Nermina Arifhodzic

Compliance with allergen immunotherapy and factors affecting compliance among patients with respiratory allergies

ABSTRACT Background: Allergen-specific immunotherapy (AIT) is safe and effective for the treatment of allergic rhinitis and allergic asthma. However, patient non-compliance is a major barrier to achieving optimal outcomes Objective: To determine the level of compliance among patients using AIT and to identify factors associated with non-compliance Methods: A retrospective analysis using questionnaires was conducted to study compliance among 236 patients with allergic rhinitis with or without asthma who began AIT in 2009 or 2010 Results: The compliance rates at 3 y were 58.7% among patients on subcutaneous immunotherapy (SCIT) and 11.6% among those on sublingual immunotherapy (SLIT). The mean durations of treatment with SCIT and SLIT were 31 (+/−18.3) and 15.9 (+/−14.7) months, respectively. The most common causes of non-compliance among patients on SCIT were the frequency of injections (82.2%), the duration of treatment (70.9%), and commuting to the Allergy Center (67.7%). Reasons for non-compliance among patients on SLIT were related to inconvenience (43.4%), improvement without treatment (30.2%) and perception of poor efficacy (25.0%) Conclusion: Compliance with AIT is low, but at 3 years, it was higher among patients on SCIT than among patients on SLIT. Reasons for non-compliance include difficulty adjusting to treatment protocols and a perception that the efficacy is low. Patient education regarding the treatment course and the slow effect, as well as the need for close follow up to effectively prevent and treat adverse reactions, are important factors for improving compliance and treatment outcomes.

Penicillin allergy evaluation: experience from a drug allergy clinic in an Arabian Gulf Country, Kuwait.

Background Hypersensitivity to penicillin has been studied worldwide, but data regarding patterns of sensitization in Arabian Gulf countries are scarce. Objective To describe the patterns of penicillin hypersensitivity during a 6-year study in Kuwait in terms of demographics, type of the culprit drug, in vivo and in vitro allergy testing. Methods One hundred and twenty-four patients referred to the drug allergy clinic for penicillin allergy were fully evaluated by skin prick and intradermal testing. Drug provocation test was done on patients with negative results. Results A total of 124 patients were evaluated for penicillin allergy. Mean age was 37.8 (standard deviation, 12.7) years, range from 8 to 74 years. Thirty-nine male (31.5%) and 85 female patients (68.5%) were included. Diagnosis of penicillin allergy was confirmed in 46 patients (37.1%). Among the 44 confirmed allergic patients by skin evaluation we had 15 (34.1%) positive skin prick test, and 29 (65.9%) positive intradermal testing. Among patients with positive skin testing, 47.7% were positive to major determinant benzylpenicilloyl poly-L-lysine, 20.4% to minor determinant mixture, 50.0% to penicillin G and 40.9% to ampicillin; 13.6% of patients were positive to amoxicillin by skin prick test. One patient had a positive radioallergosorbent test and one had a positive challenge test. Conclusion Penicillin allergy is a common problem with an incidence of about one third in our study subjects.

Environmental allergens in Kuwait.

IgE: 243.7u62.2, P.0.05), selected specific IgE levels, and skin test responses to aeroallergens (data not shown). The polymorphisms were strongly associated with one another. TGF-beta 1 is a cytokine that is constitutively expressed in the healthy airways but that also mediates a complex mix of proand anti-inflammatory activities. In contrast to some previous studies which found associations of polymorphisms in the TGF-beta 1 gene with atopic diseases or related phenotypes (3, 6), we found no association of five selected polymorphisms in this gene with clinically manifested atopic asthma or other allergies. None of the polymorphisms were associated with total serum IgE, selected specific IgE, pulmonary function tests, and other phenotypic markers of atopic predisposition. Therefore, our results do not confirm previously published data on the association of the TGF-beta 1 – 509 C/T polymorphism with increased serum total IgE levels (3). In conclusion, our results indicate that the mentioned polymorphisms of the TGF-beta 1 gene do not influence susceptibility to atopic diseases and related phenotypes, at least in the Czech population.

THE ROLE OF TARGET ORGAN DIAGNOSTIC APPROACH IN SEASONAL ALLERGIC RHINITIS: NASAL SMEAR EOSINOPHILS

Background: Allergic rhinitis (AR) related to local weeds pollen sensitization (Chenopodiaceous family) is the most common cause of respiratory allergy in Kuwait. Local nasal accumulation of different cells typical of allergic inflammation is responsible for clinical symptoms of AR. Although nasal smear for Eosinophils (NSE) is one of the earliest included valuable test in diagnosis of AR, with time is underestimated. Aim: Explore possible correlation of natural pollen allergen stimulation with appearance and quantity of Eosinophils in nasal smear. Methods: A group of randomly selected patients with clinical history suggestive for seasonal AR (SAR), who came to Al Rashed Allergy Center in period from October 2014 to October 2015, obtain Nasal Smear for Eosinophils as a screening test before further diagnostic evaluation. Nasal samples were collected by passing a sterile swab, from each nasal cavity, along the medial surface of the inferior turbinate 2 to 3 times and the specimen smeared on a clear glass slide. Nasal smears were examined by light microscopy after staining with hematoxylin and eosin stain. Skin prick test is performed in all symptomatic patients with a battery of inhalant allergens that include local pollens. The control group was recruited, with their voluntary consent, from the medical stuff with a negative history of any allergic nasal symptoms. In this group we performed only nasal smear for Eosinophils. Air Biology Laboratory Kuwait provided us with daily pollen count. Results: From total 158 study participants, 132 had SAR symptoms and are divided in four groups. Fifth, control, group is non symptomatic. For 38.6% of symptomatic patients NSE were positive, while 45% of these patients have negative SPT. From 62.1% NSE negative patients, 37.8% have negative SPT. Our results showed expected positive correlation of NSE positive patients with pollen season in Kuwait, in SPT positive group. However, presence of Eosinophils in nasal smear was moderate to high also in patients with negative SPT during the highest peak of season, in contrast to control group. Conclusion: NES showed moderate sensitivity, relatively high specificity and importance as screening test in SPT negative patients. Evaluation of AR demand wide and improved diagnostic approach due to significant number of SPT negative patients with positive NSE based on natural allergen stimulation. Our results emphasize locale allergic response of nasal mucosa and importance of target organ diagnostic approach.

Tolerability of Omalizumab in Asthma as a Major Compliance Factor: 10-Year Follow Up

BACKGROUND: There is a lack of data related to real life, long-term safety, tolerability and compliance of omalizumab treatment in asthma patients beyond 6 years. AIM: Study aimed to assess safety, tolerability, compliance and all reasons for treatment discontinuation during 10 years on omalizumab. SUBJECT AND METHODS: This is a retrospective, observational study of uncontrolled asthma patients receiving omalizumab for the last 10 years. All data were collected from patients’ files (demographics, adverse events, comorbidities, compliance index, reasons for discontinuation of omalizumab). Reactions to omalizumab were classified as local and systemic, and their severity as mild, moderate or severe. Reactions were either immediate (minutes to hours after drug administration) or delayed (after days). Compliance to omalizumab, defined as Compliance index (CI), was calculated by comparing milligrams of given to milligrams of prescribed dose/ per year. RESULTS: Out of 35 patients receiving omalizumab, 15 drop out at different time points mostly due to treatment efficacy or appearance of new comorbidities. Patients who continue for the next ten years had mild to moderate adverse events related to omalizumab. There was no increased risk of severe adverse events during 10 years on omalizumab. Patient’s treatment tolerability, despite mild to moderate adverse events, is in favour of compliance. CONCLUSION: Compliance with omalizumab mildly decreased over 10 years but was not affected by severe adverse events of treatment or new comorbidities. Although, omalizumab is safe medicine appearance of new comorbidities has to be closely followed up.

Real-life Efficacy and Safety Aspects of Four-year Omalizumab Treatment for Asthma

Objective: To evaluate the long-term efficacy and safety of omalizumab in asthma in a real-life setting. Subjects and Methods: This 4-year observational study included 65 patients treated with omalizumab during clinic visits; treatment response was rated as excellent, good, and partial based on a modified physician’s Global Evaluation of Treatment Effectiveness (mGETE) scale of emergency room visits (ERV), hospitalization, use of oral corticosteroids, inhaled corticosteroid (ICS)/long-acting β-agonist (LABA) dose, and short-acting β-agonist rescue. The following tests were done: forced expiratory volume in 1 s (FEV1) and the asthma control test (ACT). Measurements were performed 1 month before therapy and at 16 weeks, 1 year, and 4 years of treatment. Statistical analyses were done using the Wilcoxon signed-rank test, Spearman rank correlation, and McNemar χ2 test. Results: The dropout rate was 15 (18.5%): 8 nonresponders (10.0%); 2 patients died (2.5%), and 5 were lost to follow-up (6.25%). Treatment response was excellent in 35 (53.8%); good in 23 (35.4%), and partial in 7 patients (10.8%). The number of excellent responders increased from 35 (53.8%) at 16 weeks to 48 (73.8%) at the 4-year follow-up. The number of patients who did not require ERV improved from 0 to 59 (90.8%), and the lowest rate of hospitalization was 1 in year 4 (p < 0.001); patients who did not require courses of oral corticosteroids improved from 0 to 54 (83%). ICS/LABA dose significantly reduced from 65 (100%) to 25 (38.5%) after 4 years of treatment (p < 0.001); ACT scores significantly increased from 15 ± 3 at baseline to 23 ± 3 (p < 0.001) and FEV1 level from 55.6 ± 10.6 to 76.63 ± 10.34 at year 4. Conclusion: In this study, omalizumab therapy resulted in better asthma control, and was effective and well tolerated as an add-on therapy for patients with moderate-to-severe asthma.

259 Penicillin Allergy Evaluation: Experience from a Drug Allergy Clinic in Kuwait

Background To evaluate a cohort of patients with a suspected beta-lactam allergy history. Methods 42 patients with suspected beta-lactam hypersensitivity reactions were evaluated at a drug allergy clinic at a tertially allergy center. Skin prick tests (SPT) with major determinants (PPL), minor determinants (MDM), penicillin G, ampicillin, amoxicillin, intradermal tests (ID) and specific IgE determination were done. If all tests were negative, a drug challenge was performed. Results 42 patients were enrolled (mean age 39 years, 71.4% female and 28.6% males). History of atopy was present in 59.5%. The offending antibiotics were amoxicillin and amoxicillin/clavulanic acid in 28 (66.6%), penicillin in 10 (23.8%), and ampicillin in 4 (9.5%). Specific IgE to penicillin was negative in almost all patients with history of penicillin allergy (41 patients, 97.6%). SPT and ID tests were positive in 11 patients (26.1%) as follows: 3 patients (7.1%) had positive SPT to PPL, 1 patient (2.4%) SPT to MDM, 2 patients (4.8%) SPT to Penicillin G, 1 patient (2.4%) SPT to Ampicillin, 1 patient (2.4%) SPT to Amoxicillin, 8 patients (19%) ID to PPL, 3 patients (7.1%) ID to Penicillin G, 3 patients (7.1%) ID to Ampicillin. Only 1 patient had both positive specific IgE and skin tests. The remaining 31 patients (73.8%) underwent a drug challenge with the culprit antibiotic with no reported reactions. Conclusions One fourth of patients with history of beta-lactam hypersensitivity reactions were confirmed after testing. A combination of skin testing, specific IgE and drug challenge is necessary since none has sufficient sensitivity to be used alone.