At the 2012 Annual Meeting of the American Academy of Allergy, Asthma, and Immunology, held early this month in Florida, specialists learned a great deal that is important to primary care. Among the most noteworthy presentations: Why primary care isn't following asthma guidelines, the importance of body weight in asthma treatment, and the future of sublingual allergy drugs.
At the 2012 Annual Meeting of the American Academy of Allergy, Asthma, and Immunology (AAAAI), held early this month in Florida, specialists learned a great deal that is important to primary care. Among the most noteworthy presentations:
Primary care physicians and asthma guidelines. A survey of 26 primary care pediatricians found that just 46% “always” followed the guidelines in the 2007 National Asthma Education and Prevention Program’s Expert Panel Report. Of those who didn’t, the most common reason they cited was complexity of the guidelines. In addition, 61.4% said they initiated inhaled corticosteroids (ICS) as recommended for patients with persistent asthma; most did not mentioned problems with patient adherence. Of those who do initiate controller medication, half don’t wait for a year before reducing medication and never initiate step-down therapy, as the national guidelines advise.1Asthma, obesity, and inhaled corticosteroids. If your overweight or obese patients don’t seem to reap any benefits from ICS, consider their weight, not just the severity of their asthma, as the explanation. Among 61 children aged 2 to 18 who have asthma, those who were overweight or obese showed a reduced cellular response to ICS treatment. The researchers suggest that chronic inflammation spurred by obesity may be interfering with corticosteroid effectiveness, requiring a higher dose.2 Another study presented at the meeting found no correlation between body weight and the severity of asthma.3Sublingual treatments gaining ground. The day may be coming when primary care physicians provide just as much immunotherapy for allergies as allergists-without shots. Although subcutaneous injections are currently the only approved immunotherapy for allergies, several companies have sublingual tablets under investigation. Doctors in many other countries, including most European nations, have been using the tablets for years. Among the studies presented at AAAAI:
• A phase 3 study from Merck in which 565 adults with ragweed allergy were randomized to either a sublingual tablet or placebo found that depending on dosage, during the peak 2 weeks of ragweed season the tablets reduced symptoms 17% and 14% more than placebo. They also reduced the need for standard allergy medication.4
• A randomized trial in 21 children aged 7 to 13 compared oral versus sublingual immunotherapy over 6 months for treating peanut allergy. It found both similarly effective in changing challenge threshold, serologic markers, and reactivity. The investigators are following the children for 12 months total and will report the results after unblinding.5
• Long-term results of a 5-year French study of sublingual therapy for grass pollen–induced allergy in 633 adults found significant increases in quality of life in the treatment group compared with the placebo group.6 They also found greater efficacy in patients with the highest symptom scores.7 The same investigators also reported on the efficacy and safety of the treatment in the United States, among 473 adults who used it for 4 months before and during allergy season for 3 years. Participants receiving the study drug showed significant improvements in use of rescue medication, symptoms, and quality of life, confirming that the tablet was effective against US pollens. There were no anaphylactic reactions, suggesting the therapy may be safer than injections.8
Asthma and exercise. Exercise may be a challenge for people who have asthma, but there’s reason to encourage it: Results of a small study showed that asthmatic patients enrolled for 4 months in a structured exercise program at a gym had significantly better quality of life, measured by improvements in symptoms and limitations, compared with those who received education only.9 Overall, 78.3% of the exercise group demonstrated improvement compared with 39.5% of the control group (P = .05).
Aspirin allergy desensitization. Two reports demonstrated that patients with an aspirin allergy who develop cardiovascular problems requiring daily aspirin therapy can be desensitized with a supervised protocol. In one report, clinicians used a 7-step protocol (provided in an inpatient or outpatient setting) for 23 patients who were allergic to aspirin or NSAIDs.10
The desensitization involved drinking a solution containing a 1-mg dose of aspirin dissolved with an Alka Seltzer tablet in water, waiting 15 minutes, then taking progressively higher doses in 15-minute intervals ending at a 325-mg dose. If patients developed a rash, they received an antihistamine. Although 3 patients developed angioedema, 2 of them continued the protocol without further problems. Sixteen patients had no reactions and none required an emergency department or hospital visit. One patient discontinued aspirin after developing cough and shortness of breath.
Another report of desensitization used in 14 patients who required cardiac stents employed a similar protocol, with similar results11
1. Farooqui N, Stukus D. Survey of asthma management and referral preferences by primary care pediatricians at a pediatric training hospital. Abstract 251.
2. Nunez RA et al. Body mass and corticosteroid response in childhood asthma. Abstract 482.
3. Lu KD et al. Obesity is associated with nocturnal and exercise-related symptoms, but not asthma severity in urban children with asthma. Abstract 558.
4. Berman G et al. Ragweed allergy immunotherapy tablet reduces nasal and ocular symptoms of allergic rhinoconjunctivitis over the peak ragweed pollen season in North America. Abstract 938.
5. Narisety SD et al. A randomized, double-blind, placebo-controlled pilot study of sublingual versus oral immunotherapy for the treatment of peanut allergy. Abstract 102.
6. Horak F et al. Improvement in quality of life with administration of a 300 IR sublingual tablet of 5-grass pollen allergen extract in adults with grass pollen-induced allergic rhinoconjunctivitis. Abstract 174.
7. Worm M et al. Post-treatment, long-term efficacy of a 300 IR sublingual tablet of 5-grass pollen allergen extract in adults with grass pollen-induced allergic rhinoconjunctivitis: the relationship with disease severity. Abstract 177.
8. Cox L et al. A US study of 5-grass pollen allergen extract in adults with grass pollen-induced allergic rhinoconjunctivitis-results of secondary efficacy assessments. Abstract 176.
9. Pollart SM et al. Improvements in quality of life measures in a structured exercise program for persistent asthma. Abstract 231.
10. McMullan KL et al. Safety of aspirin desensitization in patients with a cardiac indication for aspirin. Abstract 325.
11. Riester DE et al. Aspirin allergy in a community teaching hospital. Abstract 327.