Issue #3, May 2021
Welcome to Issue #3 of 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
Evidence review in pediatric chronic spontaneous urticaria
Children with chronic spontaneous urticaria (CSU) experience impairment in health-related quality of life and school performance. As pediatric CSU may last up to 10 years, effective and safe symptom management strategies are needed. No treatments have been shown to alter the natural history of CSU.
Chang and colleagues reviewed the evidence for pediatric CSU patients in order to compare to existing treatment guidelines, which are mainly focused on adult populations. They conducted a narrative literature review, including studies reporting CSU treatment in pediatric patients regardless of design. They find that data generally support the existing EAACI/GA2LEN/EDF/WAO 2017 treatment guidelines. Non-sedating second-generation antihistamines (sgAHs) have demonstrated efficacy and safety in this patient population. Omalizumab use is appropriate in antihistamine-resistant adolescent patients. It has limited CSU data in children under age twelve but has been used as an asthma treatment successfully in children as young as age six. Data is limited to support up dosing of sgAHs in non-responders under age twelve, and for the use of cyclosporine and leukotriene receptor antagonists in pediatric patients of all ages.
Read more: [Sosido link] Chang J, Cattelan L, Ben-Shoshan M, Le M, Netchiporouk E. Management of Pediatric Chronic Spontaneous Urticaria: A Review of Current Evidence and Guidelines. J Asthma Allergy. 2021;14:187-199. Published 2021 Mar 9. doi:10.2147/JAA.S249765
An allergists guide to biologic economic analyses
Azzano and colleagues provide a comprehensive review of economic considerations for biologic use in atopic disorders. They first present definitions and explanations of the different types of economic analyses that are reported to enable clinicians in data interpretation. The cost utility data of biologic use in asthma, chronic spontaneous urticaria and atopic dermatitis are reviewed. The authors report the conclusions of these studies are highly variable, mainly due to inconsistent estimates of health utility benefit with therapy. They suggest development of allergy-specific validated disutility instruments and indirect costs will support fair access for patients to potentially lifechanging therapies. They also suggest measures that can be taken to improve cost-effectiveness, including appropriate use of biosimilars, discontinuing therapy in non-responders, including the chronic indirect costs resulting from lowered productivity, and using biomarkers to improve patient selection for therapy.
Read more: [Sosido link] Azzano P, Dufresne É, Poder T, Bégin P. Economic considerations on the usage of biologics in the allergy clinic. Allergy. 2021;76(1):191-209. doi:10.1111/all.14494
Practical consensus recommendations for implementing oral immunotherapy
Oral immunotherapy (OIT) in patients with food allergy (FA) has the potential to decrease the burden of disease by safely increasing the reaction threshold to an allergen. The approval by the FDA of the first pharmaceutical for OIT has accelerated use of the OIT strategy. Wasserman and colleagues review the recent guidelines published by the Canadian Society for Allergy and Clinical Immunology and add practical tips for implementing OIT in allergist offices.
Allergic reactions, both immediate and delayed, may occur during all phases of OIT. The authors include information on preparing the physical office space and staff for OIT, and how to manage both anaphylaxis and milder reactions if they occur. Appropriate patient selection and shared decisionmaking is crucial for OIT, as the process requires substantial commitment and realistic expectations from the patient and their family. Risk factors for reaction are listed in the publication, as are practical safe dosing rules to provide to patients for their home-based doses.
Read more: [Sosido link] Wasserman RL, Factor J, Windom HH, et al. An Approach to the Office-Based Practice of Food Oral Immunotherapy [published online ahead of print, 2021 Mar 5]. J Allergy Clin Immunol Pract. 2021;S2213-2198(21)00251-8. doi:10.1016/j.jaip.2021.02.046
Updated contact dermatitis patch test results
DeKoven and colleagues provide an update of the North American Contact Dermatitis Group data, reporting descriptive analyses for 4,947 referral patients who received patch tests in 2017 and 2018. Participants were predominately female (70.5%) and white (81.2%) with a median age of 49 years. The most common sites of reaction were the hands, scattered generalized, and face.
Of 10,122 positive allergic reactions, the top 15 most frequent allergens included two metals (nickel and cobalt), two antibiotics (neomycin and bacitracin), four fragrances (fragrance mix I, fragrance mix II, M.pereirae, and hydroperoxides of linalool), four preservatives (methylisothiazolinone (MI), methylchloroisothiazolinone / methylisothiazolinone (MCI/MI) 0.02%, benzisothiazolinone, formaldehyde [2%]), p-phenylenediamine, and propolis. In 2018, the Canadian government prohibited MI and MCI/MI in leave-on products and set a maximum concentration of 15ppm in rinse-off products.
Three allergens appeared to be increasing in prevalence: propolis, ylang-ylang, and M. alternifolia. Eight other allergens appeared to be decreasing in prevalence.
Read more: [Sosido link] DeKoven JG, Silverberg JI, Warshaw, EM, et al. North American Contact Dermatitis Group Patch Test Results: 2017–2018, Dermatitis 2021;32(2):111-123 doi: 10.1097/DER.0000000000000729
Humoral immunity against SARS-CoV-2 in Canadian patients
In a preprint posted to bioRxiv, Anand and colleagues report on humoral immunity in a longitudinal cohort of patients convalescing from SARS-CoV-2 infection at the centre hospitalier de l'Université de Montréal. The cohort included n=32 at 6 weeks post-symptom onset, extending out to n=13 at 31 weeks post-symptom onset. Using ELISA and flow cytometry, the authors report that anti-spike and antireceptor binding domain (RBD) IgM decays rapidly in plasma, while IgG decay is less prominent. The number of IgG+ memory B cells appears to remain stable up to 31 weeks post-symptom onset.
As a reminder, bioRxiv provides the following disclaimer on preprints, which are intended to provide researchers with the opportunity to comment on works in progress: bioRxiv is receiving many new papers on coronavirus SARS-CoV-2. A reminder: these are preliminary reports that have not been peer reviewed. They should not be regarded as conclusive, guide clinical practice/health-related behavior, or be reported in news media as established information.
Read more: [Sosido link] Anand SP, Prévost J, Nayrac M, et al. Longitudinal analysis of humoral immunity against SARS-CoV-2 Spike in convalescent individuals up to 8 months post-symptom onset. Preprint. bioRxiv. 2021;2021.01.25.428097. Published 2021 Jan 25. doi:10.1101/2021.01.25.428097
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