This Twitter summary from the 2013 meeting of the American College of Allergy, Asthma & Immunology (#ACAAI) was based on tweets by the following allergists/immunologists:
Dr. Ellis @DrAnneEllis
Dr. Dave Stukus @AllergyKidsDoc
Robert Silge, MD @DrSilge
10% of people report having allergic rhinitis
From NHANEs data: 10 % of subjects self identified as having SAR, of those about 70 to 80 % actually had supportive skin tests.
There is an association between decrease in work productivity and pollen counts rise. This is a result from a combination of patients’ symptoms plus side effects of medications (antihistamines). There are still far too many SAR patients relying on 1st generation antihistamines like diphenhydramine (Benadryl) which are sedating. There is a narrow therapeutic window for pseudoephedrine.
The WHO defines health outcomes in terms of QOL; 30 to 40% of patients with AR have moderate to severe QOL impact from their disease. Patients with AR are twice as likely to report impairments in their various activities of daily living compared to those without allergy.
Dr. Luskin challenges us to treat AR under same paradigm as Asthma - minimize impairment and reduce risk. It is Important to have goals of therapy for allergic rhinitis, similar to asthma. Goal=control of symptoms, minimal impairment.
Dr. Eli Meltzer emphasized that the Allergist is still needed in the management of allergic rhinitis. If allergic rhinitis is uncontrolled then there is a 50% rate of uncontrolled asthma in those with both conditions.
PRN nasal steroid is more effective than daily antihistamine
PRN nasal corticosteroids are not as effective as regular use, but they are more effective than PRN or regular use of OTC antihistamines.
Treatment Options for
Allergic Rhinitis (AR) and
Non-Allergic Rhinitis (NAR) (click to enlarge the image).
New treatments for allergic rhinitis
Antihistamines are not enough
47% of subjects in one study who were using antihistamines for their allergic rhinitis were still uncontrolled. Dr. Meltzer reinforced Dr. Luskins message that the goal of allergic rhinitis management should be complete control of symptoms.
Leukotriene receptor antagonists may become available OTC is the USA. However, benefit in allergic rhinitis is present but modest at best.
INS are still best
Remind patients that the onset of action of nasal corticosteroids is not immediate, don't give up if it doesn't work right away. Nasal Aerosol corticosteroids have dose counters, which helps determine adherence and need to refill prescription.
Budesonide is still the only intranasal corticosteroid that is Pregnancy category B.
Immunotherapy is underutilized
Fewer than 5% of allergy sufferers choose to undergo allergen immunotherapy of any type.
About 12% of board certified allergists are prescribing SLIT.
Newer studies are showing benefit of SLIT, but mostly with commercial preparations. There is less success in off label use of SCIT extract as SLIT. Dr. Criticos points out that SCIT has been grandfathered in to FDA approval, there is essentially no data on mixed SCIT either.
IgG4 is increased in grass SLIT studies. In some studies this increase happens, but clinical improvement are less noted.
Local side effects with SLIT
Duration of immunotherapy was shorter with SLIT by about a year compared to SCIT in an Italian study. Hower, more patients quit SLIT.
In a study by Blaiss et al of grass SLIT, nearly 40% with oral or throat symptoms.
In children, tablets for SLIT allow greater mucosal exposure than liquids.
No definitive answers, but for preseasonal SLIT treatment, starting at least 8 weeks before the season seems most effective.
SCIT is more effective than SLIT
Few trials are comparing SLIT vs SCIT, but they do tend to show advantage for SCIT. The strongest evidence for both is in asthma control.
Amar et al. had a study showing multi allergen SLIT has a decreased effectiveness compared to mono-grass SLIT.
Mechanisms of allergen-specific immunotherapy (click to enlarge the image).
Dr. Casale showed data of omalizumab's benefit in allergic rhinitis, onset of action is 14 days. Omalizumab is shown to increase safety and tolerability of rush SCIT protocols.
Medications in trials
Co-administering a TLR4 agonist (MpL) along with allergen shows clinical benefit after 4 preseasonal injections.
Others are evaluating intranasal TLR7, TLR8 and TLR9 agonists for allergic rhinitis.
CpG in virus-like particle vaccine improved asthma and SAR. Initially it was used as an adjuvant for allergen, but even on its own it helps. Cytos has developed a TLR-9 agonist that is coadministered with allergen by injection (CpG) - the CPG alone component has benefit