Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma

Allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the membranes lining the nose. It is a global health problem that causes major illness and disability worldwide. Over 600 million patients from all countries, all ethnic groups and of all ages suffer from allergic rhinitis. It affects social life, sleep, school and work and its economic impact is substantial. Risk factors for allergic rhinitis are well identified. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations.

In 1999, during the Allergic Rhinitis and its Impact on Asthma (ARIA) WHO workshop, the expert panel proposed a new classification for allergic rhinitis which was subdivided into 'intermittent' or 'persistent' disease.

This classification is now validated. The diagnosis of allergic rhinitis is often quite easy, but in some cases it may cause problems and many patients are still under-diagnosed, often because they do not perceive the symptoms of rhinitis as a disease impairing their social life, school and work.

The management of allergic rhinitis is well established and the ARIA expert panel based its recommendations on evidence using an extensive review of the literature available up to December 1999. The statements of evidence for the development of these guidelines followed WHO rules and were based on those of Shekelle et al. A large number of papers have been published since 2000 and are extensively reviewed in the 2008 Update using the same evidence-based system. Recommendations for the management of allergic rhinitis are similar in both the ARIA workshop report and the 2008 Update. In the future, the GRADE approach will be used, but is not yet available.

Another important aspect of the ARIA guidelines was to consider co-morbidities. Both allergic rhinitis and asthma are systemic inflammatory conditions and often co-exist in the same patients. In the 2008 Update, these links have been confirmed.

The ARIA document is not intended to be a standard-of-care document for individual countries. It is provided as a basis for physicians, health care professionals and organizations involved in the treatment of allergic rhinitis and asthma in various countries to facilitate the development of relevant local standard-of-care documents for patients.

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Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)

Authors Jan L. Brozek, MD, PhD – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada Jean Bousquet, MD, PhD – Service des Maladies Respiratoires, Hopital Arnaud de Villeneuve, Montpellier, France, INSERM, CESP U1018, Respiratory and Environmental Epidemiology Team, France, and WHO Collaborating Center for Rhinitis and Asthma Carlos E. Baena-Cagnani, MD – Faculty of Medicine, Catholic University of Cordoba, Cordoba, Argentina Sergio Bonini, MD – Institute of Neurobiology and Molecular Medicine – CNR, Rome, Italy and Department of Medicine, Second University of Naples, Naples, Italy G. Walter Canonica, MD – Allergy & Respiratory Diseases, DIMI, Department of Internal Medicine, University of Genoa, Genoa, Italy Thomas B. Casale, MD – Division of Allergy and Immunology, Department of Medicine, Creighton University, Omaha, Nebraska, USA Roy Gerth van Wijk, MD, PhD – Section of Allergology, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands Ken Ohta, MD, PhD – Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan Torsten Zuberbier, MD – Department of Dermatology and Allergy, Charite Universitatsmedizin Berlin, Berlin, Germany Holger J. Schunemann, MD, PhD, MSc – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada

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Allergic Rhinitis and Its Impact on Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

National Asthma Education and Prevention Program.

Single recombinant latex allergens permit the study of the pattern of sensitization to individual allergens. We aimed to quantify the IgE-response to individual latex allergens in children sensitized to latex. The study group included 31 latex-sensitized children: 26 operated at least twice, 20 of them with spina bifida; two children with one operation and three atopic non-operated children. IgE antibodies to rHev b 1, rHev b 3, rHev b 5, rHev b 6.01, rHev b 7.02 and rHev b 8, coupled to ImmunoCAPs, were measured in each serum. IgE responses to rHev b 1, rHev b 5 and rHev b 6.01 were found in 17 children each, and their mean +/- s.d. levels were 5 +/- 7.4, 16.8 +/- 14 and 10 +/- 18 kU/l, respectively. IgE responses to rHev b 3 (4 +/- 5.4 kU/l) were found in eight children. Two children had IgE to rHev b 7 (1.7 and 3.2 kU/l), and none to rHev b 8. Four sera were negative to all tested recombinant allergens. We divided the patients in three groups: sensitized only to rHev b 1, sensitized only to rHev b 5 and/or rHev b 6.01, and sensitized to both rHev b 1 and to rHev b 5 and/or rHev b 6.01. The three groups had the same profile of clinical features. Hev b 5 induces the quantitatively higher IgE responses in children with multiple surgeries sensitized to latex. Responses to Hev b 6.01 equal those of Hev b 1.

Patterns of latex allergen recognition in children sensitized to natural rubber latex

Background: The demonstration that some asthma epidemics have been caused by allergens of soybean-hull dust prompted us to develop a two-site ELISA, suitable for the quantification of the major allergen (Gly m 1), to be used for the prevention of new episodes.



Methods: BALB/c mice were injected with Gly m 1 purified from soybean hulls. After fusion and screening, 10 monoclonal antibodies (mAbs) were obtained that were shown to be specific for Gly m 1. Two of them (6G1 as the capture antibody; 1G10 as the tracer) were selected to develop a quantitative two-site ELISA for the indoor and outdoor determination of Gly m 1.



Results: The two-site ELISA developed is very sensitive, with a detection limit of less than 0.2 ng/ml and a practical working range of 0.4–10 ng/ml. The assay is also highly reproducible with an intra-assay coefficient of variation of 3.5% and an interassay coefficient of variation of 12.5%. The method was applied to measure the concentration of Gly m 1 in air-sampler filters and in house-dust samples. Our results illustrate that there is a good correlation between the content of Gly m 1 in a number of samples and the allergenic activity as measured by ELISA inhibition.



Conclusions: A specific and sensitive method is presented that can be used for the quantification of Gly m 1. The application of this method may allow the establishment of risk limits for soybean dust, and thus may contribute to the control of environmental contamination and to the prevention of new asthma epidemics.

Monoclonal antibody-based method to quantify Gly m 1. Its application to assess environmental exposure to soybean dust.

Amino acid sequence homologies in alfa-sarcin, restrictocin and mitogillin

. AN important subset of patients with exercise-induced anaphylaxis (EIA) have been found to present foodtriggered EIA (1). We present here a case of EIA triggered by apple and red wine. The patient was a 19-year-old man who presented two episodes of anaphylaxis after running for about 1 h. In both cases, the patient had eaten an apple about 1 h before beginning the exercise. Two years later, the patient again had anaphylaxis after drinking two sips of red wine during a meal and was admitted to the allergy section of the hospital for study. Serum-speci®c IgE was weakly positive for hazelnut (0.44 kU/ml), and clearly positive for peanut (1.94 kU/ml), apple (2.08 kU/ml), grape (4.13 kU/ml), and Artemisia pollen (8.45 kU/ml). Skin prick tests were positive to Artemisia pollen and several foods (including peach and hazelnut). Apple, grape, and wine were tested by the prick-prick technique and all were found to be positive. Fig. 1 shows the result of an immunoblotting experiment. The patient had IgE against different wine protein components (part A, lane 1), and a band with an apparent molecular mass of ,13 kDa is clearly detected, which is in the SDS±PAGE range of lipid transfer proteins (LTPs), important allergens detected in Rosaceae fruits, mainly peach and apple (2). LTPs are thermostable (3) and extremely resistant to pepsin digestion (4); therefore, they are probably severe food allergens. In the apple blot (part A, lane 3), a double ,13-kDa band was detected (although more faintly than in A severe reaction of apple and pollen allergy.

Anaphylaxis induced by exercise and wine.

Major wheat and rye allergens associated with baker's asthma have been identified as specific inhibitors of Dermatophagoides pteronyssinus alpha-amylase (Der p 4). the most active inhibitors were the wheat tetrameric one and the rye dimeric RDAI-1. these data suggest that interaction between mite and cereal allergens (alpha-amylase/inhibitor complexes) might occur in house-dust-mite-infected flours. In contrast to the strong inhibition of the d. pteronyssinus enzyme by the wheat and rye inhibitors, the amylases from D. farinae, Lepidoglyphus destructor, and Tyrophagus putrescentiae were much less affected. Moreover, the D. pteronyssinus amylase showed higher pH optimum (6.5 versus 5.0) and activity level (2-6 times/mg of protein in whole-mite extracts) than those from the three other mite species.

Interaction of allergens from house-dust mite and from cereal flours: Dermatophagoides pteronyssinus alpha-amylase (Der p 4) and wheat and rye alpha-amylase inhibitors.

Domingo Barber

Papers

Patterns of latex allergen recognition in children sensitized to natural rubber latex

Monoclonal antibody-based method to quantify Gly m 1. Its application to assess environmental exposure to soybean dust.

Amino acid sequence homologies in alfa-sarcin, restrictocin and mitogillin

Anaphylaxis induced by exercise and wine.

Interaction of allergens from house-dust mite and from cereal flours: Dermatophagoides pteronyssinus alpha-amylase (Der p 4) and wheat and rye alpha-amylase inhibitors.