Global strategy for asthma management and prevention

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

Background and Methods. Children with asthma commonly have positive skin tests for inhaled allergens, and in the United Kingdom the majority of older children with asthma are sensitized to the house-dust mite. In a cohort of British children at risk for allergic disease because of family history, we investigated prospectively from 1978 to 1989 the relation between exposure to the house-dust mite allergen (Der p I) and the development of sensitization and asthma. Results. Of the 67 children studied in 1989, 35 were atopic (positive skin tests), and 32 were nonatopic. Of the 17 with active asthma, 16 were atopic (P<0.005), all of whom were sensitized to the house-dust mite, as judged by positive skin tests and levels of specific IgE antibodies (P<0.001). For house-dust samples collected from the homes of 59 of the children in 1979 and from 65 homes in 1989, the geometric means for the highest Der p I exposure were, respectively, 16.1 and 16.8 μg per gram of sieved dust. There was a trend toward an ...

Exposure to house-dust mite allergen (Der p I) and the development of asthma in childhood: a prospective study.

https://ftp.cdc.gov/pub/documents/oel/06. dotson/references/platts-mills_2001.pdf

Sensitisation, asthma, and a modified Th2 response in children exposed to cat allergen: a population-based cross-sectional study.

It is well known that inhalation of an allergen is capable of inducing wheeze in a sensitized individual. But the idea that allergen exposure is a primary cause of asthma has encountered opposition. Recent advances have made it possible to study the relationship between house dust mite allergen exposure and asthma [reviewed in i]. These include the purification of the major allergens [2], the development of ELISA techniques which have facilitated allergen measurement [3] and a series of epidemiological studies from many parts of the world. In this article, we review the infonnation from diverse studies which when combined strongly suggests that exposure to allergens is an important cause of asthma. We focus on the evidence related to house dust mite allergens because it is the most complete. However there are a number of other inhaled allergens which are of importance in individual cases, in certain geographic areas or at specific times of the year. The implication from these studies is that the primary cause of asthma, especially the asthma occurring in children and young adults, is inhalation of allergens. For an allergen to have a clinical effect, prior sensitization must have occurred. Sensitization requires the combination of an innate ability to respond and exposure. Immediate sensitivity, characterized by IgE antibody production, is part of the immune response to these proteins, which also involves antigen presenting cells, T cells, B cells and other effector ceils. Exposure of a nonsensitized individual to even large quantities of an allergen will not provoke symptoms, whereas a sensitized individual is capable of reacting to extraordinarily small concentrations of allergens, i.e. in the picogram range. Immediate sensitivity can be measured by either the level of allergen specific IgE antibody or by skin testing [4,5,6]. The development of asthma can be considered to consist of two distinct processes: (i) a period resulting in sensitization followed by (ii) exposure of the sensitized person resulting in inflammation and ciinical wheeze. This latter process was elegantly referred to as 'excitement' in the early literature. The presence of inflammation may make the lung more sensitive not only to the specific allergen

House dust mite exposure as a cause of asthma.

Background Our objective was to identify the allergens associated with asthma among schoolchildren in an area of the United States where dust mite growth is expected to be poor. Los Alamos, N.M., was chosen because it has low rainfall and is at high altitude (7200 feet) making it very dry. One hundred eleven children (12 to 14 years old) from the middle school who had been previously classified according to bronchial hyperreactivity to histamine (BHR) were studied. Methods Sera were assayed for IgE antibodies to mite, cat, dog, cockroach, Russian thistle, and grass pollen, with both CAP system fluoroimmunoassay (Kabi Pharmacia, Uppsala, Sweden) and conventional RAST. Allergens were measured in dust samples from 108 homes with two-site assays for mite (Der p 1 and Der f 1), cat (Fel d 1), dog (Can f 1), and cockroach (Bla g 2). Results Concentrations of dog and cat allergens were elevated in almost all houses with pets but were also high in a significant proportion of the houses without pets. Levels of mite allergen were less than 2 micrograms/gm in 95% of the houses, and cockroach was undetectable in all but two of the houses. Among the 21 with BHR who had symptoms, 67% had IgE antibody to dog and 62% had IgE antibody to cat. For these allergens IgE antibody was strongly associated with asthma (p Conclusion The high prevalence of IgE antibody to cat and dog allergens among these children is in keeping with the presence of cat and/or dog allergen in most of the houses. Furthermore, sensitization (as judged by IgE antibodies) to cat and dog allergens was strongly associated with asthma. On the other hand, no clear relationship was found between sensitization or symptoms and the current level of allergen in individual houses. The results show that in this mite-and cockroach-free environment sensitization to domestic animals was the most significant association with asthma.

https://inbio.com/images/pdfs/65_Ingram_JACI_1995.pdf

Quantitative assessment of exposure to dog (Can f 1) and cat (Fel d 1) allergens: Relation to sensitization and asthma among children living in Los Alamos, New Mexico

Asthma in children and young adults is strongly associated with immediate hypersensitivity to indoor allergens, notably those derived from the house dust mite. In addition, outdoor air pollution is considered to aggravate existing asthma. We investigated the prevalence of asthma and the pattern of allergen sensitization in a mite-free environment with low levels of outdoor air pollution. A total of 567 children aged between 12 and 14 attending Los Alamos Middle School, NM (altitude 7,200 feet) were screened using a respiratory questionnaire; 120 children (53 control children) underwent allergen skin testing and serum IgE measurement, and their bronchial reactivity to histamine was measured. Dust was collected from 111 homes and the level of indoor mite and cat allergen measured. The prevalence of respiratory symptoms was high (13%), and from the detailed testing it was estimated that 6.3% of the children had asthma (defined as symptomatic bronchial reactivity). Children with asthma had elevated IgE, 367 (179 to 755) versus 38 (23 to 61), and predominant sensitization to cat, 68 versus 20% (p < 0.001). A high number of households (77%) had a pet cat or dog. The concentration of mite allergen was very low (mean 0.18 micrograms Der p milligrams sieved house dust), whereas that of cat allergen was high in homes with a cat (80.8 micrograms Fel d milligrams) but also in homes with no cat (3.2 micrograms Fel d milligrams). The results show that in a mite-free environment with low levels of outdoor air pollution, asthma was still a major cause of morbidity among schoolchildren.(ABSTRACT TRUNCATED AT 250 WORDS)

Richard Sporik

Papers

Exposure to house-dust mite allergen (Der p I) and the development of asthma in childhood: a prospective study.

Sensitisation, asthma, and a modified Th2 response in children exposed to cat allergen: a population-based cross-sectional study.

House dust mite exposure as a cause of asthma.

Quantitative assessment of exposure to dog (Can f 1) and cat (Fel d 1) allergens: Relation to sensitization and asthma among children living in Los Alamos, New Mexico

Association of asthma with serum IgE and skin test reactivity to allergens among children living at high altitude. Tickling the dragon's breath.