Robert Puy

Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials

Abstract Objective: To determine whether intranasal corticosteroids are superior to oral H1 receptor antagonists (antihistamines) in the treatment of allergic rhinitis. Design: Meta-analysis of randomised controlled trials comparing intranasal corticosteroids with oral antihistamines. Setting: Randomised controlled trials conducted worldwide and published between 1966 and 1997. Subjects: 2267 subjects with allergic rhinitis in 16 randomised controlled trials. Main outcome measures: Nasal blockage, nasal discharge, sneezing, nasal itch, postnasal drip, nasal discomfort, total nasal symptoms, nasal resistance, and eye symptoms and global ratings. Outcomes measured on different scales were combined to determine pooled odds ratios (categorical outcomes) or standardised mean differences (continuous outcomes). Assessment of heterogeneity between studies, and subgroup analyses of eye symptoms, were undertaken. Results: Intranasal corticosteroids produced significantly greater relief than oral antihistamines of nasal blockage (standardised mean difference −0.63, 95% confidence interval −0.73 to −0.53), nasal discharge (−0.5, −0.6 to −0.4), sneezing (−0.49, −0.59 to −0.39), nasal itch (−0.38, −0.49 to −0.21), postnasal drip (−0.24, −0.42 to −0.06), and total nasal symptoms (−0.42, −0.53 to −0.32), and global ratings gave an odds ratio for deterioration of symptoms of 0.26 (0.08 to 0.8). There were no significant differences between treatments for nasal discomfort, nasal resistance, or eye symptoms. The effects on sneezing, total nasal symptoms, and eye symptoms were significantly heterogeneous between studies. Other combined outcomes were homogeneous between studies. Subgroup analysis of the outcome of eye symptoms suggested that the duration of assessment (averaged mean score over the study period versus mean score at end of study period) might have accounted for the heterogeneity. Conclusion: The results of this systematic review, together with data on safety and cost effectiveness, support the use of intranasal corticosteroids over oral antihistamines as first line treatment for allergic rhinitis.

Sub-Lingual Immunotherapy: World Allergy Organization Position Paper 2009

Chair: G. Walter Canonica Co-Chairs Jean Bousquet, Thomas Casale, Richard F. Lockey, Carlos E. Baena-Cagnani, Ruby Pawankar, Paul C. Potter Authors Philippe J. Bousquet, Linda S. Cox, Stephen R. Durham, Harold S. Nelson, Giovanni Passalacqua, Dermot P. Ryan, Jan L. Brozek, Enrico Compalati, Ronald Dahl, Luis Delgado, Roy Gerth van Wijk, Richard G. Gower, Dennis K. Ledford, Nelson Rosario Filho, Erkka J. Valovirta, Osman M. Yusuf, Torsten Zuberbier Co-Authors Wahiduzzaman Akhanda, Raul Castro Almarales, Ignacio Ansotegui, Floriano Bonifazi, Jan Ceuppens, Tomás Chivato, Darina Dimova, Diana Dumitrascu, Luigi Fontana, Constance H. Katelaris, Ranbir Kaulsay, Piotr Kuna, Désirée Larenas-Linnemann, Manolis Manoussakis, Kristof Nekam, Carlos Nunes, Robyn O’Hehir, José M. Olaguibel, Nerin Bahceciler Onder, Jung Won Park, Alfred Priftanji, Robert Puy, Luis Sarmiento, Glenis Scadding, Peter Schmid-Grendelmeier, Ester Seberova, Revaz Sepiashvili, Dírceu Solé, Alkis Togias, Carlo Tomino, Elina Toskala, Hugo Van Beever, Stefan Vieths

Sub-lingual immunotherapy: World allergy organization position paper 2009

Co-Authors: Wahiduzzaman Akhanda, Raul Castro Almarales, Ignacio Ansotegui, Floriano Bonifazi, Jan Ceuppens, Tomás Chivato, Darina Dimova, Diana Dumitrascu, Luigi Fontana, Constance HKatelaris, Ranbir Kaulsay, Piotr Kuna, Dèsirée Larenas-Linnemann, Manolis Manoussakis, Kristof Nekam, Carlos Nunes, Robyn O’Hehir, José M Olaguibel, Nerin Bahceciler Onder, JungWon Park, Alfred Priftanji, Robert Puy, Luis Sarmiento, Glenis Scadding, Peter Schmid-Grendelmeier, Ester Seberova, Revaz Sepiashvili, Dirceu Solé, Alkis Togias, Carlo Tomino, Elina Toskala, Hugo Van Beever, Stefan Vieths*

Immunotherapy in asthma: an updated systematic review

Allergen-specific immunotherapy (hyposensitization or desensitization) has long been a controversial treatment for asthma. Although beneficial effects upon clinically relevant outcomes have been demonstrated in randomized controlled trials, there remains a risk of severe and sometimes fatal anaphylaxis. The recommendations of professional bodies have ranged from cautious acceptance (1) to outright dismissal (2). A recent WHO position paper, which has been endorsed by eight other intemational and national bodies, concluded that allergen immunotherapy was an effective treatment for patients with allergic asthma (3). We have previously conducted a meta-analysis of 20 randomized controlled trials of allergen immunotherapy for asthma published between 1954 and 1990 (4). We subsequently conducted a systematic review for the Cochrane Collaboration, including a further 34 trials published between 1957 and 1997 (5). Both reviews concluded that subjects randomized to immunotherapy reported significantly fewer asthma symptoms, required significantly less asthma medication, and demonstrated both reduced nonspecific and reduced allergen-specific bronchial hyperreactivity (BHR) compared to those randomized to placebo. During recent years, there has been increasing interest in new allergen vaccines and new methods of delivery including oral, sublingual, and inhaled immunotherapy. Recombinant peptides containing the relevant epitopes, but lacking the ability to cross-link IgE bound to mast cells, have been evaluated in clinical trials. Finally, the Cochrane Collaboration has standardized protocols for systematic reviews and improved the statistical software for performing meta-analysis. Thus, it was again opportune to update our systematic review of allergen-specific immunotherapy for asthma.

Chlorhexidine anaphylaxis: a case report and review of the literature.

A 25-year-old man presented for assessment after an episode of anaphylaxis following insertion of a urethral catheter. He required intermittent dilatation of a urethral stricture after a previous pelvic fracture. Six months earlier he had developed an itchy rash minutes after urethral catheterization under local anaesthetic, which subsided over some hours. On this occasion, a catheter was inserted after infiltration of the urethra with lignocaine 2% with chlorhexidine 0.05% (Pharmacia, Bentley, WA, Australia). Within minutes, his blood pressure fell to 90/60 and he developed a generalized pruritic rash, wheeze and dizziness. He was treated with nebulized salbutamol, intravenous hydrocortisone and subcutaneous adrenaline. He recovered without further incident and was subsequently discharged from hospital.

Intranasal Corticosteroids Versus Oral H1 Receptor Antagonists in Allergic Rhinitis: Systematic Review of Randomised Controlled Trials

Searching MEDLINE and EMBASE were searched for randomised controlled trials published between 1966 and 1997. The search terms were not given. Review articles identified were surveyed for additional and earlier citations. HealthGate and Winspirs software were used to search MEDLINE for more recently published studies. Where relevant abstracts were identified in conference proceedings, MEDLINE searches were conducted and enquiries made of the authors or sponsoring companies to identify any subsequent full publications. Publications in languages other than English were considered.

Experience with a new commercial skin testing kit to identify IgE-mediated penicillin allergy

Many patients who describe a history of allergy to penicillin do not prove to be allergic and can be treated safely with penicillin. After a period of 2 years where testing of penicillin allergy was not possible, a new commercial kit has recently become available. We report our initial experience with use of the kit with 29 patients and discuss one patient who experienced anaphylaxis during i.d. testing.

Adverse Drug Reactions Reported by Healthcare Professionals: Reaction Characteristics and Time to Reporting

We describe adverse drug reaction (ADR) reporting characteristics and factors contributing to length of time to report by healthcare professionals. This is a retrospective study of voluntary reports to an Australian healthcare ADR Review Committee over a 2‐year period (2015–2016). Descriptive and univariate models were used for outcomes, employing standardized ADR definitions. Hospital pharmacists reported 84.8% of the 555 ADRs: 70.3% were hospital onset reactions, and 71.7% were at least of moderate severity. Immunologically mediated reactions were most commonly reported (409, 73.7%). The median time to submit an ADR report was 3 (interquartile range 1–10) days. Longer median times to reporting were associated with multiple implicated agents and delayed hypersensitivity reactions, especially severe cutaneous adverse reactions. A total of 650 medications were implicated that involved multiple agents in 165/555 (29.7%) reports. Antimicrobials were the most commonly implicated agents. Immunologically mediated reactions were most commonly associated with antimicrobials and radiocontrast agents (P < .0001, odds ratio [OR] 3.6, 95%CI 2.4–5.5, and P = .04, OR 4.2, 95%CI 1.2–18.2, respectively). Opioids and psychoactive medications were more commonly implicated in nonimmunological reported ADRs (P = .0002, OR 3.9, 95%CI 1.9–7.9, and P < .0001, OR 11.4, 95%CI 4.6–27.8, respectively). Due to the predominant reporting of immunologically mediated reactions, a targeted education program is being planned to improve identification and accuracy of ADR reports, with the overall aim of improved management to ensure quality service provision and patient safety.