Traditionally, AR has been subdivided into seasonal AR (SAR) or perennial AR (PAR). SAR symptoms usually appear during a specific season in which aeroallergens are present in the outdoor air such as tree and grass pollen in the spring and summer and weed pollens in the autumn (fall); and PAR symptoms are present year-round and are triggered by dust mite, animal dander, indoor molds and cockroaches. Oral histamine H1-receptor antagonists (H1 antihistamines) are one of the most commonly prescribed medications for the treatment of AR. There are several oral H1 antihistamines available and it is important to know the pharmacology, such as administration interval, onset of action, metabolism and conditions that require administration adjustments. When prescribing oral H1 antihistamines, the healthcare provider must take into account the clinical efficacy and weigh this against the risk of adverse effects from the agent. In addition to the clinical efficacy, potential for improvement in QOL with a particular treatment should also be considered.

Efficacy and safety of the SQ-standardized grass allergy immunotherapy tablet in mono- and polysensitized subjects.

The efficacy of single‐allergen‐specific immunotherapy in polysensitized subjects is a matter of debate. We therefore performed a post hoc analysis of pooled data from six randomized, double‐blind, placebo‐controlled trials (N = 1871) comparing the efficacy and safety of the SQ‐standardized grass allergy immunotherapy tablet (AIT), Grazax (Phleum pratense 75 000 SQ‐T/2800 BAU, ALK, Denmark), in mono‐ and polysensitized subjects. A statistically significant reduction in the mean total combined symptom/medication score (TCS) of 27% was demonstrated in actively treated subjects compared with placebo (P < 0.0001). This was not dependent on sensitization status (P = 0.5772), suggesting a similar treatment effect in mono‐ and polysensitized subjects (i.e. reductions of the TCSs of 28% and 26%, respectively, both P < 0.0001). Finally, a comparable and favourable safety profile of grass AIT was demonstrated in the two subgroups. Thus, no difference in efficacy and safety of single‐allergen grass AIT was observed between mono‐ and polysensitized subjects.

Management of rhinitis and asthma in pregnancy

OBJECTIVES To objectively critique recent available data on the proper management of allergy and asthma during pregnancy, with an emphasis on understanding the risk and benefit of medications used during pregnancy for these disorders. DATA SOURCES Data for this article were obtained from a MEDLINE search of literature from 1975 until the present published in English. STUDY SELECTION It was the expert opinion of the author to select and synthesize recently published articles and reviews on this broad subject. RESULTS Asthma is estimated to affect up to 4% of pregnancies, whereas rhinitis complicates up to 20%. The cornerstones of management are environmental avoidance procedures, pharmacologic treatment, and allergen immunotherapy. Pharmaceutical treatment for allergic rhinitis should start with the first-generation antihistamines, chlorpheniramine and tripelennamine. In pregnant women, who cannot tolerate first-generation antihistamines, use of a second-generation agent, either loratadine or cetirizine, should be considered. Though data are lacking, intranasal corticosteroids appear to be safe during pregnancy. For pregnant women with persistent asthma, the use of inhaled cromolyn should be the first-line therapy, followed by inhaled budesonide if symptoms worsen. Other agents such as salmeterol, leukotriene modifiers, and newer inhaled corticosteroids may be considered in women who exhibited a good response to these agents before pregnancy. Immunotherapy is the only disease-modifying treatment for allergic rhinitis and asthma. It can be continued during pregnancy. CONCLUSIONS Understanding the important differences in treatment for the pregnant patient is vital for all physicians caring for these patients. Proper medical management needs to take into consideration possible adverse effects of different agents used in asthma and rhinitis.