Allergy & Asthma Care of Fairfield County

Welcome

Our practice provides outstanding care to adults and children with allergies, asthma, and food allergies throughout Fairfield and New Haven Counties. We offer compassionate, honest, and personal care in a comfortable, convenient setting. We also have early morning and evening hours to accommodate your busy lifestyle. All of our providers have been fully vaccinated for COVID-19.

Pediatric & Adult
55 Walls Dr., Suite 105, Fairfield, CT (203) 259-7070
35 Corporate Drive, Suite 1115, Trumbull, CT  (203) 445-1960
Kenneth Backman, MD, Katherine Bloom, MD, Sara Dever, MD,

Jillian Ross, APRN, Danielle Khorsandi, APRN

Food allergy may be birectionally associated with atopic dermatitis

Children diagnosed with atopic dermatitis or food allergy were more likely to develop either disorder as time went on, according to a study published in Pediatric Allergy and Immunology.  The key takeaways were: 1. By age 4 years, children with atopic dermatitis were 5 times more likely to develop a food allergy, and 2. Children with food allergy were 8 times more likely to develop atopic dermatitis by age 1 year.

“Atopic dermatitis (AD) is considered to occur before the development of food allergy (FA),” Carina Venter, PhD, RD, associate professor of pediatrics at the University of Colorado Denver School of Medicine, Children’s Hospital Colorado, told Healio “We wanted to study if there are other directions these two diseases occur as well. We conducted a descriptive analysis of transitions between no disease (ie, no FA and no AD), FA but not AD, AD but not FA, or both FA and AD,” continued Venter, who also is chair of the European Academy of Allergy and Clinical Immunology Work Group on Immunomodulation and Nutrition.

The study recruited pregnant women aged at least 16 years from obstetrics clinics between 2009 and 2014. The women were given questionnaires on their medical history and asked to give consent for the review of their children’s medical records for up to 4 years. Researchers studied the transitions between disease status in early infancy as well as two critical time periods in FA and AD development. The time periods included up to 12 months of age and up to 4 years of age. “The majority of children develop AD in the first year of life, and most children develop food allergy before 5 years of age,” Venter said.

In total, medical records were obtained from 1,261 children (47.7% girls; 50% white) to determine the onset of FA and AD. Among the 1,261 children, 1,157 had neither AD or FA, 107 had AD, two had FA and one had both AD and FA. By age 6 months, children with AD but not FA were 7.8 times (95% CI, 2.5-24.3) more likely to be diagnosed with FA by age 1 year compared with those with no disease, whereas children with FA but not AD were 8.3 times (95% CI, 2-33.9) more likely to face an AD diagnosis. Those with AD but not FA by age 6 months were also 5.3 times (95% CI, 2.8-10.3) more likely to be diagnosed with FA by age 4 years vs. children with no disease. Children with FA but not AD were 5.3 times (95% CI, 2.4-11.95) more likely to have an AD diagnosis by age 4 years.

“It is important to understand that not all food allergy is preceded by AD,” Venter said. “This has implications for food allergy prevention, ie, all infants should be targeted for food allergy prevention, rather than just the high-risk group presenting with AD in early infancy.” She further explained that in future studies, the data need to be replicated in larger cohorts with clearly defined disease outcomes. “Disease outcomes should be studied as they occur rather than based on retrospective questionnaire data,” Venter said.

 

Early childhood infections linked to asthma risk

Novel research has identified a strong connection between early-life respiratory tract infections and the development of asthma in children, particularly in children with allergic rhinitis. This study, part of the Copenhagen Prospective Studies on Asthma in Childhood 2010 birth cohort, examined how the burden and types of common infections in the first three years of life influence asthma risk from age 3 to 10 and lung function at age 10.  

The study followed 662 children, documenting infections such as colds, acute tonsillitis, acute otitis media, pneumonia, gastroenteritis, and fever in daily diaries from birth to age 3. Asthma diagnoses were tracked longitudinally until age 10.   Children in the study experienced a median of 16 infections by age 3. Those with a higher-than-median number of infections had a 3.61 times greater risk of developing asthma between ages 3 and 10. This increased risk was primarily linked to colds, pneumonia, gastroenteritis, and fever but not to acute otitis media or tonsillitis. Lower lung function at age ten was associated with early pneumonia but not the overall infection burden.  

The study found that children with allergic rhinitis at age six and a high number of colds had an even higher risk of developing asthma, suggesting a significant interaction between allergic rhinitis and infection burden. Specifically, these children were 14.4 times more likely to develop asthma than those with fewer infections. In contrast, children without allergic rhinitis but with a high infection burden were 3.62 times more likely to develop asthma. There were no significant associations between the overall burden of common infections and lung function measurements at age 10. However, pneumonia in early childhood was linked to lower FEV1 (forced expiratory volume) and maximal midexpiratory flow, indicating reduced lung function.  

The results revealed a significant association between a high number of early infections and an increased asthma risk. The study authors recommended randomised controlled trials of maternal and child vaccinations, antibody administration, bacterial lysate treatment, and vitamin D supplementation to explore their potential in preventing infections and reducing asthma risk, particularly in children with respiratory allergies. The results underscore the importance of monitoring and managing early childhood infections to mitigate long-term respiratory health risks. Moreover, the findings suggest that early interventions targeting infection prevention could play a crucial role in reducing the incidence of asthma in children, especially those with predisposing allergic rhinitis. 

Dr. Katherine Bloom comments: "This study expands on prior evidence that early childhood infections are related to the risk of developing asthma.  Studies have not confirmed a causative connection, but it is looking increasingly likely that certain infections in early childhood may play a causative role. Further studies, including possible interventions, are under way."

Early introduction guidelines may reduce risk of peanut anaphylaxis in children

The 2017 Addendum Guidelines for the Prevention of Peanut Allergy were associated with lower new-onset anaphylaxis rates in children, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice. “Food allergies, especially to peanuts, have been on the rise,” Joshua Yu, MD, internal medicine resident, department of medicine, faculty of medicine, McMaster University, and first author of the study, told Healio.

“Early introduction of peanuts to infants has shown promise in preventing peanut allergies at least within randomized controlled trials,” Yu said. “In 2017, Canada introduced new guidelines encouraging early introduction. However, it was unclear how these guidelines affected the rates of peanut-induced severe allergic reactions (anaphylaxis) in Canada.”

Methods

The retrospective study analyzed data from a longitudinal registry of anaphylaxis presentations at the ED at Montreal Children’s Hospital between May 2011 and December 2019. Patients were divided into groups based on prior known peanut allergies and then further stratified into two age groups: 0 to 2 years and 3 to 17 years. The former age range was chosen since those patients had the opportunity to participate in early peanut introduction from 2017 to 2019, unlike the latter age group. Rates of peanut-induced anaphylaxis were calculated by presentations per 100,000 age-adjusted all-cause ED visits in 4-month intervals. To compare anaphylaxis rate trends before and after 2017, an interrupted time series analysis was used.

Results

Among 2,011 cases of pediatric anaphylaxis, 429 (21%) were peanut-induced, including 180 (mean age, 4.11 years; 58% boys) with no known prior peanut allergy and 249 (mean age, 9.13 years; 63% boys) with a known prior peanut allergy at ED presentation. Prevalence of baseline asthma was significantly lower in the younger subgroup, with a significantly higher prevalence of baseline eczema. Within the known peanut allergy in this subgroup, 11 patients had no history of prior anaphylaxis but had a history of eczema and egg allergy, and of these patients, four presented with anaphylaxis following 2017.

Analysis showed a significant yearly –7.96 (95% CI, –14.57 to –1.36) slope change in anaphylaxis rates after 2017 in the 109 children in the 0 to 2 years age group without prior known peanut allergy. “In young children ages 0 to 2 without known prior allergy to peanuts, we found a significant decrease in the rate of peanut-induced anaphylaxis presentation rates to the Montreal Children’s Hospital ED after the introduction of the 2017 guidelines,” Yu said. “In contrast, there was no significant change in rates in children aged 3 to 17 years or in patients with known peanut allergies of any age group.”

Yu explained that these findings provide real-world evidence that early peanut introduction is associated with reduction in incidence of peanut-induced anaphylaxis in young children.“This supports the efficacy of early allergen introduction as a preventive measure,” he said. “The lack of significant changes in older children and those with known allergies underscores the importance of early intervention. It suggests that the window for preventing peanut allergies may be limited to early childhood.” He further stated that physicians should focus their efforts on educating new parents and caregivers about the benefits that early introduction of allergens can bring and that further studies need to be done in order to fully assess the benefits. “Future research should investigate the long-term effects of early peanut introduction across Canada and explore its impact on other food allergens,” Yu said. “Studies on guideline adherence and demographic influences on anaphylaxis rates are also needed.”

Early peanut introduction can provide lasting protection from peanut allergy

Consuming peanut products from infancy through age 5 years provided lasting tolerance into adolescence without the need to regularly upkeep consumption, according to a study published in NEJM Evidence.Findings come from the LEAP-Trio study, which builds on the results from the LEAP study and the following LEAP-On study, both of which were sponsored by the National Institute of Allergy and Infectious Diseases. 

“The results from the original LEAP study, which was published almost 10 years ago now, showed that introducing peanut products to infants before the first year of life resulted in protection from peanut allergy developing later,” Patricia Fulkerson, MD, PhD, chief of NIAID’s Food Allergy, Atopic Dermatitis, and Allergic Mechanisms Section, told Healio. “The last time they checked on these kids, it was around 6 years of age and so, they wanted to see if it was durable. This protection was durable all the way into adolescence,” Fulkerson, who was not an author on the study, continued.

The trial examined the durability of peanut tolerance at 144 months (12 years) of age with at-will peanut consumption, eating or avoiding peanuts as desired. Enrollment took place from July 2018 to August 2022. In the original LEAP study, 640 infants aged 4 to 11 months with severe eczema, egg allergy or both were randomly assigned to consume or avoid peanuts until reaching age 60 months. In the current study, researchers evaluated 508 (79.4%; mean age, 13 years) of these children, including 253 from the original peanut avoidance group and 255 from the original peanut consumption group.

The primary outcome of the LEAP-Trio study was the number of participants with a peanut allergy at 144 months of age. This was determined by either an oral food challenge or self-reporting from participants who consumed at least 2 g of peanut protein during a single occasion without a reaction in the prior year. Allergy status for the remaining participants was determined by a prediction model using biomarker data. From the 508 participants, 497 had sufficient data to determine peanut allergy, 400 (80.5%) of which underwent an OFC to establish allergic status.

Within the intention-to-treat analysis, 15.4% of 246 children in the peanut avoidance group and 4.4% of 251 children in the peanut consumption group at 144 months had peanut allergy (P < 0.001), showing a 71% reduction in the prevalence of peanut allergy with consumption. Among early peanut consumption participants who originally had a negative skin prick test, 2.8% of 213 children manifested a peanut allergy in the consumption group at 144 months compared with 12.7% of 205 children in the avoidance group. Among participants who initially had a positive SPT, 29.3% of 41 children were allergic in the avoidance group compared with 13.2% of 38 children in the consumption group. Researchers show that overall, there was a 75% reduction in the prevalence of peanut allergy during the lifespan of the LEAP-Trio participants.

“The most important findings were that the kids are still well protected,” Fulkerson said. “When they were babies, they were at high risk for developing food allergies, and peanut allergy is not an allergy that’s often outgrown. It’s persistent to adulthood. And so, when we checked, when they were around 13 years of age, they were still well protected.” In the LEAP-Trio per-protocol analysis, which included 470 children, peanut allergy was present in 15.1% of 232 participants in the avoidance group and 0.8% of 238 participants in the consumption group, showing a 14.2 (95% CI, 9.5-19) percentage point difference between groups. The effect size was similar in SPT negative and positive groups with an 11.1% difference (95% CI, 6.3%-15.9%) and 29.3% difference (95% CI, 15.3%-43.2%) between the avoidance and consumption groups. Peanut consumption varied widely among both groups in the 4 weeks before the 144-month assessment. The consumption group participants ate a geometric mean of 2.9 ± 12 g, and the avoidance group participants ate 0.2 ± 20.6 g (ratio of geometric means, 12.2; 95% CI, 7.2-20.5).

Researchers also reported significant diversity in peanut consumption in both the avoidance and consumption groups in years following their last LEAP or LEAP-On visits. Among yearly intervals, 26.8% to 33.1% of the consumption group reported eating 50 g or less of peanuts per year, and 13.3% to 15.1% reported avoiding any consumption for more than 6 months at a time. “The most surprising finding was that it didn't really matter how much peanut they ate,” Fulkerson said. “So, they had to ingest peanut in order to avoid developing the peanut allergy. But once that protection was set in place, they didn't have to keep ingesting it. So many of these kids stopped eating peanut for months at a time and they were still well protected from developing food allergies.”

At 144 months, mean SPT wheals were 1.4 ± 2.6 mm in the consumption group and 2.8 ± 4.7 mm in the avoidance group, for a –1.4 mm mean difference (95% CI, –2.1 to –0.7 mm). The geometric mean levels of Ara h 2-specific IgE were 0.03 ± 3.42 µg/L in the consumption group and 0.06 ± 11.2 µg/L in the avoidance group (ratio of geometric means, 0.4; 95% CI, 0.3-0.7). Ara h 6-specific peanut IgE levels included 0.03 ± 3.04 µg/L in the consumption group and 0.06 ± 10.75 µg/L in the avoidance group, demonstrating a ratio of geometric means of 0.4 (95% CI, 0.3-0.6) For peanut-specific IgG4, geometric mean levels were 535.5 ± 5 µg/L in the consumption group and 209.3 ± 3.8 µg/L in the avoidance group (ratio of geometric means, 2.6; 95% CI, 1.9 to 3.4).

Fulkerson said that these findings can assuage parents and doctors about the feasibility of early introduction and its long-term effects. “This isn’t something that has to be done for their entire lifetime,” she said. “They can only do it for a short period of time in these early years and they’ll be protected for at least until the 13-year mark.” In the future, researchers hope to expand their study into other food groups. “The evidence is clear for peanuts,” Fulkerson said. “But, what about early introduction of other foods? We don’t really have good, strong data to support the introduction of these other allergens. But that’s something that we want to build on as well.”

Reference:   Du Toit G, et al. N Engl J Med. 2015;doi:10.1056/NEJMoa1414850.

Dr. Sara Dever from Allergy & Asthma Care of Fairfield County, LLC comments: "We've known since the LEAP study that early introduction of peanut into the diet reduces the risk of peanut allergy. This study demonstrates that tolerance of peanut persists into teenage years and likely beyond, even if the child stops eating peanut regularly. The benefits of early introduction of other foods will likely be found to similar, but we await further data on other foods."

Subcutaneous immunotherapy for dust mites (allergy shots) reduces asthma risk and improves control

Subcutaneous allergen immunotherapy for house dust mite reduced the number of prescriptions for allergic rhinitis and asthma medications, according to a study published in The European Journal of Allergy and Clinical Immunology. Compared with a control group that did not use allergen immunotherapy (AIT), the subcutaneous immunotherapy (SCIT) group showed a reduced probability for asthma onset as well as for developing asthma from allergic rhinitis (AR) over time, Marek Jutel, MD, PhD, professor and head of the department of clinical immunology at the Wroclaw Medical University and director of the ALL-MED Medical Research Institute in Wroclaw, Poland, and colleagues wrote. The retrospective, observational, comparative cohort study was conducted in Germany using anonymized claims data from IQVIA LRx.

Participants included house dust mite(HDM) allergic subjects aged 5 to 70 years divided into an SCIT group (n = 892) and a control group (n = 2,676) evaluated over a 6-year follow-up. Subjects in the SCIT group received their first prescription of SCIT with a native HDM product between 2009 and 2013. The control group was matched in a 3:1 ratio and received prescriptions for only symptomatic AR medication with an evaluation period of up to 6 years ending in February 2017. The study measured the progression of AR and asthma, asthma occurrence and time to the onset of asthma after at least 2 years of treatment.

Results:

The progression of AR and asthma after up to 6 years of follow-up was measured by counting numbers of prescriptions in the retrospective claims database analysis. Mean annual AR prescription numbers fell from 0.48 before the index to 0.17 in the follow-up period for the SCIT group for a 62.8% reduction (P < .0001) but remained the same at 0.48 for the control group. Subanalyses showed that children and adolescents initially had more allergic rhinitis prescriptions (mean, 0.54; standard deviation [SD], 1.06) than adults (mean, 0.45; SD, 1.1), which after follow-up showed a reduction in the SCIT group by 53% (P < .0001) in underage patients and 66.5% (P < .0001) in adults.

The mean number of asthma prescriptions in the SCIT group dropped by 2.51 a year compared with 1.63 in the control group. This was equivalent to a 42.4% reduction in asthma prescriptions in the SCIT group compared with the non-AIT group (P = .0003). The SCIT group showed comparable results in children/adolescents (47.2%; P = .0051) and adults (39%; P = .0166). Within the SCIT group, 10.2% developed asthma from the index date up to the 6-year follow-up, whereas 13.1% developed asthma in the control group. Logistic regression showed that the SCIT group had a 27% less chance of developing asthma than the control group (OR = 0.73; 95% CI: 0.559-0.954).

The authors concluded that the native HDM SCIT product was effective in preventing asthma.

Dr. Kenneth Backman of Allergy & Asthma Care comments: "This study reinforces previous data that has shown that allergen immunotherapy helps reduce the risk of asthma development, and improves control of allergic rhinitis and asthma symptoms."

Xolair approved for food allergies

What is Xolair?

Xolair is an anti-IgE monoclonal antibody by Genentech and Novartis that works by inhibiting the allergic reaction process. On February 16, 2024, it was approved by the FDA for the reduction of food allergic reactions, including anaphylaxis, in people with food allergies.  

Is Xolair Approved for Food Allergies?

Yes. In February 2024, the FDA approved Xolair as the first and only medicine to reduce allergic reactions for people with one or more food allergy. It may not be appropriate for all patients with food allergy. Clinical criteria for the appropriate patients are still in development, but Xolair is available now for patients with severe food allergies. 

How Does Xolair Work?

Xolair is an anti-IgE monoclonal antibody that works by inhibiting the allergic reaction process. At Allergy and Asthma Care of Fairfield County, we will be offering Xolair for appropriate food allergy patients, and may in the future be using it in conjunction with oral immunotherapy.

For more background on oral immunotherapy with anti-IgE Xolair (omalizumab), we recommend the following published studies and meta-analysis:

• Omalizumab for the Treatment of Multiple Food Allergy (OUtMATCH)

• A Phase 2 Randomized Controlled Multisite Study Using Omalizumab-facilitated Rapid Desensitization to Test Continued vs Discontinued Dosing in Multifood Allergic Individuals, Lancet 2019
• Anti-IgE treatment with oral immunotherapy in multifood allergic participants: a double-blind, randomised, controlled trial, Lancet Gastroenterology and Hepatology, 2018
• Observational long-term follow-up study of rapid food oral immunotherapy with omalizumab, Allergy, Asthma & Clinical Immunology 2017
• Combining anti-IgE with oral immunotherapy, Pediatric Allergy & Immunology 2017
• Omalizumab facilitates rapid oral desensitization for peanut allergy, Journal of Allergy and Clinical Immunology 2017
• A randomized, double-blind, placebo-controlled study of omalizumab combined with oral immunotherapy for the treatment of cow’s milk allergy, Journal of Allergy and Clinical Immunology 2017

Is Xolair Covered by Insurance?

With the recent FDA approval of Xolair, it is likely to be covered by insurance. Previously, Xolair had been granted Breakthrough Therapy Designation for the prevention of severe allergic reactions to food allergy by the FDA, but this was considered an off-label usage and often not covered by insurance. If our allergist prescribes this medication for you, we can work with you and your insurance plan to help understand if there will be any out-of-pocket costs before proceeding.

From the AAAAI:

Study highlights a valuable option for safe and effective food allergy treatment.

Washington, DC – Sixteen weeks of omalizumab results in a higher tolerated threshold for multiple food allergies according to new research presented today at the 2024 American Academy of Allergy, Asthma & Immunology (AAAAI) Annual Meeting and published in the New England Journal of Medicine.
 
“Food allergies affect millions of individuals in the U.S., and those impacted face a daily threat of life-threatening reactions. This can lead to substantial anxiety with a profound effect on quality of life. To remain safe, constant vigilance is required and even then, accidental exposures are very common,” said Dr. Robert A. Wood, MD, FAAAAI, lead author of the study. “The OUtMATCH study demonstrated that omalizumab (Xolair) significantly increased the threshold for reaction in most patients for peanut and the six other foods studied, enough to provide real protection against small, accidental exposures. We are extraordinarily excited by this advance in the world of food allergy.”

The results found that in multi-food allergic patients as young as a year old, 16 weeks of omalizumab treatment was superior to placebo in increasing the reaction threshold for peanut and other common food allergens to levels that would likely protect against reactions upon accidental exposure. As food allergies are common, this study highlights a valuable option for safe and effective food allergy treatment.

Researchers screened 1- to 55-year-old participants who were allergic to peanuts and two additional study-specified foods. Study inclusion required food challenge reactivity to be less than 100 mg of peanut protein and less than 300 mg of two other foods. Participants were then randomized to receive 16 weeks of omalizumab or a placebo, after which the food challenges were repeated to find the proportion of participants who could ingest 600 mg or more of peanut protein and 1000 mg or more of the other foods without dose-limiting symptoms. The first 60 participants entered a 24-week open-label extension.

Of the 462 screened participants, 180 were randomized and 120 were treated with omalizumab. Of the omalizumab-treated participants 66.7% achieved the primary endpoint compared to only 6.7% of the participants who received a placebo. Most participants maintained or increased their reaction threshold during the open-label extension, and the treatment success was associated with higher total IgE, smaller skin test size and higher tolerated baseline food challenge dose. Safety outcomes were similar between the groups. The study was funded by the National Institute of Allergy and Infectious Diseases (NIAID), part of NIH. Genentech, a member of the Roche Group, and Novartis Pharmaceuticals Corporation also supported the work.

Visit the AAAAI to learn more about food allergies. Research presented at the AAAAI Annual Meeting, February 23-26 in Washington, DC, is published in an online supplement to The Journal of Allergy and Clinical Immunology.

The American Academy of Allergy, Asthma & Immunology (AAAAI) is the leading membership organization of more than 7,100 allergists, asthma specialists, clinical immunologists, allied health professionals and other professionals with a special interest in the research and treatment of allergic and immunologic diseases. Established in 1943, the AAAAI has more than 7,100 members in the United States, Canada and 72 other countries and is the go-to resource for patients living with allergies, asthma and immune deficiency disorders.

 

Prepare for spring pollen season

Winter may not be over, but now is the time to prepare for spring allergies. As temperatures rise, pollen and other allergens will fill the air, leaving you sneezing and wheezing instead of enjoying sunnier days. To prepare for spring allergies, consider starting your medication at least two weeks before symptoms start. For many people, mid-February, around Valentine’s Day, is the ideal time to start your allergy medication routine.  The allergists at Allergy and Asthma Care of Fairfield County, all members of the American College of Allergy, Asthma, and Immunology, want to help you stay ahead of  allergy symptoms this spring. Check out the ACAAI’s top seven tips to help you protect yourself from allergens and reduce allergy symptoms.

1. Close your windows

Although your house may feel a bit stuffy after being closed up all winter, resist the urge to throw open your windows for a breath of fresh air. Leaving your windows open invites allergens like pollen into your home. Instead, during pollen season, keep them closed and run air conditioning to improve airflow and generate a little breeze.

2. Use filters

Even if you’re careful to keep windows and doors closed, allergens can still sneak into your home. Invest in High-Efficiency Particulate Air (HEPA) filters for an air cleaner for a single room. Check to see that the filter has a CADR (clean air delivery rate) that matches the size of the room where it will be used. If your home has a central heating, ventilation and air conditioning (HVAC) system, you can turn it into a “whole house” filtration system by installing a better permanent or disposable air filter. Remember to check and change filters regularly so you can continue breathing easily at home.

3. Change your clothes

Changing into comfortable clothes when you get home can be relaxing and help you manage your allergies. Pollen and other allergens can stick to your clothing, shoes, hats and other accessories. As soon as you get home, ditch your outside clothes for a clean, pollen-free outfit. Also, make it a habit to set these clothes in the laundry room to wash as soon as possible.

4. Add a shower to your evening routine

If you don’t shower at night, it may be time to consider a switch. Rinsing off before bed can wash away allergens that cling to your hair, face and body throughout the day. It will also prevent you transferring pollen to your pillow. Best of all, a warm shower before bed can be incredibly relaxing. So, add a shower to your evening routine and wake up refreshed and ready to take on the day.

5. Know your allergy triggers

Do you know your allergy triggers? The causes of your specific allergies can vary. Whether you have pollen allergies or suffer from pet allergens or dust mites, it’s a good idea to get tested by a board-certified allergist. They can help take the guesswork out of allergy management so you can better avoid allergy triggers. Also, be aware of when allergy season starts in your region. In southern climates, spring allergy season often begins as early as mid-February and can be in full swing before the first of March. It may be mid- to late March before pollen season starts in colder climates. Check the internet for the specifics of pollen levels near you.

6. Find the right medication

Is your medication effective in managing your allergy symptoms? If not, you might not have found the right match. For example, if antihistamines aren’t working, it may be time to give nasal sprays a chance. You may even consider allergen immunotherapy, also known as allergy shots, which can be extremely effective for treating grass and pollen allergies and can help prevent and control asthma.

7. Talk to a professional

While there are many steps you can take on your own to keep allergy symptoms at bay, it’s always a good idea to talk to an expert. Allergists are the best-trained medical professionals to treat allergies and asthma. They can help you manage allergy challenges, so you’re better equipped to deal with them and feel better this spring and beyond.

Using these seven simple tips, you can get ahead and stay ahead of allergies. To learn more about your specific allergies and how to best control them, please contact our office at 203-259-7070.

High intensity interval training leads to reduced inhaled corticosteroid dose in asthma

Inhaled corticosteroid (ICS) is a potent anti-inflammatory agent that attenuates airway inflammation, improves asthma control, and lowers the risk of acute worsening. However, due to local and systemic side effects, and various other reasons, many patients wish to take as little medication as possible. Furthermore, some patients, especially those with obesity and type 2 low inflammation, tend to respond less to ICS treatment. As aerobic exercise improves asthma control, it could be a putative strategy to lower ICS dose without compromising asthma control. Although exercise is widely accepted as a supplementary treatment of asthma, its potential for reducing the need for ICS has yet to be evaluated.

In a recently published study in The Journal of Allergy and Clinical Immunology: In Practice, Pitzner-Fabricius et al. undertook a randomized controlled trial investigating the corticosteroid-sparing effect of 6 months of supervised high-intensity interval training (HIIT) 3-times a week using spinning-bikes. An additional 6 months of follow-up was included to evaluate the long-term effects of the exercise intervention.

A total of 150 untrained patients with symptomatic, persistent asthma, treated year-round with ICS, were included. Participants were randomly assigned to either an exercise group (n=102) or a control group (n=48), using asthma symptoms, level of blood eosinophilia and sex as stratification factors. A clinical assessment was performed by a blinded assessor at baseline and every second month. The patients in both groups had their asthma treatment adjusted (e.g., reduced, increased or no change) based on this assessment using a rigid, predefined algorithm. The main scope was to evaluate if exercise could reduce the dose of daily ICS, while the secondary outcomes focused on markers of disease control and physical activity.

Compared with the control group, the exercise group experienced a significant reduction in their daily use of ICS. After six months of HIIT, the reduction was 234ug, corresponding to a 24% reduction, and this was increased to 32% after the follow-up period. Importantly, this reduction was found without compromising markers of asthma control, including inflammatory markers, asthma symptoms, and exacerbations. The authors performed a subgroup analysis to identify patients with a large (two-step) reduction in asthma treatment based on baseline characteristics. This analysis showed that patients with uncontrolled asthma, based on either symptoms or an exacerbation requiring systemic steroid, and female patients with obesity were significantly more likely to be large responders when allocated to the exercise group. This knowledge could guide clinicians in identifying patients likely to benefit greatly from aerobic exercise. The authors conclude that their results add to the mounting data suggestive of exercise having a role in future asthma management beyond the general health benefits.

Dr. Sara Dever of Allergy & Asthma Care comments: "This study adds to the evidence that aerobic exercise can improve asthma control. Regular exercise is important for a wide range of health benefits, and it is becoming increasingly clear that improved asthma control is one of them."

Protocol eliminates or mitigates hypersensitivity reactions to iodinated contrast media

Key takeaways:

• 84.8% of patients who followed the protocol completed CT scans without any adverse reaction.
• 53.3% of patients who did not follow the protocol experienced a recurrent reaction.

A two-track protocol helped physicians select safe iodinated contrast media for patients with immediate hypersensitivity reactions, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.

Patients who followed the protocol had lower rates of recurrence and reduced severity in recurrent cases, Ji-Hyang Lee, MD, PhD, of the department of allergy and clinical immunology at Asan Medical Center, University of Uslan College of Medicine, and colleagues wrote. The study comprised 427 patients (mean age, 54.65 years; 61.6% women), including 349 (81.7%) who had been exposed to iodinated contrast media (ICM) a mean number of 5.45 times before experiencing an immediate hypersensitivity reaction (IHR). Causative agents included iohexol (Omnipaque, GE Healthcare; 23.4%), iopamidol (Pamiray, Dongkook Lifescience; 17.8%), iomeprol (Iomeron, Bracco; 17.8%), iobitridol (Xenetix, Guerbet; 13.6%), ioversol (Optiray, Guerbet; 12.6%), iopromide (Ultravist, Bayer Healthcare; 7.7%) and iodixanol (Visipaque, GE Healthcare; 7%).I

The protocol began with by taking each patient’s history of ICM hypersensitivity, followed by intradermal testing (IDT) with the causative ICM. Patients with negative skin tests then received premedication and a randomly changed ICM during their next CT examination. Those with a positive IDT received additional skin tests with other available ICMs, and they underwent their next CT examination with premedication and an ICM that yielded a negative IDT. The protocol concluded with assessment of any IHR that may have followed. With a mean time interval between the index event and skin test of 14.38 months, IDT using the causative agent yielded negative results for 283 patients (66.3%) and positive results for 144 patients (33.7%).

After undergoing the IDT, 86 patients with positive results and 213 with negative results were re-exposed to ICM. This group included 269 patients who followed the study protocol and 30 who did not. The group that followed the protocol included 41 (15.2%) who experienced recurrent IHR and 228 (84.8%) who completed their CT scans without any adverse reactions.

Meanwhile, 16 patients (53.3%) who did not follow the protocol experienced an IHR. Thus, the protocol effectively prevented IHRs (P < .001), the researchers found. Among the patients who did not follow the protocol, both patients who used an IDT-positive ICM experienced recurrence, as did 12 of the 16 patients (75%) who did not change the ICM and one of the 11 patients (9.1%) who did not receive premedication.

Among the 355 re-exposure cases, a greater proportion of patients who did vs. did not follow the protocol completed their re-exposure without an IHR (86.5% vs. 51.4%; P < .001). Recurrence rates included 14.9% among patients whose previous reactions were mild, 13% among those whose previous reactions were moderate and 13.1% among those with severe previous reactions, with no statistical differences between these groups. Breakthrough reaction rates in skin tests with culprit ICMs included 18.4% (14 of 76) in the IDT-positive group and 14% (27 of 193) in the IDT-negative group. Also, iodixanol was prescribed in a greater proportion of cases that did vs. did not have repetitive IHR (34.2% vs. 15.8%; P = .005).

Among those who followed the protocol, percentages of moderate and severe cases decreased significantly from the index to recurrent reactions, while the percentage of mild cases increased (P = .003 with American College of Radiology criteria and P = .013 with Brown’s criteria). Conversely, IHR severity did not change significantly among the patients who did not follow the protocol.Finally, with 237 patients getting skin tests with at least two different ICMs, cross-reactivity included iohexol and ioversol (21.9%), ioversol and iomeprol (19%) and ioemprol and iohexol (18.1%), with greater than 10% cross-reactivity between iohexol and the other six ICMs that were tested. Based on these findings, the researchers concluded that their protocol reduced the recurrence of IHRs by 85.8% among patients with previous reactions and mitigated the severity of hypersensitivity reactions when recurrent cases did happen.

Dr. Kenneth Backman of Allergy & Asthma Care comments: "This study demonstrates the effectiveness of a testing protocol in dramatically reducing the risk of recurrent reactions to iodinated contrast media (CT scan dye. While most allergy practices do not have access to these contrast media to perform these tests, academic centers should be able to implement this protocol to protect patients with a history of iodinated contrast media reactions."

Testing options for insect sting allergy

PARK CITY, Utah — Patients who have had systemic reactions to insect stings should be evaluated, including education and testing, according to a presentation here. “We all try to avoid stinging insects,” Melinda M. Rathkopf, MD, MBA, allergist and immunologist with Children’s Healthcare of Atlanta, said during her presentation at the Association of PAs in Allergy, Asthma and Immunology Annual Allergy, Asthma & Immunology CME Conference. “But we’ll talk a little more.”  Education should include avoidance, according to Rathkopf, who also is a provisional associate professor of pediatrics in the division of allergy and immunology at Emory University School of Medicine, and patients should be considered for venom immunotherapy when testing is positive.

Insect avoidance

Patients with systemic reactions to insect stings should be instructed to avoid preparing, grilling or eating food outdoors, Rathkopf said. They also should avoid flowering plants and drinking from straws, cans or bottles outdoors.“[If] you’re going to have a can at a picnic, have something over it,” she said, adding that she has taught her children to hold any cans that they are drinking out of up to their ear to listen for any insects that may have flown or crawled inside. Fallen fruit and pet feces should be removed from yards as well, she continued. Plus, trashcans should be covered. When mowing the lawn, patients should watch out for nests in the bushes or in the ground. Patients should avoid going barefoot outdoors as well. Insect repellants are not effective, Rothkopf said, and neither is avoiding fragrances or brightly colored or floral clothing. “We used to say, ‘Don’t look like a flower. Don’t smell like a flower,’” she said. “That really doesn’t seem to change it.”

Patient evaluations

Venom-induced anaphylaxis may include skin symptoms such as generalized urticaria, flushing and angioedema.“In most children, this can be the sole manifestation. About 60% of those will just have these skin symptoms,” Rathkopf said. “But only about 15% of adults with systemic reactions develop cutaneous isolation.”Adults are more likely to have respiratory symptoms such as a hoarse voice, upper airway obstruction, shortness of breath and wheezing or cardiovascular symptoms such as lightheadedness to hypotension, shock and circulatory collapse.“You want to test patients with suspected or known systemic allergic reaction to sting,” Rathkopf said, adding that patients with a history suggestive of or convincing for a past systemic allergic reaction to a sting that involved organs other than the skin should be tested as well.

However, she continued, patients with cutaneous systemic reactions should not be tested.“The chance of a future systemic reaction has been estimated to be about 7% to 10% per sting,” Rathkopf said. “Most of these reactions are limited to the skin, and less than 3% will have severe anaphylaxis.” Testing and immunotherapy(allergy shots) are not indicated in most of these cases, Rothkopf advised. Patients who do not have a sting history should not be tested either, she continued. These patients may be concerned about the possibility of a severe reaction to a sting because someone in their family has a venom allergy, Rathkopf explained, but that does not mean that they should be tested, nor should they be recommended for immunotherapy. Additionally, most patients who have large local reactions should not be tested. These reactions come with a 5% to 10% risk for a future systemic reaction, with less than a 3% risk for anaphylaxis. Testing and immunotherapy, Rathkopf said, are not indicated.

Testing options

Skin testing and in vitro testing are options for venom-specific IgE, Rathkopf said, but skin testing is preferred for initial testing in most patients because it is more sensitive and less expensive in most health care systems. “Skin testing is positive in 66% to 90% of patients with a history suggestive of venom,” Rathkopf said. “Fifteen percent to 20% of those with positive skin tests will have negative in vitro blood tests.” When skin testing is positive and results support the clinical history, she said, in vitro testing is not necessary.

Also, 5% to 10% of patients with negative skin tests may have in vitro results that are positive. In vitro testing is indicated when skin testing is negative with a suggestive clinical history or when it cannot be performed. It also is helpful when the skin testing results and clinical history are not consistent or when they leave unanswered questions, according to Rathkopf. “The combination of skin testing and in vitro together, though, should detect 95% of patients who will have a systemic reaction to a subsequent sting,” she said. Rathkopf recommended testing occur at least 4 to 6 weeks after the sting because tests that are administered immediately after the sting can be negative.  “You can test, but if it’s negative, you have to retest,” Rathkopf said, adding that retesting is expensive and invasive. Testing also should include venoms from all the potentially relevant insects that inhabit the area. “In the U.S., that pretty much means honeybee, yellowjacket, yellow hornet, white-faced hornet and wasp,” Rathkopf said. Typically, testing is intracutaneous or intradermal. It is not necessary to use skin prick testing first, Rathkopf said, unless the patient has had severe anaphylaxis and may be highly sensitive to venom at concentrations of 100 µg/mL.

“If I had someone very high risk, I would probably start with specific IgE testing in the blood first,” Rathkopf said. Honeybee, yellowjacket, white-faced hornet, yellow hornet and wasp venom extracts all are available for skin testing and venom immunotherapy. When the history is positive but the skin test is negative, Rathkopf recommended sIgE testing and basal serum tryptase. “And you may need to repeat the skin test in 3 to 6 months,” she continued.

When the history is positive but the tests are a mix of positive and negative results, Rathkopf said, further evaluation for negative venoms based on serum IgE and/or repeat skin tests may be needed to identify potentially relevant sensitivities before venom immunotherapy begins. “Even repeat negative in vitro skin test results do not fully exclude the possibility of anaphylactic reactions,” Rathkopf said. In vitro testing is indicated for patients who have a convincing clinical history of systemic symptoms following a sting and negative skin testing. It also is indicated for patients who cannot participate in skin testing because of a dermatographism or severe or active skin diseases. Additionally, some patients cannot get skin tests because they cannot discontinue medications that can render the skin unreactive such as high-dose tricyclic antidepressants. In vitro testing is indicated when evaluation is needed in the initial weeks following a systemic event and there is concern that skin reactivity may be suppressed. “Or, again, when the results of skin testing are not fully consistent with the clinical history and you still have some questions,” Rathkopf said.

CT MAGAZINE TOP DOCS 2023

We are pleased to announce that all three of our physicians, Drs. Kenneth Backman, Katherine Bloom, and Sara Dever, are listed in this year's CT Magazine Top Doctors issue. CT Magazine uses Castle Connolly for their doctor ratings. Please click on the link below to see the listing.

Castle Connolly Top Doctors

Tree nut oral immunotherapy deemed safe for preschoolers, under investigation

OIT (oral immunotherapy) for tree nut allergies was safe and tolerable among a preschool population with results comparable to OIT for peanut allergy, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice. Considering these results, tree nut OIT should be offered as an alternative to strict avoidance, Stephanie C. Erdle, MD,FRCPC, investigator and allergist, division of allergy and immunology, department of pediatrics, University of British Columbia, BC Children’s Hospital, and colleagues wrote

The study involved 92 children (median age, 35 months; 65.2% boys) enrolled in tree nut OIT as part of the Food Allergy Immunotherapy registry at four community and academic allergy clinics in Canada between August 2018 and April 2021. These patients included 79 (85.9%) with a single tree nut allergy, including cashew (n = 58), walnut (n = 19), hazelnut (n = 1) and macadamia (n = 1). Also, 13 (14.1%) had allergies to multiple tree nuts, including 10.8% with allergies to two tree nuts and 3.3% with allergies to three tree nuts, including combinations of cashew, walnut, hazelnut and almond.

Additionally, 88 (95.7%) had histories of reactions to at least one tree nut, including 35 (38%) grade 1 reactions, 49 (53.3%) grade 2 reactions, no grade 3 reactions and four (4.3%) grade 4 reactions. Nineteen (20.7%) of the patients had a baseline oral food challenge. Also at baseline, median tree nut specific IgE level was 4.02 kU/L (IQR, 1.14-9.61) and skin prick test wheal diameter was 8 mm (IQR, 6 mm-10 mm). Doses were escalated every 2 weeks for 37 (40.2%) of the patients, every 2 to 4 weeks for 44 (47.8%) and every 4 weeks for 11 (12%).

Four patients (4.3%) dropped out of treatment, and 88 (95.6%) reached maintenance. Three of those who dropped out were on OIT for cashew allergy, and the fourth was on OIT for walnut and cashew allergy. One of these patients dropped out due to moving. The other three dropped out for symptom-related reasons, including one due to abdominal pain and another who experienced delayed vomiting after dosing, which the researchers said could be consistent with eosinophilic esophagitis such as OIT-related syndrome. During the buildup phase, 70.6% experienced symptoms, including 35 (38%) who experienced grade 1(mild) reactions and 30 (32.6%) who experienced grade 2 reactions(mild to moderate,) with no grade 3 or 4 reactions.

Among patients treated for one tree nut allergy, 53 (67%) had grade 1 reactions and 25 (31.6%) had grade 2 reactions, and 53% of these grade 2 reactions were isolated gastrointestinal symptoms such as abdominal cramps, vomiting or diarrhea that did not require treatment. Physicians considered 26.7% of the remaining grade 2 reactions to be mild reactions that did not require epinephrine. However, the physicians said they would have recommended epinephrine for 20% of these remaining reactions. Two patients (2.53%) receiving OIT for single tree nut allergies received epinephrine for their grade 2 reactions. One of them (1.27%) went to the ED. Four patients who should have received epinephrine based on the physicians’ recommendations did not.

The researchers reported that these patients all received education about the importance of epinephrine after these reactions and before they continued with OIT. The patients treated for multiple tree nut allergies included seven (53.8%) with grade 1 reactions and six (46.2%) with grade 2 reactions. None of the patients treated for multiple allergies received epinephrine or went to the ED. The researchers did not report any significant differences in frequency or grade of reaction based on the timing of the dose escalations. Also, none of the patients were diagnosed with EoE during buildup.

According to the researchers, these findings were consistent with their previous research in peanut OIT, which found 67.8% of patients experiencing symptoms, 4.07% receiving epinephrine, 0.37% diagnosed with EoE and 10% dropping out during buildup. The researchers expressed confidence that the safety profile for tree nut OIT for a preschool population was comparable to the safety profile for peanut OIT in this age group, which is now common, and that physicians should not hesitate to offer it.

Similarly, the researchers expect the effectiveness of OIT for tree nut allergy to be comparable to peanut OIT as well. Next, the researchers said they will continue to examine the safety and tolerance of tree nut OIT as well as its effectiveness based on follow-up OFCs and its impact on quality of life in this age group.

Reference: Soller L, et al. J Allergy Clin Immunol Pract. 2019;doi:10.1016/j.jaip.2019.04.010.

Dr. Kenneth Backman of Allergy & Asthma Care comments: "Early peanut oral immunotherapy has been shown to be safe and effective for infants and toddlers, and helps protect these peanut allergic children from accidental reactions. There is now emerging evidence that this age group can also be safely treated for tree nut allergy as well. This represents a huge advance in the management of life threatening food allergies in young children. While this is still experimental, the data is promising"

 

Allergen immunotherapy improves quality of life in children with nasal and eye allergies

Pollen subcutaneous immunotherapy("allergy shots") improved health-related quality of life (HRQoL), decreased symptom scores with 1 year of treatment, and maintained improvements for the next 2 years (total observation was 3 years) among children and adolescents with allergic rhinoconjunctivitis, according to study findings published in Allergy, Asthma & Clinical Immunology. Researchers sought to assess the effect of pollen subcutaneous immunotherapy (SCIT) on HRQoL and to characterize the association between HRQoL and symptoms of allergic rhinoconjunctivitis among children and adolescents.

The researchers conducted a longitudinal prospective cohort study at a pediatric clinic in Stockholm, Sweden, from 2012 to 2016 that included 158 children (mean age 11 years, range 5-16 years; 52 girls) on SCIT (birch and/or grass). This allergen-specific immunotherapy was offered if allergic rhinoconjunctivitis symptoms were poorly controlled with standard treatment. At index and after 1, 2, and 3 years of treatment, researchers measured HRQoL (via DISABKIDS questionnaires), symptoms (using unvalidated scoring questions) and allergen-specific IgE and IgG4 antibodies (via blood test or skin prick test). Among the study population, 77% received allergen treatment for birch, 8% for grass, and 15% for birch and grass. At index, 26% of participants had rhinoconjuncitivitis, and 74% had asthma and rhinoconjunctivitis.

Researchers found overall HRQoL mean scores improved from 79.5 (index) to 85.1 after 1 year of pollen SCIT (P <.001). These improvements were maintained after year 2 (mean 84.8) and year 3 (mean 87.2).  Also with respect to HRQoL, investigators found statistically significant improvements in participants’ scores after 1 year of pollen SCIT for independence (from 80.3 to 86.3; P ≤.001), inner strength (from 81.7 to 89.0; P ≤.001), equality (from 87.0 to 91.7; P ≤.001), and physical ability (from 67.0 to 74.7, P ≤.001), with these improvements maintained during the study period. Boys reported significantly greater improvement in physical ability than girls after both 2 and 3 years of SCIT, and younger children (age 5 to 10 years) reported significantly greater improvement in physical ability than older children (age 11 to 16 years) after 1 year of treatment. No other significant improvement in HRQoL results were noted between participant subgroups.

Mean symptom scores decreased from 19.9 (index) to 11.5 after 1 year (P <.001); this was maintained for year 2 (mean 11.9) and year 3 (mean 10.3).  Subgroup analysis of girls, boys, and younger and older children showed similar results. Overall, researchers noted a decrease in the proportion of children with severe or very severe symptoms, from 35.6% to 4.5%, after 1 year of SCIT. Allergen-specific IgE antibodies showed a statistically significant decrease for birch (from 151.0 to 76.8kU/L), and IgG4 antibodies showed a statistically significant increase for grass (from 0.5 to 14.3g/L) and birch (from 2.2 to 17.6g/L) during the study period (all P <.001). Study limitations include lack of placebo control, the use of subjective and objective circumstances inherent in measuring HRQoL, parental bias in questionnaire responses (especially among younger children), use of unvalidated instruments for measuring symptom scores, and lack of data on medication use during immunotherapy.

“In children and adolescents with allergic rhinoconjunctivitis, pollen SCIT improved HRQoL and decreased symptom scores after 1 year of treatment, and the improvements were maintained during the study years,” researchers concluded. “The proportion of severe and very severe symptoms significantly decreased after 1 year of pollen SCIT,” they added. “Further there was a decrease in IgE levels and an increase in IgG4 levels after 3 years’ SCIT.”

From: Agenäs H, Brorsson AL, Kull I, Lindholm-Olinder A. Treatment with pollen allergen immunotherapy improves health-related quality of life in children and adolescents: A 3-year follow-up-study. Allergy Asthma Clin Immunol. Published online January 17, 2023. doi:10.1186/s13223-023-00756-9

Dr. Kenneth Backman of Allergy & Asthma Care of Fairfield County comments:  "We've long known that subcutaneous allergen immunotherapy is highly effective for pollen allergy, as well as dust mites, molds, and pet allergies. This study confirms that children not only see symptom improvement, but see significant quality of life benefits from allergy injections. Allergy injections remain the most effective natural, nonmedication treatment for airborne allergies, buidling the body's tolerance of allergens rather than just suppressing symptoms."

Moisture damage and mold in the home during infancy associated with persistent childhood wheeze

Residential exposure to moisture damage and mold during infancy had a dose-dependent association with wheeze later in childhood, according to a study published in Pediatric Allergy and Immunology. Exposures were particularly associated with persistent and recurrent wheeze, which is a risk factor for later asthma, Anne M. Karvonen, PhD, adjunct professor and chief researcher, Finnish Institute for Health and Welfare, Department of Health Security, Environmental Health Unit, and colleagues wrote.

The researchers examined data from 214 rural and 228 suburban children in the LUKAS cohort born between September 2002 and May 2005 in middle and eastern Finland. Trained civil engineers inspected their homes for moisture damage when the children were aged a mean 5.42 months, finding minor moisture damage in the child’s main living areas in 23.8% of the homes and major moisture damage or any moisture damage with visible mold in 13.4% of the homes.  “We have previously shown that moisture damage and visible mold in a child’s main living area — including the child’s bedroom, living room and kitchen — of the house are associated with an increased risk of developing asthma,” Karvonen said.

Over the following 6 years, 63.4% of the children had no or infrequent wheezing, 23.3% had transient wheezing, 3.8% had intermediate wheezing, 3.5% had late-onset wheezing and 6% had persistent wheezing. Adjusted analyses revealed a dose-dependent association between moisture damage or mold in the child’s main living area and an increased risk for persistent wheeze, with adjusted odds ratios of 2.04 (95% CI, 0.67-6.18) for minor moisture damage, and 3.68 (95% CI, 1.04-13.05) for major damage or any moisture damage with visible mold. Persistent wheeze also tended to be associated with minor and major moisture damage in the living room, in the child’s bedroom and in other main living areas, although confidence intervals were wide due to small numbers, but not in the bathrooms, other interior spaces or the whole house.

“According to our study, moisture damage in the main living area where children spend most of their time is particularly associated with persistent asthma, not transient asthma. Transient asthma is associated with infections in small children,” Karvonen said. Further, the researchers found nonsignificant associations between transient wheeze and minor damage with or without mold spots (aOR = 1.59; 95% CI, 0.85-2.99) and major moisture damage or any moisture damage with visible mold (aOR = 1.75; 95% CI, 0.78-3.94), driven by exposures in the kitchen but not other living spaces.

Based on these results and their previous studies, the researchers concluded that exposure to moisture damage and mold during infancy was associated with wheeze, especially its persistent and recurrent phenotypes. Considering these risks, which include later asthma outcomes, the researchers wrote, home environments need to be free of major moisture damage during early childhood. “The risk of asthma is increased if the moisture damage and/or mold is located in the rooms, or if there is an air connection from damage to these rooms, where children spend most of their time,” Karvonen said.

Families can prevent this risk for asthma caused by moisture damage by keeping their homes and indoor environments in good condition, Karvonen added, noting that she and her team will continue their research. “We’re trying to figure out what kind of microbes explain the association between moisture damage and asthma,” she said. “It is now well known what causes the adverse health effects of moisture damage.”

Dr. Kenneth Backman of Allergy & Asthma Care comments: "This study demonstrates that mold exposure in infancy increases the risk of wheezing and asthma. It is one more study confirming the critical importance of exposures in infancy in the development of allergies and asthma. It is important to remediate water damage and avoid mold in interior living spaces."

Begin medications in late February or early March to help prevent spring allergy symptoms

It's important to begin allergy meds two weeks before symptoms are expected to appear when possible, according to the American College of Allergy, Asthma and Immunology (ACAAI).  And although spring allergies aren't necessarily top of mind in February, climate change means that temperatures are rising, and allergy symptoms occur earlier in the year," May said in a college news release. "In southern regions of the United States, allergies often start at the end of January." In the northeast, it is recommended to start medications in late February or early March, as pollen season can begin as early as mid-March.  The ACAAI offered several other suggestions for those who suffer during spring allergy season.

 

Seasonal allergies can look different for different people, with symptoms that might include sneezing, sniffling, coughing and red, itchy eyes. An allergist can identify what your triggers are, the ACAAI suggested. If over-the-counter medications don't help, ask about possible prescription treatments. Patients with these symptoms should be tested for allergies to pets, dust mites, trees, grasses, weeds and mold. Medications known as intranasal corticosteroids are the most effective treatment for these persistent allergy symptoms. These include fluticasone, mometasone, budesonide and triamcinolone. They may even help control the symptoms that accompany eye allergies.

 

Other medications may have side effects. Pseudoephedrine, for example, clears up nasal congestion but can bring on insomnia, loss of appetite, irritability and heart palpitations. It should not be taken by someone who is pregnant. Some states allow it to be dispensed only by prescription. The ACAAI suggests not using antihistamines such as diphenhydramine, better known as Benadryl, and chlorpheniramine, sold as ChlorTrimeton. They can cause drowsiness as well as dry mouth, dry eyes and constipation.  Look instead for medications that don't cause sedation, the ACAAI advised. These include cetirizine, levocetirizine, fexofenadine, loratadine or desloratadine.

 

One of the best methods for targeting allergens is immunotherapy, the group said. These shots or tablets are formulated for your specific allergy triggers and can greatly reduce the severity of symptoms. They can also prevent development of asthma in some children with seasonal allergies, the ACAAI said.

 

More information

The U.S. National Center for Complementary and Integrative Health has more on seasonal allergies.

SOURCE: American College of Allergy, Asthma and Immunology, news release, Jan. 24, 2023

Early peanut introduction can prevent peanut allergy for infants across risk categories

LOUISVILLE, Ky. — The medical community should ask two questions about preventive peanut allergy interventions among infants, according to a presentation at the American College of Asthma & Immunology Annual Scientific Meeting. “First, is it worthwhile targeting the whole population of infants if only a fragment of the population is at risk for peanut allergy?” Gideon Lack, MD, professor of pediatric allergy at King’s College London and head of the children’s allergy service at Guys’ and St. Thomas’ NHS Foundation Trust, said in his presentation. “But if a significant amount of peanut allergy occurs across different groups of the population, then is it worthwhile targeting all these groups?” he continued. “We need the second question to be answered.”

Lack and his colleagues conducted a meta-analysis of two studies — LEAP, or Learning Early About Peanut Allergy, and EAT, or Enquiring About Tolerance — which examined the effects of early introduction of peanut into infants’ diets. “We put them into an integrated database using skin tests, specific IgE and positive challenge outcomes, and this provides for a more accurate overall effect estimate,” Lack said. “It increases the power because we’ve got a larger sample size. But it allows you to look into covariates and subgroups with more precision and more power as well.”

For example, 33.3% of the infants with severe eczema who avoided peanut introductions developed peanut allergy. But despite this high risk, these infants only comprise 6.64% of the peanut allergy population burden, Lack said. Applying peanut allergy prevention strategies to these patients only reduces the overall burden by 4.55%. Infants who do not have eczema do not have increased risk for peanut allergy, so why bother subjecting them to allergy prevention interventions, Lack asked hypothetically. “They actually make up 33% of the peanut allergy burden because although the risk is lower, there are more of these kids around,” Lack explained. “You need to focus on these kids as well.”

Ethnicity is another risk factor, Lack said, noting how the intervention does not seem to work as well among non-white infants in Australia, and particularly does not work well for Asian infants. “But here across the board, you can see in intention-to-treat and per-protocol populations that there is a big treatment effect whether you’re Asian, Black, Caucasian or mixed ethnicity,” he said. Skin prick testing also indicated successful treatment when infants in Sweden and Norway, who consumed peanut protein five times a week beginning at age 12 weeks, were compared with those who avoided peanut. “We showed a very big effect in the intention-to-treat group and an even bigger effect in the per-protocol group, about a 75% reduction,” Lack said. “This would seem to work around the world.”

Although peanut allergy occurs most often in infants with severe eczema or egg allergy, Lack said, most of the population burden is experienced by infants who do not have eczema or who have mild eczema because they make up most of the population. Although targeting early peanut introductions exclusively to infants with severe eczema would reduce the population burden of peanut allergy by 6%, early introduction across the entire infant population would reduce the burden by 88%, he continued. The intervention also is highly effective for all infants regardless of their risk category, including eczema severity, ethnicity, egg allergy and sensitization, Lack said, and it is most effective when it is initiated before age 6 months. “All infants in the general population will be encouraged to consume peanut products once they have reached 4 months of age,” Lack said.

Dr. Kenneth Backman of Allergy & Asthma Care of Fairfield County comments: "We have good evidence that early introduction of peanut in high risk infants dramatically reduces the likelihood of peanut allergy. This study demonstrates that all infants, regardless of risk factors, benefit from early introduction of peanut with reduced risk of allergy development. It's become clear that introducing highly allergenic foods into the diet of infants under age 1 year can help reduce the likelihood of food allergy."

Early emollient use reduces incidence of atopic dermatitis among high-risk infants

Infants at high risk for atopic dermatitis who used emollients daily through their first 2 months of life experienced less disease in their first year than high-risk infants who did not use emollients, according to study results. The high adherence rates among participants indicate that this emollient use represents a feasible and family friendly strategy for AD prevention as well, Carol Ní Chaoimh, BSc, PhD, a postdoctoral researcher at University College Cork and project manager at the INFANT research center at University College Cork, both in Cork, Ireland, and colleagues wrote in the study, published in Allergy.

The randomized controlled clinical trial involved 321 infants recruited at Cork University Maternity Hospital with at least one parent with a self-reported history of AD, asthma or allergic rhinitis, indicating that the infants were at high risk for AD as well. Within 4 days of birth, researchers randomly assigned 161 of these infants to a group that would apply Aveeno Dermexa Fast & Long-Lasting Balm (Johnson & Johnson) twice a day to their whole body for the first 8 weeks of life, and 160 to a control group that would follow standard skin care advice given at the hospital. Caregivers and infants attended study visits throughout the next 12 months, and caregivers completed questionnaires and maintained study diaries.

Most of the participants in the treatment group applied emollients once or twice daily at 2 weeks (89%; 63.3%) 4 weeks (91.7%; 69.2%) and 8 weeks (86.6%; 73.1%), with 68.2% of the control group reporting emollient use less than four times a week at all three time points. None of the families sought emergency medical assessments due to the intervention. Also, parent-reported skin infections occurred in 5% of the treatment group and 5.7% of the control group during the 8-week intervention period. Cumulative incidence rates of AD at 12 months, which served as the primary outcome, were 32.8% for the treatment group and 46.4% for the control group (RR = 0.707; 95% CI, 0.516-0.965). These rates at 6 months, which was one of the secondary outcomes, included 18.3% for the treatment group and 36.4% for the control group (RR = 0.503; 95% CI, 0.325-0.779).

Overall, a time-to-event survival analysis showed the treatment group remained AD free for a longer period during the first 12 months than the control group (P = .016). The study cohort also included 253 patients who provided filaggrin gene (FLG) genotype data, including 44 (17.4%) with loss-of-function FLG mutations, which lead to skin barrier defects and contribute to the inherited risk for AD. The effect size associated with the intervention was greater at 6 months among those with FLG mutation (RR = 0.337; 95% CI, 0.13-0.873) than those with wild-type FLG (RR = 0.527; 95% CI, 0.318-0.871), with a nonsignificant trend showing the same association at 12 months (mutated, RR = 0.524; 95% CI, 0.265-1.036; wild type, RR = 0.722; 95% CI, 0.502-1.038).

The researchers noted that the mechanisms behind the reduced incidence of AD among the patients who used daily emollients is unclear, although they added that an ongoing analysis of microbiome diversity and inflammatory markers in a subgroup of these patients may provide additional information. Additionally, the researchers called for studies that would examine the use of more complex emollients that would enhance the skin barrier in various populations and ethnicities. These studies should identify an effective and acceptable treatment window for patients and caregivers as well, the researchers continued.

Children with asthma not at increased risk of COVID-19 infection

In a new study published in Pediatrics, researchers concluded that children with asthma have similar risk for for SARS-CoV-2 infection compared with children without asthma.“We found no evidence that children with asthma are at higher risk of COVID-19 or of developing severe illness from COVID-19,” Matthew Kelly, MD, MPH, associate professor of pediatrics and global health, associate program director of the Pediatric Infectious Diseases Fellowship and associate director of physician-scientist development in the Office of Pediatric Education at Duke University School of Medicine in Durham, North Carolina, told Healio.

Kelly and colleagues conducted a retrospective cohort study that included 46,900 children aged 5 to 17 years in the Duke University Health System with a Durham County, North Carolina, residential address. Children with asthma were classified using previously validated electronic health record-based definitions, and SARS-CoV-2 infections were identified via positive polymerase chain reaction testing of samples collected from March 2020 to September 2021. Children with asthma were matched to those without asthma.

“Because severe asthma exacerbations are often associated with respiratory virus infections, there has been concern that children with asthma who acquire SARS-CoV-2 might be at high risk for severe illness,” Kelly told Healio. “However, we and others had seen relatively few children with SARS-CoV-2 infections hospitalized with asthma exacerbations; moreover, there were some data to suggest that asthma, or the inhaled corticosteroids commonly prescribed to children with asthma, might lower the risk of acquiring SARS-CoV-2.” Overall, 13.5% of children had asthma (median age, 11 years; 58% boys). Twenty-two percent of all children had one or more SARS-CoV-2 tests during the study period. The propensity score-matched cohort included 12,648 children, half of whom had asthma and half did not.

Children with asthma had a higher likelihood of testing positive for SARS-CoV-2 infection compared with children without asthma (33% vs. 20.9%; P < .0001). In the propensity score-matched cohort, 5.6% of children tested positive for SARS-CoV-2; this included 2.8% of children with asthma and 2.8% of children without asthma (RR = 0.98; 95% CI, 0.85-1.13). Researchers reported similar risk for SARS-CoV-2 infection among children with asthma who were prescribed inhaled corticosteroids (RR = 0.88; 95% CI, 0.73-0.94) and children without an inhaled corticosteroid prescription (RR = 1.08; 95% CI, 0.89-1.34). There was also no difference in risk for infection among children with a history of severe asthma exacerbations (RR = 0.95; 95% CI, 0.71-1.25) and children with comorbid atopic disease (RR = 0.94; 95% CI, 0.79-1.12), according to the results. One child with asthma and seven children without asthma required hospitalization for SARS-CoV-2 infection during the study period.

“We still know very little about the immunological or biological factors that contribute to the low disease severity of SARS-CoV-2 infection among children, including children with asthma. Understanding the mechanisms underlying these age-related differences in disease severity has the potential to inform future development of novel SARS-CoV-2 vaccines or therapeutics,” Kelly said. “More broadly, we need more information regarding the potential effects of severe COVID-19 and multisystem inflammatory syndrome in children (MIS-C) on the long-term health of children.”

Dr. Katherine Bloom from Allergy & Asthma Care comments: "This is reassuring data that confirms previous findings that, in most cases, asthma does not appear to be a risk factor for contracting COVID-19, or for more severe COVID-19 infections. Patients with uncontrolled asthma may be at higher risk of more complications from COVID according to other studies, but the average child with asthma is likely at no increased risk."

Prompt oral immunotherapy to peanut in infants who fail early introduction can improve outcomes

When peanut introduction fails, peanut OIT for infants should be offered as soon as possible via shared decision-making, according to a review published in The Journal of Allergy and Clinical Immunology: In Practice. Previous studies have demonstrated that peanut OIT is effective and safe for infants, Gilbert T. Chua, MBBS, FHKAM(Paed), clinical assistant professor with the department of pediatrics and adolescent medicine of the Li Ka Shing Faculty of Medicine at The University of Hong Kong, and colleagues wrote.

Although the results of the Learning Early About Peanut, or LEAP, study have led to recommendations for introducing infants to peanuts in their first year, the authors noted, the prevalence of peanut allergy does not appear to have decreased significantly in this age group. Peanut allergies impair quality of life and increase anxiety, the authors continued. For patients who develop allergy despite early introduction, management strategies include avoidance of peanut, serial testing and initiation of immunotherapy when available.

But before beginning OIT among infants who have peanut allergy, the authors cautioned, providers should engage in a shared decision-making process with families and balance the option with avoidance and without precluding later initiation of OIT. “Failed early introduction therefore leaves a gap, whereby any negative aspects of life with peanut allergy are accelerated and started at a younger age, without any available intervention,” the researchers wrote. “Thus, it is necessary to evolve our approach for this unique population of infants who have failed primary prevention.”

Early infant OIT vs. avoidance

Compared with prolonged avoidance and missed opportunities for OIT, the authors wrote, earlier initiation of OIT could have a favorable risk/benefit profile that providers should discuss with families. When early peanut introduction fails, the authors added, early OIT could lead to numerous favorable outcomes. The authors advised that screening could be coupled with decisions to proceed in a timely manner to a confirmatory oral food challenge with use of the highest tolerated dose for initiating OIT if the infant does not tolerate the OFC. Providers also could offer low fixed-dose OIT when infants have been screened but families are apprehensive about OFC but want to begin therapy. When families choose an avoidance strategy instead, allergists should be able to support them and manage treatment as well, the authors wrote.

However, Chua and colleagues warned that ongoing peanut avoidance could elevate risks for increased peanut sensitization with age as Th2 cytokine expression and specific IgE production progressively intensify with low likelihood for relenting. Specifically, the authors recommended early OIT for any infant aged younger than 12 months who has failed primary prevention of peanut allergy when there is a convincing history of immediate IgE-mediated reaction or when there is evidence of allergic sensitization and no history of ingestion in screened infants whose families have deferred OFC.

Benefits of early OIT

Compared with peanut OIT initiated later in childhood, early OIT is similarly safe and effective, according to the authors. It also provides robust health and economic outcomes compared with avoidance. Previous studies have found desensitization rates ranging from 71% to 81% and tolerance rates of up to 100% with early peanut OIT, the authors noted, with savings of $12.3 billion to $47 billion in societal costs in the United States through an 80-year lifetime.

In addition to improving quality of life and reducing food-related anxiety, the authors continued, initiating OIT very soon after the initial diagnosis could psychologically benefit the family earlier in the child’s life. By beginning OIT within days or weeks of failed early introduction, families may adapt sooner to a controlled approach to peanut introductions, while infants likely would develop higher thresholds and experience less severe reactions.

Also, the authors said, these infants more likely may be able to openly ingest peanut or reach a stable maintenance dose before beginning school, which would shift avoidance requirements for school and enable socialization that reduces vulnerability related to food allergy such as bullying. Further, the authors indicated that infants experience anaphylaxis less frequently and have milder index reactions, supporting the implementation of OFCs for early introduction and infant peanut OIT. In fact, the authors said, OIT-related safety outcomes are the same or better among infants compared with older children.

Barriers

Barriers remain in accessing OIT treatment, however. Few allergists offer OFCs to infants, and only some offer skin prick tests, in early introduction assessment. Also, Peanut (Arachis hypogaea) Allergen Powder-dnfp (Palforzia, Aimmune Therapeutics) is the only commercially available peanut OIT product approved by the FDA, although the authors indicated that nonprescription products are safe, feasible and effective for peanut OIT among infants as well.

The lack of procedural terminology code specific to OIT also makes reimbursement a barrier, with many families needing to pay out of pocket for services. Similarly, Peanut Allergen Powder-dnfp is not robustly covered outside of commercial insurance plans. Worldwide, resources for allergy services vary, even though OIT should only be performed under the supervision of an allergist. Wait times may be extensive, leading to prolonged food avoidance and persistent psychological burden on these families, the authors wrote.

But once the allergist and family are keen to proceed, the authors wrote, early infant OIT should be offered with a review of risks and benefits in addition to alternatives. When allergists are not comfortable offering infant OIT, the authors continued, they should refer families to their colleagues, lest families miss this window of opportunity for timely intervention.

Dr. Kenneth Backman comments: "There is abundant evidence that early introduction of allergic foods, such as peanut, reduces the risk of future allergy to those foods. This has not helped those infants unlucky enough to react to the early introduction. We have had great success with peanut oral immunotherapy in older children, and we now have a protocol for early peanut oral immunotherapy in infants found to be allergic, allowing early introduction of peanut into their diets as well. This has the potential to provide life-changing benefits for these children, many of whom would otherwise face a lifetime of peanut avoidance."

 

Children who react to first COVID vaccine dose can safely receive second dose

Children with immediate allergic reactions to their first dose of the Pfizer-BioNTech COVID-19 vaccine safely received the second dose, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice. Children with a history of allergy to polyethylene glycol (PEG) or polysorbate also safely received the second dose, Joel P. Brooks, DO, MPH, staff allergist and immunologist at Children’s National Hospital in Washington, D.C., and colleagues wrote in the study

“We began this study as we were receiving several referrals at Children’s National Hospital from the community regarding patients who had reactions to their first dose of their Pfizer-BioNTech COVID-19 vaccine,” Brooks told Healio. “We sought to help these families protect themselves during the COVID-19 pandemic by completing their vaccination cycle.”

When the COVID-19 vaccines first became available, the CDC recommended that patients who experienced reactions to a first dose abstain from receiving a second. Studies later reported that adults with these histories who received a second dose did so safely. However, the researchers indicated that there have been no similar studies among children, with limited guidance for evaluating and proceeding with the second dose for children who reacted to the first dose.

Safe second shots

The researchers evaluated nine children (average age, 13 years; range, 8-17 years; girls, n = 2) who experienced an allergic reaction to the first dose of the Pfizer-BioNTech COVID-19 vaccine. Seven of these children had a history of allergic rhinitis, food allergy, asthma or penicillin allergy, with three reporting a history of anaphylaxis in response to food or medicine.

After the first dose of the vaccine, three of these children experienced symptoms of anaphylaxis in line with the National Institute of Allergy and Infectious Disease and Food Allergy and the Anaphylaxis Network and Brighton criteria. The other six children reported symptoms, but they did not meet this case definition. The children received the second dose of the vaccine in clinic (n = 8) or at a local pharmacy (n = 1). All nine children received the second shot in a single dose without premedication, and they experienced no or minimal symptoms.

“We were very pleased to find that all the patients who reported previous reactions to their first dose of the Pfizer-BioNTech COVID-19 vaccine were able to tolerate their second and, in some cases, third doses without any adverse reactions,” Brooks said. “This suggests that their symptoms might not have been triggered by the traditional allergic pathways.” These results were consistent with data from studies of reactions to the Pfizer-BioNTech vaccine among adults, according to the researchers. Also, most of the initial reactions to the vaccine did not support a mechanism mediated by IgE, which is why they did not use any premedication before the second dose.

PEG allergies

Next, the researchers evaluated four children (average age, 16 years; range, 15-17 years; girls, n = 2) who had clinical histories concerning PEG or polysorbate allergy. mRNA vaccines contain PEG 2000, an excipient that stabilizes the lipid nanoparticle of the vaccine. Each of these children tolerated PEG 3350 laxative without any issues. Three of them then received the first and second doses of the Pfizer-BioNTech COVID-19 vaccine without any symptoms. The fourth received the Johnson & Johnson COVID-19 vaccine. “We were also reassured to find that patients with suspected polyethylene glycol or polysorbate allergies were able to safely receive their Pfizer-BioNTech COVID-19 vaccine without any adverse reactions,” Brooks said.

Talking with patients, parents

Although the researchers cautioned that their study used a small sample size and that it was characterized by referral bias and a lack of objective diagnostic measurements, they concluded that children with mild to moderate reactions to the first dose of an mRNA COVID-19 vaccine could safely receive the second. “The second dose of Pfizer-BioNTech vaccine can be administered safely in children with a history of immediate and potentially allergic reactions to the first dose, as well as in children with a history of polyethylene glycol or polysorbate allergy,” Brooks said.

Brooks also advised clinicians to engage in clear communication with parents who may be hesitant about their children receiving the vaccine. “When discussing the Pfizer-BioNTech COVID-19 vaccine with hesitant parents, we recommend building trust, presenting vaccination as the default approach, describing the benefits of vaccines, being honest about side effects, providing reassurance on a robust vaccine safety system and focusing on protection of the child and community,” he said. “While the Pfizer-BioNTech COVID-19 vaccine was created quickly, it was rigorously tested for safety.”

Noting how their research provides insight into the safety of administering the Pfizer-BioNTech COVID-19 to children who had reactions to the first dose, Brooks said these findings will help them resume their normal activities and keep communities safe and healthy. “Our next project is to analyze the data reported to the Vaccine Adverse Event Reporting System for pediatric patients to better understand the complications affecting this unique population,” Brooks said.

Reference:

• Children with a history of allergic reactions to first dose of Pfizer COVID-19 vaccine can safely receive second dose. https://www.aaaai.org/About/News/News/reaction. Published July 13, 2022. Accessed July 22, 2022.

Combination nasal medication treatment improves nasal allergy symptoms better than one alone

Intranasal corticosteroid and intranasal antihistamine therapies did a better job of alleviating nasal and ocular symptoms in allergic rhinitis than intranasal corticosteroid therapy alone, according to a review. Examples of these medications include fluticasone or mometasone nasal sprays (corticosteroids,) plus azelastine or olopatadine nasal sprays (antihistamines.)

The combination also more significantly improved quality of life, Minji Kim, MD, PhD, of the department of pediatrics at Chungnam National University Sejong Hospital, Sejong, Korea, and colleagues wrote in the review, which was published in Allergy. The review assessed 13 randomized controlled trials, with 10 evaluating differences in symptom scores and 12 describing adverse events. The combination of intranasal corticosteroid (INCS) and intranasal antihistamine (INAH) therapies produced a more significant reduction in mean morning and evening 12-hour reflective total nasal symptom scores (TNSS) than INCS monotherapy (mean deviation [MD] = –0.44; 95% CI, –0.61 to –0.27; I² = 8%).

The combination also produced a more significant reduction in total ocular symptom scores than INCS monotherapy (MD = –0.62; 95% CI, –1.05 to –0.19; I² = 36%). However, it did not lead to a more significant reduction in total symptom score (TSS; MD = –0.53; 95% CI, –2.83 to 1.77; I²= 99%).Further, total mean Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) scores significantly improved with the combined therapy (MD = –0.24; 95% CI, –0.42 to –0.06; I² = 79%). However, the combination treatment did not exceed the thresholds of minimally clinically important differences of 0.28 for TNSS or 0.5 for RQLQ.

The researchers also found significantly greater risks for treatment-emergent adverse events with INCS/INAH combination therapy than with INCS monotherapy (RR = 1.52; 95% CI, 1.28-1.81; I² = 1%). The risk is especially great, the researchers found, for dysgeusia, or a bad or bitter taste in the mouth or throat (RR = 7.4; 95% CI, 3.6-15.23; I² = 0%). The researchers did not find a significant risk with the combination therapy for serious adverse events (RR = 1.72; 95% CI, 0.47-6.38; I² = 0%).

Overall, the researchers called INCS/INAH combination therapy significantly better for alleviating nasal and ocular symptoms and improving quality of life among patients with allergic rhinitis than INCS monotherapy. The researchers cautioned, however, that there were uncertainties related to bias in the studies they reviewed, along with deviations from intended interventions and missing outcome data. They recommended further studies to verify the potential therapeutic utility of combination therapy compared with monotherapy.

We've moved our Fairfield office - same building, first floor

Allergy & Asthma Care of Fairfield is excited to announce that our Fairfield office has moved to a bigger, better space in the same building, 55 Walls Drive, Suite 105, on the first floor of the building. We have more rooms for patients so we can continue to offer all of the excellent care you've come to expect, plus continue to expand our oral immunotherapy / desensitization to foods program that applies the latest advances in food allergy management. We continue to remain at the forefront of allergy treatment, and are excited to be able to expand this life-changing program for our food allergy patients. We look forward to welcoming you to our brand new space. Please excuse some of the missing furniture and ongoing millwork, as supply chain issues have led to some delays in updating our office chairs, cabinetry, etc. 

Nearly 30% of peanut allergies and 90% of egg allergies resolve by age 6

About three out of 10 peanut allergies and nine of 10 egg allergies resolved by age 6 years, although infants with early-onset severe eczema or multiple allergies were less likely to outgrow them, according to a longitudinal study.

These findings may inform the use of disease-modifying treatments such as oral immunotherapy or proactive treatment of eczema in early life, the researchers wrote in the study, which was published in The Journal of Allergy and Clinical Immunology.

Data were derived from Peters RL, et al. J Allergy Clin Immunol. 2022;doi:10.1016/j.jaci.2022.04.008.

“Prioritizing research of these and future interventions for infants less likely to naturally outgrow their allergy would yield the most benefit for health care resources and research funding,” Rachel L. Peters, PhD, associate professor, epidemiologist and team lead within the population allergy research group at Murdoch Children’s Research Institute, Royal Children’s Hospital, in Parkville, Victoria, Australia, said in a press release.

The researchers examined data from the HealthNuts population-based longitudinal study, which tracks the prevalence and natural history of allergic diseases among 5,276 children recruited at age 1 year from council-run immunizations in Melbourne, Australia, from 2007 to 2011. Food allergy testing was performed during the 1-year visit, with follow-up oral food challenges or new testing for patients with new symptoms conducted at 2 (egg only), 4 and 6 years along with parental questionnaires. Although 156 children had a peanut allergy at age 1 year, these allergies resolved in 29% (95% CI, 22-38) of children with definite allergy by age 6 years. Compared with those children whose peanut allergy had resolved by age 6 years, persistent peanut allergy appeared more common among children who had early-onset severe eczema (adjusted OR = 3.23; 95% CI, 1.17-8.88), sensitization to at least one tree nut (aOR = 2.51; 95% CI, 1-6.35) and skin prick test results of 8 mm or larger (OR = 2.35; 95% CI, 1.08-5.12) at 1 year.

Among the 471 children with raw egg allergy at age 1 year, allergies resolved in 89% (95% CI, 85-92) of those with definite allergy by age 6 years. Additionally, compared with children whose egg allergy had resolved, persistent egg allergy was more likely among children with an SPT result of 4 mm or larger (OR = 2.98; 95% CI, 1.35-6.36), peanut or sesame food sensitizations (aOR = 2.8; 95% CI, 1.11-7.03), early-onset severe eczema (aOR = 3.77; 95% CI, 1.35-10.52) and baked egg allergy (aOR = 7.41; 95% CI, 2.16-25.3) when aged 1 year.

During the time children were aged 1 to 6 years, new-onset peanut allergies developed in 0.7% (95% CI, 0.5-1.1), and new-onset raw egg allergies developed in 0.09% (95% CI, 0.03-0.3) of the children. At age 6 years, peanut allergy — including definite, probable and possible outcomes — had an overall weighted prevalence of 3.1% (95% CI, 2.6-3.7), and egg allergy had an overall weighted prevalence of 1.2% (95% CI, 0.9-1.6). Additionally, SPT responses at age 1 year appeared larger among children with persistent food allergy compared with those children whose allergies had resolved, although the researchers cautioned that these test results were poor predictors of predicting peanut allergy prognoses (area under the curve, 0.64; 95% CI, 0.54-0.74) and egg allergy prognoses (area under the curve, 0.68; 95% CI, 0.58-0.78) at age 6 years.

According to the researchers, this was the first study to monitor food allergy status through standardized questionnaires, SPTs and OFCs, and its results highlight how the onset of peanut allergy after age 1 year is a real and potentially increasing problem. Further, the researchers wrote, challenges remain in predicting which patients will outgrow their allergies and when this tolerance will occur. Such information, they continued, would help clinical management, implementation of emerging therapies such as oral immunotherapy, and family counseling. “Prioritizing research of these and future interventions for infants less likely to naturally outgrow their allergy would yield the most benefit for health care resources and research funding,” Peters said.

Dr. Sara Dever of Allergy & Asthma Care comments: "We've long known that the majority of children with egg allergy will "outgrow" their allergy, but this shows that almost all do so by age 6, which is very reassuring. Prior studies have found that about 20% of peanut allergies resolve, so this is encouraging data that nearly 30% of young children with peanut allergy will "outgrow" this allergy. Correlation with eczema, other food allergies, and skin test size are helpful in deciding who may be a candidate for oral immunotherapy / desensitization to peanut and/or egg."

First treatment approved for eosinophilic esophagitis (EoE)

Dupilumab (Dupixent) became the first drug approved to treat eosinophilic esophagitis in adults and pediatric patients ages 12 and older weighing at least 40 kg (~88 lb), the FDA announced. Eosinophilic esophagitis is a chronic, progressive disease in which the esophagus becomes inflamed due to a buildup of eosinophils, creating difficulty swallowing and eating. Dupilumab is a monoclonal antibody that acts to inhibit part of the inflammatory pathway, blocking interleukin-4 and -13 receptors. "As researchers and clinicians have gained knowledge about eosinophilic esophagitis in recent years, more cases of the disorder have been recognized and diagnosed in the U.S.," Jessica Lee, MD, director of the division of gastroenterology in the FDA's Center for Drug Evaluation and Research, said in a statement. "Today's approval will fulfill an important unmet need for the increasing number of patients with eosinophilic esophagitis," she added.

The FDA's greenlight expands the indication for dupilumab, which is also approved for moderate-to-severe atopic dermatitis in certain adult and pediatric patients, some types of moderate-to-severe asthma, and poorly controlled chronic rhinosinusitis with nasal polyposis. The FDA's decision was based on a parallel-group placebo-controlled trial that included two 24-week treatment periods -- Part A and Part B -- conducted independently in separate groups of patients. In both parts of the trial, participants received placebo or 300 mg of dupilumab weekly. Primary efficacy measurements were the proportion of patients who achieved a certain level of reduced eosinophils in the esophagus at week 24 and the change in Dysphagia Symptom Questionnaire (DSQ) score from baseline to week 24. The DSQ measures difficulty swallowing associated with eosinophilic esophagitis; total scores range from 0 to 84, with higher scores indicating worse symptoms.

In Part A, 60% of patients who received dupilumab achieved the pre-determined level of reduced eosinophils, compared with 5% in the placebo group. Dupilumab-treated patients reported an average improvement of 22 points on the DSQ, compared with a 10-point improvement in the placebo group. In Part B, 59% of patients who received dupilumab reached the pre-determined level of reduced eosinophils compared with 6% of the placebo group. Patients who received dupilumab reported an average improvement of 24 points in DSQ scores versus 14 points for placebo. Patient perspectives supported that DSQ scores with dupilumab represented clinically meaningful improvement in dysphagia.

The most common side effects associated with dupilumab include injection site reactions, upper respiratory tract infections, joint pain, and herpes viral infections, the FDA said. The drug is contraindicated for patients with known hypersensitivity to dupilumab or any of its inactive ingredients. Dupilumab carries warnings and precautions about the potential development of allergic reactions, conjunctivitis, keratitis, or joint pain; use in patients with certain parasitic infections; and use in conjunction with live vaccinations, the agency added.

Dupilumab is being jointly developed by Sanofi and Regeneron under a global collaboration agreement. It has been studied in 60 clinical trials involving more than 10,000 patients with various chronic diseases driven in part by type 2 inflammation.

Dr. Katherine Bloom of Allergy & Asthma Care comments: "Eosinophilic esophagitis has become a very common cause of symptoms in both pediatric and adult patients, often leading to chronic discomfort and dramatic dietary limitations. Swallowed corticosteroid formulations originally developed for asthma, acid suppressant medications, and food elimination diets have been the mainstay of treatment, but this is the first therapy specifically approved for EoE, and offers the opportunity for relief to a large number of patients who have not been controlled on current treatment protocols. It is the first in what is likely to be a number of biologic medications geared toward controlling the underlying inflammation involved in this disorder."

Severe asthma exacerbations associated with short acting beta agonist use

Increasing exposure to short-acting beta 2 agonist rescue or reliever medication appeared associated with greater risk for severe asthma exacerbations regardless of inhaled corticosteroid use, according to study results. Published in The Journal of Allergy and Clinical Immunology: In Practice, the study results suggest that rescue/reliever management using short-acting beta 2 agonist (SABA) monotherapy should be avoided, according to the researchers.

Jennifer K. Quint, MD, PhD, FRCP, professor of respiratory epidemiology at Imperial College London National Heart and Lung Institute, and colleagues examined data from 1,033,564 patients in the SABa use IN Asthma (SABINA) series of observational studies including 10 North American and European datasets. Patients were aged 12 years and older with asthma and had been prescribed or possessed at least one SABA canister per year. Mean ages ranged across the datasets from 23.2 years (U.S. Medicaid cohort) to 72.2 years (U.S. Medicare cohort), and most patients were women (range across datasets, 55.8%-68.2%).

With a Global Initiative for Asthma (GINA) score of one or two, 56.5% of patients had mild asthma. Also, 40.2% of patients were prescribed or possessed three or more SABA canisters a year, and only 39.2% of patients with GINA scores between 2 and 5 received maintenance therapy 50% or more of the time. Patients who were prescribed or who possessed one or two SABA canisters per year had a numerically lower mean number of severe exacerbations than patients who were prescribed or who possessed three or more canisters per year in every dataset but one, with the greatest association observed in Poland (incidence rate ratio [IRR] = 2.15; 95% CI, 2.01-2.3).

The exception was the dataset based on Medicare findings, in which patients who were prescribed or who possessed one or two canisters per year saw higher incidence of severe exacerbations than patients with three or more canisters per year (IRR = 0.89; 95% CI, 0.86-0.91). Patients who had GINA scores of three to five and three or more prescriptions or possessions of SABA canisters per year experienced more severe exacerbations than patients with fewer canisters per year across all countries and datasets.

Within the U.S. datasets, patients with GINA scores between two and five had higher incidences of severe exacerbations with three or more vs. one to two SABA canisters per year (IRR = 1.23; 95% CI, 1.22-1.24) than those with GINA scores between 1 and 5 (IRR = 1.03; 95% CI, 1.02-1.04). In fact, the researchers wrote, there was an association between use of three or more SABA canisters per year and increased incidence of exacerbations that required emergency, face-to-face evaluations with health care providers or hospitalizations among patients treated via SABA monotherapy in the U.S. (IRR = 1.31; 95% CI, 1.29-1.34).

“These data are concordant with observations that U.S. patients and health care providers tend to underestimate the consequences of asthma symptoms, relying predominantly on SABA for rapid relief,” the researchers wrote. “These findings suggest the need for inhaled corticosteroid administration, either as regular maintenance treatment or intermittently, to address variability in airway inflammation in SABA monotherapy-treated patients and lend support to the GINA recommendation of not distinguishing intermittent from mild persistent asthma.”

Overall, the researchers found a 32.2% (adjusted IRR = 1.32; 95% CI, 1.18-1.49) greater risk for severe exacerbations among patients who were prescribed or who possessed three or more canisters per year than those with one or two canisters, independent of inhaled corticosteroid use or other exacerbation risk factors.

These findings indicate that asthma may remain uncontrolled even though these patients have potentially reasonable exposure to their prescribed maintenance therapy, showing that their asthma severity may be underestimated, the researchers wrote. Providers may use yearly SABA canister prescription and possession totals of three or more as a practical and quantitative measure of reliance on SABA and as an aid in tracking rescue and reliever use, the researchers continued, adding that careful monitoring of SABA use at any level could help identify at-risk patients.

Dr. Kenneth Backman of Allergy & Asthma Care  comments: "We've known for many years that overuse of short acting beta agonists is associated with increased risk of hospitalization and death from asthma. The latest GINA guidelines recommend avoiding use of these medications. The NHLBI guidelines from the NIH still support use, but the most important thing is maintaining control of asthma with anti-inflammatory medications. Overuse of relief inhalers clearly increases the risk of death from asthma. Controller medications are critical to prevent asthma exacerbations and deaths."