Issue #5, July 2021
Welcome back to The Buzz, a monthly feature of the HIVE community where we summarize recent articles with high clinical relevance for Canadian allergists, immunologists and dermatologists. View archived issues of The Buzz at thehivecommunity.org/the-buzz
In Issue #5 of The Buzz, we highlight new publications in urticaria, angioedema, asthma, and draw attention to the new food allergy guidelines for childcare centres and schools.
Urticaria disease activity during and after pregnancy
PREG-CU is a prospective, international observational study conducted at Urticaria Centers of Reference and Excellence (UCARE) network centers. The study captured 288 pregnancies in 288 CU patients from 13 countries. Patients were asked to complete a 47-item questionnaire. Sixty-seven (67) percent of patients had CSU, 13% had CIndU, and 20% had both CSU and CIndU.
Fifty-one (51) percent of patients rated their CU as improved during pregnancy, while 29% felt it had worsened and 20% reported no change in severity. Risk factors for worsening included mild disease and no angioedema before pregnancy, not taking treatment before pregnancy, CIndU, CU worsening during a previous pregnancy, treatment during pregnancy, and stress. Exacerbations were reported more often during the first and third trimesters. Ten (10) percent of women presented to an emergency department due to CU during their pregnancy. Urticaria disease activity stayed the same (44%) or worsened (37%) in the majority of patients after delivery. The authors hypothesize some potential mechanisms for the observed improvement in CU disease activity during pregnancy.
Pregnancy outcomes were not reported in this publication. The authors noted analysis is ongoing.
Read more: [Sosido link] Kocatürk E, Al-Ahmad M, Krause K, et al. Effects of pregnancy on chronic urticaria: Results of the PREG-CU UCARE study [published online ahead of print, 2021 May 22]. Allergy. 2021;10.1111/all.14950. doi:10.1111/all.14950
A practical approach to identifying angioedema and urticaria mimics
Peter and colleagues present two clinical cases that illustrate some of the skin and systemic conditions that can imitate the clinical appearance of either angioedema or urticaria, or that produce urticaria or recurrent angioedema as part of disease manifestations. They note that it critical that alternative skin and multisystem diseases are recognized so that tailored therapy can be offered, and diagnostic delays are avoided. They provide a practical approach to identifying if a mimic should be included in the differential. Some of the red flags identified include angioedema isolated to a single anatomic location, associated systemic symptoms, urticarial lesions that persist for more than 24 hours, or bruising with resolution. It is noted that detailed clinical history, examination, and awareness of key differential diagnoses is sufficient to recognize the majority of the mimics. If red flags are identified, standard investigations are nonconclusive, or response to standard treatments is unsuccessful, clinicians should investigate further.
Read more: [Sosido link] Peter J, Krause K, Staubach P, Wu MA, Davis M. Chronic Urticaria and Recurrent Angioedema: Clues to the Mimics [published online ahead of print, 2021 Apr 24]. J Allergy Clin Immunol Pract. 2021;S2213-2198(21)00428-1. doi:10.1016/j.jaip.2021.03.043
Conditional recommendations on the prevention and management of allergic reactions in schools and childcare centers
An international panel of stakeholders were convened to review the evidence and produced eight toplevel recommendations for the prevention and management of allergic reactions to food in childcare and school settings. All of the recommendations listed are “conditional”, based on limited evidence available, but the panel felt the benefits in most situations outweighed the potential burdens and harms. Based on reported rates of allergic events in schools and childcare settings, the authors estimate that anaphylaxis would occur in approximately 1 in 15 schools per year, and epinephrine would be administered in approximately 1 in 24 schools per year. Ninety percent of pediatric allergic reactions occur outside of school and childcare settings.
Briefly, the new guidelines suggest, in accordance with local conditions and applicable laws, that childcare centers and schools implement allergy training and action plans; use epinephrine to treat suspected anaphylaxis; stock unassigned epinephrine autoinjectors instead of requiring students to supply their own to be stored on site; and not implement site-wide food prohibitions or allergen-restricted zones, except in very specific circumstances.
Read more: [Sosido link] Waserman S, Cruickshank H, Hildebrand KJ, et al. Prevention and management of allergic reactions to food in child care centers and schools: Practice guidelines. J Allergy Clin Immunol. 2021;147(5):1561-1578. doi:10.1016/j.jaci.2021.01.034
Prestudy treatment effect on the SYGMA 1 and 2 outcomes
The SYGMA 1 and 2 studies examined asthma control using an inhaled corticosteroid (ICS) plus longacting beta agonist (LABA) combination compared to standard Step 1 (as-needed short-acting β2-agonists (SABA) alone) and Step 2 (low-dose ICS + as-needed SABA) asthma therapies.
In a post-hoc analysis of the SYGMA studies, the influence of pre-study treatment was assessed in two prespecified subgroups. The subgroups were patients with uncontrolled asthma on as-needed SABA alone (Subgroup 1), and those whose asthma is well-controlled on low-dose ICS (Subgroup 2).
The annual severe exacerbation rate was significantly lower in Subgroup 1 with as-needed budesonideformoterol compared to low-dose ICS maintenance (rate ratio [RR] 0.74 [0.56, 0.98]), while no statistical difference was found in Subgroup 2 (RR 1.10 [0.86, 1.41]). In SYGMA 1, the annual severe exacerbation rate was significantly lower in both Subgroups with as-needed budesonide-formoterol vs as-needed terbutaline. The number needed to treat to prevent one severe exacerbation with as-needed budesonide-formoterol and low-dose ICS maintenance vs as-needed terbutaline was 20 and 34 in Subgroup 1 and 13 and 12 in Subgroup 2, respectively.
Read more: [Sosido link] Bateman ED, O'Byrne PM, FitzGerald JM, et al. Positioning As-needed Budesonide-Formoterol for Mild Asthma: Effect of Pre-study Treatment in Pooled Analysis of SYGMA 1 and 2 [published online ahead of print, 2021 May 12]. Ann Am Thorac Soc. 2021; 10.1513/AnnalsATS.202011-1386OC. doi:10.1513/AnnalsATS.202011-1386OC
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