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Desensitisation:
treating allergy at its origin
Every day we make advances in treating respiratory allergic diseases,
improving the quality of life of patients

EDITORS IN CHIEF
A. Sabbah (Angers – France), S. Bonini (Roma – Italy) R. Asero (Milano) Clinical Immunology THE OFFICIAL JOURNAL OF AAITO - C. Lombardi (Brescia – Italy) ASSOCIAZIONE ITALIANA ALLERGOLOGI IMMUNOLOGI TERRITORIALI E OSPEDALIERI ReviewAllergic rhinitis and associated pathologies: the rationale M.B. Bilò (Ancona – Italy) for steroid options P. Blaive (Nice – France) B. Farabollini, M.C. Braschi, F. Bonifazi F. Bonifazi (Ancona – Italy) P. Bonnaud (Limoges – France) Original articles D. Charpin (Marseille – France) The impact of air pollution on hospital admission for respirarory and P. Demoly (Montpellier – France) cardiovascular diseases in an oil and gas-rich country V. Di Rienzo (Latina – Italy) A. Bener, M. Dogan, M.S. Ehlayel, N.J. Shanks, A. Sabbah M. Drouet (Angers – France) M. Fernandez-Rivas (Madrid – Spain) A murine model of cow's milk protein-induced allergic reaction: F. Mastandrea (Taranto – Italy) use for safety assessment of hidden milk allergens D.A. Moneret-Vautrin (Nancy – France ) B. Proust, C. Astier, J.M. Renaudin, E. Magueur, P. Parronchi (Firenze – Italy) D. Maurice, C. Belcourt, F.T. Yen, G. Kanny, G. Passalacqua (Genova – Italy) B.E. Bihain, S. Jacquenet G. Pauli (Strasbourg – France) A. Pradalier (Paris – France) F. Rancé (Toulouse – France) S. Voltolini (Genova – Italy) L. Antonicelli (Italy) A. Bener (Qatar) H. Bazin (Belgium) J. Bellanti (USA) Geler Bernstein (Israel) S. Bonini (Italy) G.W. Canonica (Italy) B. David (France) R. de Marco (Italy) Associazione Italiana Allergologi Immunologi Territoriali e Ospedalieri A.-L. De Weck (Switzerland) G.-P. Girolomoni (Italy) Vice Presidents R. Jarish (Austria) S.G.O. Johansson (Sweden) M. Beatrice Bilò F. Levi-Shaffer (Israel) Costantino Troise Valerio di RienzoRocco Longo P. Lowenstein (Denmark) Past President Francesco Murzilli J.L. Malo (Canada) Floriano Bonifazi A.-G. Palma-Carlos (Portugal) E. Stevens (Belgium) Francesco Pezzuto A. Szczeklik (Poland) A. Tedeschi (Italy) GENERAL MANAGEMENT MARKETING MANAGEMENT Vice President and FOUNDER AND CORRESPONDING MEMBER
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Fax 0039-(0)524-892006 ognizes the adoption of the International Systems of Units Eur Ann Allergy Clin Immunol VOL 41, N 3, 67-79, 2009 B. Farabollini†, M.C. Braschi, F. Bonifazi Allergic rhinitis and associated pathologies: therationale for steroid options Allergy Unit, Department of Internal Medicine, Immuno-Allergic and Respiratory Deseases, AziendaOspedaliero-Universitaria "Ospedali Riuniti" di Ancona, Ancona, Italy Key words
Summary
The aim of this review article is to provide greater insight into the relationship between
Upper airway inflammation, allergic rhinitis and the three most frequently diagnosed conditions of exacerbating viral atopy and sleep disorder, nasal infections, chronic rhinosinusitis with polyps and obstructive sleep apnoea syndrome. polyps, upper viral infection The alleged physiopathological effects of steroids are also investigated within the scope ofthis paper. Regarding the exacerbating viral infections, seems to establish a dynamic andcounter relationship between the load and nature of the viral infection on one hand andwidespread and pre-existing allergic inflammation on the other. If chronic rhinosinusitiswith polyps and allergic rhinitis present overlapping picture of inflammatory cell and cy-tokine, the etyiological relationship between the two conditions appears to be influencedby the type of antigenic stimulus. Allergic rhinitis can influence the presence of OSASthrough both obstructive and inflammatory mechanical factors. Topical corticosteroidtherapy is a promising candidate as a new therapeutic tool able to improve symptomsand quality of life in patient with chronic rhinosinusitis with polyps and obstructivesleep apnoea syndrome. Other study are necessary to elucidate relationship between corti-costeroids therapy and hypothetical benefit effect on viral infection when concomitantatopy in patient. fied as co-morbidities in subjects with allergic rhinitis.
The aim of this paper is to provide greater insight into the The ARIA guidelines were the first ever to recognise the relationship between allergic rhinitis and the three most association of allergic rhinitis and its risk factors with the frequently diagnosed conditions of exacerbating viral in- onset and severity of bronchial asthma, involving the up- fections, chronic rhinosinusitis with polyps and obstruc- per and lower airways as a single entity, though they pre- tive sleep apnoea syndrome. The alleged physiopathologi- sent distinct organ symptoms and are treated differently cal effects of steroids are also investigated within the (1). Similarly, other conditions (e.g. chronic rhinosinusitis scope of this paper.
with and without nasal polyps, vocal cord dysfunction, se- It has long since been established that allergic reactions occur cretory otitis media and viral infections) have been identi- in two separate phases, the first of which is triggered within a

B. Farabollini, M.C. Braschi, F. Bonifazi few minutes of exposure to allergen-induced histamine re- inflammatory effects of respiratory viral infections (12).
lease with arachidonic acid metabolites (leukotrienes, In one study on spontaneously virally infected airway mu- prostaglandins and thromboxanes) progressing into a late cosa the majority of the documented cases were caused by stage reaction developing 6-12 hours once exposed to mast rhinoviruses followed by coronaviruses, flu B virus, and cells, T-lymphocytes, basophils and eosinophils.
respiratory syncytial virus (12) (Fig. 1).
Activation of these cells produces Th2 cytokines which in For the most part, the data in the literature come from ex- turn are responsible for activating endothelials and epithe- perimental nasal and/or bronchial inoculations. In wors- lials, thereby inducing endothelial adhesion molecules like ening asthma, rhinovirus was the most frequent causative ICAM-1 to be expressed along with vascular cell adhesion pathogen with hospitalisations correlating with the sea- molecules, such as VCAM-1. ICAM-1 is a surface glyco- sonal peak of the infection (14).
protein which normally directs leukocyte traffic and regu- More than 90% of rhinovirus serotypes (15,16) are uti- lates its accumulation into the inflamed site through the lized the ICAM-1 adhesion molecule that trought cell re- cell-surface ligand of the lymphocyte function-associated ceptors and ligands enable the virus to penetrate a host antigen (LFA)-1 and macrophage-1 antigen (MAC)-1.
cell and insert its DNA into the host's genome eventually Epithelial activation is associated with the production and leading to infection (17). Rhinovirus infection induces release of numerous immunoregulatory cytokines which in- ICAM-1 expression, thereby making epithelia susceptible clude RANTES, macrophage proteins, inflammatory to further viral spread (18).
(MIP)-1·, monocyte chemotactic proteins (MCP)-1, IL-8, Rhinovirus infection typically causes common cold symp- and eotaxin (2).
toms which include rhinorrhoea, nasal congestion, sneez- The inflammatory mechanisms described above are activated ing, sore throat, coughing and headache.
and detectable in viral infection-mediated exacerbations of Experimentally infected samples of bronchial epithelial the upper airways, in chronic rhinosinusitis with polyps and cells along with slight cellular damage reveal a pattern of in nocturnal apnoea syndrome, leading to the hypothesis of a immunological responses, showing that rhinovirus acts by set of mechanisms common to allergic rhinitis and the afore- causing clinical worsening through mechanisms not asso- ciated with cell damage (19).
The corticosteroid molecules routinely used in the local Studies based on genetic expression performed using in- treatment of allergic rhinitis with good clinical outcomes (1) fected epithelial cells suggest that viral replication induces include beclometasone propionate, flunisolide, budesonide, cytokine and chemokine production which are required triamcinolone acetomide, fluticasone propionate, mometa- for recruiting inflammatory cells for the antiviral re- sone furoate and more recently fluticasone furoate. Topical sponse: IL-1, IL-6, IL-8, GM-CSF, eotaxin and corticosteroids provide elevated selectivity for the glucocorti- RANTES (19-22). The secretion of these mediators can coid receptor and low oral bioavailability (3-5). The effec-tiveness of fluticasone furoate appears interesting also on oc-ular symptoms, widening the therapeutic spectrum of this Figure 1 - Adapted from Edwards MR et al. New treatment regi-
drug class to the naso-lacrimal duct (3,6-8).The mechanism mes for virus-induced exacerbations of asthma. Pulmonary Phar- of action of corticosteroids involves changes in DNA mole- macology & Therapeutics 2006; 19: 320–334 (13) cule which results in a down regulation of transcription, ofpro-inflammatory proteins, in an enhanced production ofanti-inflammatory proteins, which limits recruitment andaction of inflammatory cells, as well as in a reduced secretionof pro-inflammatory mediators during the late phase allergicresponse (2,9-11).
Allergic rhinitis and viral exacerbations
Airway viruses are powerful stimulants of chemokine andcytokine production. These, rather than the cytopathicimpact of the virus itself, are the real culprits of the pro-

Allergic rhinitis and associated pathologies: the rationale for steroid options contribute to virus-induced activation mechanisms and phase, and higher inflammatory cytokine levels of IL-1β, inflammatory cell recruitment (Fig. 2).
IL-6, RANTES and ICAM-1 along with the prolonged This not only means that the epithelial cells are a target eosinophilis of the airways during the convalescence for a potential virus reservoir, but also the site and source phase (12). The reduced concentration of IL-10, a power- of a preliminary inflammatory response.
ful anti-inflammatory cytokine which inhibits the synthe- The cellular response to rhinovirus which takes place in sis of both Th1 and Th2 would enhance a Th2 anti-in- this way is both innate and adaptive. T-cell recruitment flammatory response (29).
(adaptive response) can contribute to the clearance of the According to the premise that the mechanisms which are virus through Th1 cytokine production, including IFN-γ the basis for the link between viral infection and atopy for e IL-12. Indeed, the production of RANTES and protein rhinitis and allergic asthma are similar (30), it is clear that inducing IFN-γ (IP-10) promotes chemotaxis of Th1 a typical Th1 anti-viral immune response in atopic indi- cells (23). IFN-γ plays a crucial role in the protection of viduals can be inhibited by a pre-existing Th2 (31) envi- the host by promoting inflammation which acts as a ronment, thereby favouring the persistence of viral in- chemotactic factor towards eosinophils (24) and perhaps flammation. Indeed, compelling clinical evidence demon- by increasing basophil and mast cell histamine release strates the inverse relationship between IFN-γ production and synthesis of Th2 cytokines like IL-4 and IL-5 Besides the production of specific IgA, IgM, IgG, in ex- perimental models, the B lymphocyte response to viral in- Additionally, an IgE increase towards airborne allergens has oculation induces a rapid increase in total IgE sera in sub- been considered to be a marker of a greater risk factor for jects with allergic rhinitis with no evident increase in spe- the worsening of both the upper and lower airways during cific IgE (26).
an inflammatory response to viral infections (33). On this Apart from histamine release (27), leukotriene C4 is an- point, the analysis of experimentally induced rhinovirus in- other mediator whose levels are elevated in nasal lavage fection in adults with mild asthma reveals that a subset of mucus and debris during rhinovirus infection (28).
patients whose total IgE is greater than 300 UI/mL present The influence which atopic status and specific sensitisa- a significant increase in symptoms involving the upper and tions have on the airway responses to viral infections is lower airways compared to healthy controls (33).
still under investigation.
One possible explanation of this evidence could lie in the There are important differences in the immunological demonstration that IL-13 and other Th2-like cytokines mechanisms which are activated in atopic and non-atopic are able to increase ICAM-1 expression on in vitro rhi- individuals. Atopic individuals show elevated histamine novirus-infected epithelial cell lines (EC line) (34) and release and reduced levels of IL-10 during the acute that in epithelial cells harvested from nasal brushing inatopic individuals ICAM-1 expression is higher than inhealthy subjects; this increase can be ascribed to the expo- Figure 2 - Adapted from Edwards MR et al. New treatment regi-
sure to an allergen of an atopic subjects (35).
mes for virus-induced exacerbations of asthma. Pulmonary Phar- On one side exposure to an allergen in sensitised subjects macology & Therapeutics 2006; 19: 320–334 (13) can favour viral infections thereby increasing ICAM-1 ex-pression, while as regards the adaptive immune response,the clinical outcome to the respiratory viral infection in al-lergic subjects depends on how the individual immune re-sponse balances the load and type of virus as well as theseverity of the pre-existing atopic inflammation. (30)(Tab.1).
Some in vitro studies have shown that glucocorticos-teroids can block virus-induced pro-inflammatory mecha-nisms in the airways at an epithelial level by means ofcorticosteroid-induced down-regulation of ICAM-1 ex-pression by epithelial cells. Indeed, treatment with corti-costeroids can inhibit the up-regulation of rhinovirus-in-duced ICAM-1 (37-40).

B. Farabollini, M.C. Braschi, F. Bonifazi Other data show that glucocorticoids can reduce basic could be related to the increase in nuclear activation fac- ICAM-1 expression and its subsequent induction on ex- tors like the virus-induced activator protein-1 (AP-1) and posure to allergens (40).
nuclear-kB factor (NF-kB) (51).
Similarly, corticosteroids inhaled in vivo are able to re- Papi et al. (45) demonstrated that high corticosteroid con- duce ICAM-1 expression in bronchoalveolar lavage cells centrations do not affect rhinovirus replication or the ability in mild asthmatics (41-44).
to infect cell lines, which supports the hypothesis that corti- Hence, corticosteroids limit the inflammatory action of costeroids negatively influence rhinovirus replication.
rhinovirus, not only by inhibiting ICAM-1, but also by Likewise, Farr et al (52) investigated the role of pred- reducing cytokine production (Fig.3).
nisone (30 mg twice daily) or intranasal beclometasone Corticosteroids indeed interfere with the inflammatory (168 mg twice daily) administered 3-4 days prior to the process by binding to specific cytoplasmic receptors rhinovirus challenge which was repeated on 5 successive which: 1) interfere directly with the nuclear -kB factor days. Treatment successfully reduced congestion, rhinor- (NF-kB) and preventing this molecule from attaching it- rheoa and kinin production for up to 48 hours after virus self to DNA and subsequently leading to the release of inoculation, though any improvement ceased after stop- pro-inflammatory molecules and 2) repress the transcrip- ping steroid therapy, suggesting the drug's lack of carry- tion gene of pro-inflammatory molecules through gluco- over effect. The limited amount of experimental data on corticoid-responsive elements, or induce the activation of viral infections of the upper airways and on the clinical effectiveness of topical steroids available to date does not t For example, pre-treatment with corticosteroids reduces provide a definitively clear picture of the associated risks rhinovirus-induced IL-6 production by bronchial epithe- and of the efficacy of the treatment (18,53,54).
lials (46), through suppression of the IL-6 gene promotersequence or reduces IL-8 production through a trans-re-pression mechanism, inhibiting activator protein-1 (AP-1) Allergic rhinitis and chronic rhinosinusitis with polyps
and nuclear-kB factor (NF-kB) translocation inside thenucleus, which is required for IL-8 production (41-44).
In the general population, the prevalence of chronic rhinos- Interestingly, however, in virus-induced exacerbations of inusitis is 15.5% (55), while that of nasal poliposys ranges asthma inhaled corticosteroid therapy produces a poorerclinical response, suggesting that mechanisms of steroidresistance develop during worsening,. This circumstance Figure 3 - Adapted from Papi A., Nikolaos G. Papadopoulos, De-
gitz K, Holgate S. T., Johnston S. L. Corticosteroids inhibit rhino-
virus -induced intercellular adhesion molecule- 1 up-regulation
Table 1 - Cellular mechanism of susceptibility to the effects of
and promoter activation on respiratory epithelial cells. J Allergy rhinovirus infection (RV) in asthmatics Clin Immunol 2000;105:318-26 (45) RV ligand:ICAM-1 expression Epithelium integrity Post-RV ligandIFN-β response Cellular lysis VS apoptosis Apoptosis damaged Increase in cellular lysis Release of inflammatory Immune responseNeutrophil recriutment Allergic rhinitis and associated pathologies: the rationale for steroid options between 1-4%, with a probable multi-factor inflammatory If subjects with nasal polyposis and controls with chronic mechanisms which is still being studied (56-62).
rhinosinusitis are compared for allergic sensitisation a ma- Chronic rhinosinusitis with nasal polyps currently pre- jor prevalence of sensitisation to perennial allergens sents as a chronic inflammatory disease of the paranasal emerges in the former and seasonal allergens in the latter sinuses, associated with Th2 inflammation, increased numbers of eosinophils (63), presence of mast cells in Though nasal polyposis is classified as showing two dif- polyps which are often degranulated (64,65), and local ferent histopathological subtypes, showing a predomi- production of polyclonal IgE which often does not corre- nance eosinophils and neutrophils, respectively, atopic sta- late with the patient's allergic status (66).
tus did not significantly differ between the 2 subsets, be- Unlike chronic rhinosinusitus without nasal polyps which in ing 62.7% and 81.8% respectively (86).
immunological terms presents with a prevalent Th1 profile In contrast with studies reporting that atopy is more fre- with elevated levels of interferon-γ (IFN-γ) and transform- quent in patients with nasal polyposis other studies have ing growth factor-β (TGF-β), nasal polyps are characterised not been able to confirm this finding (87-89). In a recent by eosinophil inflammation (55) with elevated concentra- paper, Bachert et al. (56) demonstrated that the presence of tions of eosinophil cationic protein (ECP), with eotaxin cel- atopy, based on allergy testing with airborne allergens, does lular activation markers and IL-5 cooperating in eosinophil not correlate with total IgE or IgE antibodies present in recruitment and activation. The activated eosinophils infil- nasal polyp tissue and that atopy has no impact on IL-5, trate the nasal polyps producing toxic mediators as well as a IL-4, eotaxin, LTC4/D4/E4, ECP levels nor on the num- variety of chemokines, cytokines and growth factors whose ber of eosinophils in nasal polyp tissue. Moreover, Wagen- action probably reduces apoptosis and favours increased tis- mann et al. (90) demonstrated that Th1 and Th2 cytokines sue infiltration through an autocrine mechanism.
increased esinophils in nasal polyps irrespective of allergic It is widely accepted that eosinophils are one of the mark- test results. This finding was confirmed by the observation ers of allergic inflammation.
that IL-5 concentration in nasal polyps, which is signifi- In patients with nasal polyps and concomitant allergic cantly higher than in controls, correlates independently rhinitis, eosinophils seem mainly attracted by the release with atopic status (55). By contrast, Hamilos et al (91) of IL-5. In contrast, in the absence of allergy, recruitment identified different cytokine content in polyp tissues sam- appears to correlate with GM-CSF release (67). Never- ples collected from allergic and non-allergic subjects.
theless, the eventual eosinophil influx seems to be identi- Although the relationship between allergy and nasal cal for both atopic and non-atopic subjects.
polyps is not clear, from clinical point of wiev the symp- Factors associated with chronic rhinosinusitis with polyps ton score does not have increase effect.
are aspirin intolerance (68-73) where 36-96% of sufferers Indeed, it has been demonstrated in atopic subjects with have polyposis, asthma (26-42% of asthmatic with nasal nasal polyposis that allergen exposure does not correlate polypolsis) (59), genetically pre-disposed to chronic rhi- with sectioned polyps, clinical scores and the frequency of nosinusitis with nasal polyps and environmental factors, worsenings (92,93).
especially cigarette smoke (74-77).
The histological findings of a chronic inflammatory infil- When an allergy clinic medical records of almost 5,000 trate made up of lymphocytes, plasma cells, eosinophils patients were re-examined, the prevalence of nasal poly- and respective cytokines suggest a chronic inflammatory posis was 4.2% (78), highest among asthmatics (6,7%).
type mechanism. Research is underway to isolate theagents responsible for inducing and/or favouring persis- The aetiology of polyposis has been ascribed to to allergy, tent inflammation of paranasal sinuses.
but this has never been definitely established (79). Between Several micro organisms have been investigated to deter- 0.5% and 4.5% of subjects with allergic rhinitis present mine their causal role in chronic rhinosinusitis with with nasal polyposis (78,79), a prevalenche that matches polyps. Ponikau et al (94) reported that fungi were pre- that of general population (80). In children, the prevalence sent in 96% of 210 patients evaluated for rhinosinusitis.
of chronic rhinosinusitis with polyps shows a wide variabil- Braun et al. (95) found a comparably high incidence of ity ranging between 0.1% (78) and 25.6%. (81) of cases.
fungal colonisation in chronic rhinosinusitis sufferers On the other hand the prevalence of allergic sensitisation (91%), but together with Ragab et al. they demonstrated in patients with nasal polyposis varies between 10% and that the colonisation occurs frequently in healthy controls 64% (79-84).
(91-100%) (96).
B. Farabollini, M.C. Braschi, F. Bonifazi Other pathogens frequently seen in mucus from patients jects (106, 107), whereas others hypothesise increased an- with nasal polyposis are bacteria, especially Staphylococ- giogenesis at a nasal level (108,109).
cus aureus (66,97,98).
All authors agree, however, that limited damage to nasal Van Zele et al. documented that Staphylococcus aureus allergic rhinitis mucosa is indicative of extensive remodel- colonises the centre of middle meatus prevalently in pa- ling of bronchial mucosa in asthmatics (104).
tients with nasal polyposis (64%) compared to those with In the extensive review of the literature on the treatment chronic rhinosinusitis (27%) and healthy controls (33%) of nasal polyposis, the European Position Paper on Rhi- (97). Colonisation by Staphylococcus aureus is paralleled nosinusitis and Nasal Polyposis (55) stresses the impor- by IgE specific for Staphylococcus aureus-derived entero- tance of disease management recommending steroid ther- toxin. The tissue concentration of specific IgE towards apy as the mainstay of treatment for this condition. Sub- Staphylococcical enterotoxinin the nasal polyposis is asso- stantial evidence exists supporting the efficacy of topical ciated with asthma and aspirin intollerance. Similarly, ele- corticosteroids in reducing the size of nasal polyps vated levels of eosinophils infiltrating nasal polyps and (110,111). However, certain patients are either poor re- IgE production were detected in this group of patients.
sponders to steroid therapy or develop resilience to it.
This IgE production appears to be polyclonal, indicating Consistent with studies of the lower airways which that the S.aureus-derived enterotoxin can behave as a su- demonstrate that glucocorticoid-insensitive asthma is as- perantigen and activate large subpopulations of T-lym- sociated with a significantly elevated level of GRβ+inflam- phocytes (56). Besides the enterotoxin, these bacteria ex- matory cells (112-114), the same mechanism has been hy- press a number of surface proteins like Protein A (SpA) pothesised for nasal polyps as well. Hamilos et al. under- which have the potential to interfere with host defence line an association between GRβ expression and gluco- corticoid insensitivity in nasal polyposis and in particular A recent study revealed (101) different temporal and im- in patients with aspirin intolerance. Specifically, the au- munological stimulations by various S.aureus-derived thors report an inverse correlation between GRβ basal ex- products: while staphylococcal enterotoxin is activated pression and post-corticosteroid therapy reduction of through the release of several immunoregolatory and pro- eosinophils, T-lymphocytes and the expression of inflammatory cytokines in the late stage (after approxi- VCAM-1 and mRNA cells positive to IL-4 (115). How- mately 24 hr) favouring a Th2 type pattern, Protein A ever, other authors having failed to determine the role of (SpA) induces the release of mast cell mediators, namely GRα and GRβ as markers of corticosteroid-insensitivity histamines, the leukotrienes LTC4/D4/E4 and in nasal polyposis cannot confirm this finding (112), ulti- prostaglandin PGD2 after only 30 minutes. These data mately leading to the conclusion that neither the GRα re- highlight the influence of S.aureus-derived products on ceptor, nor GRβ are responsible for glucocorticoid sensi- nasal polyposis inflammation inducing mast cell degranu- tivity in nasal polyposis.
lation and T-cell activation.
Based on the data above, further studies will be necessary Another extremely interesting chapter in understanding to clarify the various degrees of sensitivity to topical the natural history of chronic allergic rhinitis and rhinosi- steroids and for a better comprehension the therapeutic nusitis with and without nasal polyposis is the remodel- effect should be valuated differentiating allergy sufferers ling in the upper airways (102).
with eosinophil polyposis and allergy sufferers without Similarly to bronchial asthma, chronic rhinosinusitis with eosinophil polyposis (92,93,116).
polyps shows epithelial damage, basement membranethickening and oedema, at times, with extensive fibrotictissue (103). A recent study evaluated the presence of Allergic rhinitis and obstructive sleep apnoea syndrome
MMP-7, MMP-8, MMP-9 and tissue inhibitor of met-alloproteinases (TIMP) in chronic rhinosinusitis with Obstructive sleep apnoea syndrome (OSAS) is a clinical polyps, suggesting the role of an imbalance between met- condition characterised by recurrent nocturnal episodes of alloproteinases and their natural inhibitors (104,105).
apnoea ed hypopnoea, experienced by 4-10% of men and By stereologically testing the vascular surface and the 2-4% of women (117,118).
density of nasal tissue volume in rhinitic and non-rhinitic The physiopathological mechanisms underlying OSAS subjects, some authors have demonstrated a lack of vascu- are complex and have yet to be fully understood (119).
lar remodelling in the mucous membrane of allergic sub- There are two types of relationships that can occur be- Allergic rhinitis and associated pathologies: the rationale for steroid options tween allergic rhinitis and OSAS: purely mechanical or supine body position and worsens during sleep, especially inflammatory, both local and systemic.
in the case of allergic rhinitis when inflammatory media- Interaction between nasal and oral resistance could be im- tors peak in the early hours of the morning which com- plicated in the physiopathology of this disorder. Indeed, the bine with a reduced sympathetic nocturnal tone inducing upper airways are described as a Starling resistor which re- a corresponding increase in parasympathetic tone which is sembles an empty tube partially occluded at the start of the associated with nasal congestion (131).
nose area and partly collapsed at the section below it corre- Several studies have investigated the relationship between sponding to the oropharynx (120). The clinical significance nasal obstruction in allergic subjects and respiratory of the properties of the resistor imply that changes in pres- changes during sleep. In their cohort study of 911 subjects sure and intraluminal resistance and/or the collapsibility of who were given a polysomnograph Young et al. (128) re- the airways influence patency, so that high inspiratory pres- ported substantial respiratory changes during sleep in sub- sure will reduce airflow (121,122).
jects with symptomatic allergic rhinitis compared to those Among the factors that influence maximal airflow in the without nasal symptoms. However, the same authors found collapsible section of the airways (122) besides increased no linear correlation between reduced upper airways air- intranasal pressure, which occurs during therapy (CPAP, flow and the severity of breathing changes during sleep.
BiPAP), or greater collapsibilty due to an anatomical pre- As allergic rhinitis produces various types of nasal ob- disposition of the intermediate region of the resistor struction it has been the subject of study: micro-awaken- (oropharynx), a possible third factor is upper airway resis- ing associated with breathing disorders in sleep are far tance, particularly in the nose (123).
more frequent in subjects with seasonal allergic rhinitis In the presence of nasal obstruction, the ability of the sec- than in healthy controls (132,133).
tion below to collapse increases (119) in that a Bernoulli- One case control study by Canova et al (134) aimed to type effect occurs due to increased negative pressure at evaluate whether atopy to perennial allergens and subse- the oropharyngeal level during inspiration (124).
quent allergic rhinitis were risk factors for OSAS. The au- The Starling resistor theory therefore hypothesises that thors concluded that the prevalence of allergic rhinitis was nasal obstruction plays an important role in the phys- higher in OSAS subjects than in COPD controls. There- iopathology of OSAS (119), though the success rate of fore the author hypothesized that allergic rhinitis to corrective nasal surgery is poor, only rarely substantially perennial allergens is a risk factor for OSAS and that reducing the frequency of apnoea/hypopnoea attacks treatment of this comorbidity is important in reducing OSAS morbility (134). This is the first study to identify On this point, data is largely controversial regarding nasal the link between OSAS and perennial allergic rhinitis obstruction as a risk factor for OSAS. On the one hand (134). To support this paper's case we cite the study by studies done using objective parameters of nasal resistance McNicholas et al. (132) which documents that seasonal in snorers have been unable to produce a correlation be- allergic rhinitis patients have a higher apnoea/hypopnoea tween increased resistance to airflow in the nasal fossa index (AHI) and more protracted seizures of sleep apnoea and OSAS (126-128), while on the other, a subsequent in the pollen season. More recently, the same author (135) study performed on a large snorer population who under- evaluated the efficacy of intranasal steroid therapy in sub- went posterior rhinomanometry successfully found that jects with OSAS and allergic rhinitis by applying the pa- nocturnal nasal obstruction is an independent risk factor rameters of nocturnal apnoea severity, sleep quality, snor- for OSAS (124).
ing and daytime symptoms. The OSAS was found to im- The authors who used multiple regression analysis prove, as indicated by a fall in the apnoea/hypopnoea in- demonstrated that nasal obstruction contributes to the dex, with no snoring improvement, leading to the author's development of OSAS in 2.3% of cases, while other not- conclusion that steroid therapy could benefit selected ed risk factors such as the distance between the hyoid groups of patients with OSAS.
bone and mandibular plane, BMI, male sex and age con- Subsequent studies reported significant associations be- tribute 6.2 %, 4.6%, 3% and 1.3% respectively to the vari- tween breathing disorders during sleep and nasal obstruc- ation (124).
tion of diverse origins (134,136,137).
In addition, a stronger correlation was found between an As for inflammatory factors in OSAS, it has recently been increase in nasal resistance when supine and OSAS reported that the presence of systemic inflammation is as- (129,130). Indeed, nasal congestion increases in the sociated with daytime sleepiness and an increased risk for B. Farabollini, M.C. Braschi, F. Bonifazi cardiovascular complications or metabolic syndrome in adenoid size in 71% of cases with an associated decrease these patients (138).
of the nasopharyngeal cavity in 93% of subjects during The underlying inflammation of OSAS has been attrib- the pollen season (151). These changes subside in 90% of uted to a mechanical change in airways tissue induced by the subjects after the pollen season ends.
repeated trauma from snoring and the hypoxia-normoxia As a result, in children, snoring and OSAS are associated cycle of the disorder (138).
with adenotonsillar hypertrophy and chronic rhinitis, and Systemic inflammation in OSAS is characterised by an allergic rhinitis increases the risk for OSAS especially in increase in TNF-α, IL-6, PCR, IL-1‚ and the ICAM-1 children with habitual snoring (152).
adhesion molecule plasma values (139, 140). Intermittent The combination of steroid therapy and adenoidectomy is hypoxemia can also stimulate transition factors like nu- a key competitor in the treatment of paediatric popula- clear factor-kB and increase cytokine production (141).
tions (153). However, in the management of OSAS the A comparison of nasal lavage in OSAS and normal sub- benefits of oral corticosteroid therapy do not appear to be jects yields a higher number of neutrophils and, concen- diminished when compared to the outcome of an ade- trations of bradykinins and VIP in the former (142).
noidectomy (153), practised by general consensus in the The evaluation of inflammation through analysis of in- last decade to reduce the size of upper airways lymphoid duced sputum confirms the high percentage of neu- tissue (154-158).
trophils and reduced number of macrophages in OSAS More recent studies (159) have demonstrated that the up- sufferers, while other cell populations do not appear to per airways lymphoid tissue in children with OSAS pre- present any differences from those of healthy controls sents a large number of glucocorticoid receptors α, and (143). IL-6 and 8-isopentane values measured in exhaled hypothesise that the better topical steroid therapy re- breath condensate were elevated in OSAS patients com- sponse is linked to this circumstance.
pared to those of obese and control subjects (144).
In one study (145) of 62 children polysomnographically These data demonstrate that similarly to systemic inflam- diagnosed with mild OSAS, the administration of in- mation in OSAS patients, the airways are also charac- tranasal corticosteroids seemed to reduce the severity of terised by local inflammation and oxidative stress (138).
OSAS and the size of the underlying adenoid hypertro- As previously mentioned, through the hypothetical resis- phy, which lasted eight weeks after discontinuing therapy.
tor model the mechanics of the upper airways determines Moreover, in a previous study, after six weeks of topical the significant role of nasal obstruction (119). A recent fluticasone treatment, the steriod improved the editorial by (119) McNicholas et al. makes the assump- apnoea/hypopnoea index (AHI) in children with OSAS tion that variable nasal obstruction plays a more impor- (155), which was confirmed by a fall in the number of tant role in the physiopathology of OSAS than anatomi- episodes of haemoglobin desaturation, activation of the cal obstruction in the nasal cavities. This is a partially bi- respiratory muscles and night time awakenings.
ased point of view which bases itself on the hypothesisthat in subjects with fixed nasal obstruction an oral respi-ration adaptive response develops which limits the impact of the pathogenesis of nasal obstruction OSAS. The re-sponse does not seen to occur in intermittent nasal ob- Though allergic rhinitis, viral exacerbations, chronic struction, whose relationship is more closely linked with rhinitis with polyps and OSAS have many inflammatory automatic nasal respiration.
mechanisms in common, further studies will be necessary In children, the prevalence of OSAS is 2-3% (145) of to investigate the most controversial hypotheses.
which the highest incidence is between 2-8 year olds.
Viral exacerbations in particular belong to this category, Though anatomical and neuromuscular abnormalities can where a dynamic relationship and counter relationship contribute to the development of OSAS its severity is es- seem to develop between the load and nature of the viral pecially related to adenoid and palatine tonsil size (146, infection on one hand and widespread and pre-existing 147) to such an extent that the choice treatment is an allergic inflammation on the other. That being so dy- namism related therapy, Any data remains necessarily un- Adenotonsillar hypertrophy is frequent in children with defined regarding the effects of steroid therapy, when allergic rhinitis (149,150). A study of 28 children with there is a concomitant viral inflammatory response of the seasonal allergic rhinitis revealed a significant increase in airway mucus.
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Eur Ann Allergy Clin Immunol VOL 41, N 3, 80-84, 2009 A. Bener1,2, M. Dogan3, M.S. Ehlayel4, N.J. Shanks5, A. Sabbah6 The impact of air pollution on hospital admissionfor respiratory and cardiovascular diseases in an oiland gas-rich country 1 Dept. of Medical Statistics and Epidemiology, Weill Cornell Medical College, Hamad MedicalCorporation, Hamad General Hospital, Qatar; 2 Dept. Evidence for Population Health Unit, School ofEpidemiology and Health Sciences, The University of Manchester, Manchester, United Kingdom; 3 Dept.
of Chemistry, Faculty of Science, Yildiz Technical University, Istanbul, Turkey; 4 Dept. of Pediatrics,Section of Allergy-Immunology, Hamad Medical Corporation, Qatar; 5 Community Medical Director, AlKhor QatarGas, RasGas, Doha, Qatar; 6 25 Avenue Jeanne d'Arc, 49100 Angers , France Key words
Summary
Objectives: Aim of this study was to evaluate the impact of air pollution on hospital
Epidemiology. air pollution, admissions for respiratory and cardiovascular diseases in an oil rich developing country, PM10, SO2 and O3 pollutant, State of Qatar. Methods: A prospective cohort population based study was conducted at
Qatar, respiratory and coronary different stations of Qatar during the period (2002-2005) for recording the concentra- heart diseases tion of air pollutants daily for sulphur dioxide (SO2), nitric oxide (NO), nitrogen
dioxide (NO2), carbon monoxide (CO), ozone (O3) and particulate matter (PM10).
Hospital admission data were collected from the inpatient discharge database of the
Medical Records Department, Hamad General Hospital. Results: An average of 5.36
admissions from ischemic heart diseases was counted daily in all the population which
was even higher than the respiratory diseases (3.4/day). Minimum temperature was
inversely correlated with all pollutants except for O3 and SO2. Conclusion: There was
an association between increasing air pollutant levels and patients admitted for respi-
ratory and cardiovascular diseases.
million people in urban areas worldwide were exposed todangerous levels of traffic generated air pollutants (2). Air Air pollution and its public health impacts are drawing pollution and its impact on human health have been con- increasing concern from the environmental health re- sidered a serious problem in urban areas.
search community, environmental regulatory agencies, in- At the present time, motor vehicle emissions are the main dustries as well as the public. The quality of the air, both source of urban pollution than other sources such as heat- indoors and outdoors, is closely related to morbidity and ing and industrial activities. Daily levels of air pollutants mortality from respiratory and cardiovascular diseases. Air have been associated with increased daily mortality and pollution is composed of many environmental factors morbidity. The time series studies in North America have which include Carbon Monoxide (CO), Nitrates, Sulphur indicated that particles and ozone are related to emer- dioxide (SO2), Ozone (O3), lead, tobacco smoke and gency hospital admissions for respiratory conditions (3).
Particulate Matter. Urban atmospheric pollution has a Some studies showed strong correlations between air pol- well-known impact on acute and chronic respiratory dis- lutants levels and causes of morbidity with respiratory and ease (1). The United Nations estimated that over 600 cardiovascular diseases (4-11). Also, a study reported as- The impact of air pollution on hospital admission sociation between ambient carbon monoxide levels and air pollutant from each individual station was retrieved hospitalizations for congestive heart failure in the elderly during the period 2002 – 2005 and the daily mean of each in (10) Canadian cities (12,13), air pollution and hospital air pollutant was calculated. Pollutant concentrations are admissions for cardiovascular disease in Tucson14 and obtained from 24-h average (starting at 4:00 P.M. of the stroke in Kaohsiung, Taiwan (15) and effects of tempera- preceding day). Meteriological data including tempera- ture and air pollutants on cardiovascular and respiratory ture and humidity were obtained from the department of diseases for males and females older than 65 years of age Meteorology, Civil Aviation Department.
in Tokyo (16). There is substantial epidemiological evi-dence indicating a link between respiratory and cardiovas- Hospital admissions data cular morbidity and outdoor air pollution levels.
In the State of Qatar, there are five government hospitals Air pollution in the State of Qatar originates mostly from under the umbrella of the Hamad Medical Corporation motor vehicle traffic and industry. As a result, concentra- (HMC) managing 1567 beds and accounts for 90% of all tions of CO, NO2, O3, and airborne particles are gener- hospital admissions. These hospitals provide in-patient ally high. Expanding industrialization and increasing services for all residents of Qatar and are the main tertiary traffic volumes in the developing countries will drastically care centers in the country making an ideal center for increase total emissions of many air pollutants as has been population-based studies. All hospital inpatient data in- predicted by a study in East Asian Country (17). Hence, cluding demographic characteristics, dates of admission the present study was designed to investigate the air pol- and discharge, diagnoses and procedures on discharge us- lution and evaluate the impact of air pollution on hospital ing the International Classification of Diseases, 9th Revi- admissions for respiratory and cardiovascular diseases in sion, Clinical Modification (ICD-9-CM), have been stored in a central-computerized database in the MedicalRecords departments. We have retrieved the data onmonthly hospital admission during the study period for Subjects and methods
respiratory diseases including Pneumonia and Asthma[(460-466), (480-486), (490-492), & (493-496)], Is- This is a prospective cohort population based study aim- chemic heart disease (410-414) and Cardiovascular illness ing to investigate the air pollution and the impact of air [(420-438) & (440-444)].
pollution on respiratory and cardiac diseases in the Stateof Qatar during the period (2002 – 2005). The State of Statistical Analysis Qatar is located halfway along the western coast of the Student-t test was used to ascertain the significance of Arabian Gulf. The length of the peninsula from south to differences between mean values of two continuous vari- extreme north is about 160 km, and the total area includ- ables and confirmed by non-parametric Mann-Whitney ing the islands is about 11493sq.km. The population esti- test. One-way analysis of variance (ANOVA) was em- mate of Qatar for the year 2005 was 796186. Doha is the ployed for comparison of several group means and to de- capital and commercial centre of the country. Mesaieed termine the presence of significant differences between as the second important town is a modern industrial group means of continuous variables. Multiple regression town. Qatar is characterized by a hot summer starting analysis was used to assess the relationship between the from June till August. Winter is warm with little rainfall.
dependent variable and independent variables. Pearson's It starts from December to February; Spring starts from bivariate correlation was utilized for association between March to May; and Autumn starts from September to continuous variables. The level p<0.05 was considered as the cut-off value for significance.
Data on Air quality and weatherData on six air pollutants CO, NO2, NO, O3, SO2, PM10 were obtained from the Environmental health de-partment of the Qatar Petroleum. There were stations for Table 1 shows the summary of environmental variables monitoring general air quality across the territory and we and daily hospital admissions during the study period have taken the readings from the important stations of (2002 – 2005). A daily average of 3.4 respiratory dis- the urban areas. The hourly concentration record of each eases, 3.53 cardiovascular diseases, 5.36 Ischemic heart A. Bener, M. Dogan, M. S. Ehlayel, N. J. Shanks, A. Sabbah diseases were observed in the study period. An average of correlated with all pollutants except for O3 and SO2. But, 5.36 admissions from Ischemic heart diseases was counted humidity was inversely correlated with all the air pollu- daily in all the population which was even higher than the tants except for NO and NO2. The critical air pollutants respiratory diseases (3.4/day).
in urban areas of Qatar were CO and NO2.
Table 2 presents the day-to-day correlation between Air Table 3 presents the effect of meteorological factors on the Pollution and Meteorological Measures. The concentra- air pollutants in Qatar. There was a highly significant asso- tions of CO and NO2 were highly correlated with other ciation between meteorological factors and air pollution.
pollutants. PM10 and SO2 were weakly correlated with Table 4 shows the trend in concentration of air pollutants other pollutants. Minimum temperature was inversely and the number of daily admissions from respiratory andcardiovascular diseases during the study period 2002-2005. As there was a slight increase in the concentration Table 1 - Summary of environmental variables and daily hospital
admission from the respiratory and cardiovascular diseases
of air pollutants in the year 2005, the daily admissions from the respiratory, Ischemic heart diseases and cardio-vascular diseases also increased slightly.
Pollutant variable Exposure to air pollution has been considered to be one of 0.022 0.030 0.039 the leading factors in public health problems in develop- 0.003 0.009 0.023 ing and oil-rich developing countries. This problem has 0.015 0.027 0.039 long been the focus of attention in developed countries 0.002 0.004 0.041 and their exposure rates have been greatly reduced where- as, relatively, there has not been much effect in reducing Environmental variable the magnitude of the problem in oil-rich developing 20.60 26.90 31.70 countries. Documentation of air pollution and sources inthe State of Qatar has never been reviewed in terms of its 47.55 64.00 75.70 effect on health. No research by means of a population- Hospital admissions based study has been conducted in order to define the im- portant epidemiological characteristics of air pollution in human health.
Cardiovascular illness Many authors have reported the effects of air pollutants Ischemic Heart diseases 5.36 on the cardiovascular system (4, 16). Carbon monoxide Table 2 - Day-to-day correlation between Air Pollution and Meteorological Measures
Tmin: Minimum temperature; Hmed: Relatively humidity†p<0.05*p<0.01 The impact of air pollution on hospital admission Table 3 - The effect of meteorological factors on the air pollutants in Qatar
Meteorological factors Relative humidity * Significance p-value and Student t-testNS = Not –significant† One-Way Analysis of variance and p-valu from Ischemic heart diseases was counted daily during the Table 4 - The trend in concentration of air pollutants and the
study period. Daily admissions of other cardiovascular number of dailyadmissions from respiratory and cardiovascular diseases were 3.53 admissions. Also in our study, the data diseases, 2002 - 2005 revealed that as the concentrations of CO, SO2, increasedin the year 2005, the admission of Ischemic and cardio- vascular diseases also increased slightly in the same year.
CO and NO2 have become a major air pollution problem in the urban areas of Qatar, resulting from, ongoing con- struction nearby, demolition activities, busy traffic, atmos-pheric chemical reactions, sea spray, and wind-blown sands.
The air pollution data in the present study showed that the concentration of CO and NO2 was highly correlated with other pollutants. But, PM10 and SO2 were weakly corre- lated with other pollutants. This is in consistent with the results reported by Burnett et al. (20) in ten CanadianCities. In contrast, in south Boston, the concentrations of Hospital Admissions PM2.5 and PM10 were highly correlated. CO and NO2 Respiratory diseases were moderately correlated with PM10 (21).
Cardiovascular diseases 3.419 Among the gaseous pollutants, NO2 and O3, which are Ischemic Heart diseases 5.218 powerful oxidating agents, may also trigger an inflamma-tory pulmonary, then systemic reaction with an increase of (CO) is a well recognised cardiovascular toxicant and its blood coagulability and platelets (22, 23). The data association with the exacerbation of Angina and Myocar- showed that as the concentrations of NO2 and O3 in- dial infarctions has already been reported (12, 18, 19).
creased, there was an increase in the number of admis- Another study reported that in Hong Kong and London sions from respiratory diseases. This shows a positive as- SO2 was associated with increases in cardiovascular dis- sociation between air pollution and respiratory diseases, as ease hospital admissions (8). An increase in SO2 was as- has been reported elsewhere (24). These findings are sup- sociated in more than one-third of the studies with in- ported by similar associations between hospitals admis- creased hospital admissions for myocardial infarction, sions for respiratory diseases and mortalities that have angina, or Ischemic heart disease (9). Also, the effects of been reported in a study done in China (9).
particulate and gaseous air pollution on cardio respiratory This study indicated the importance of following points: hospitalizations was reported by Burnett et al. (20). It was Developing a new control strategy to manage and im- found from our data that an average of 5.36 admissions prove air quality. Consideration should be given to the fu- A. Bener, M. Dogan, M. S. Ehlayel, N. J. Shanks, A. Sabbah ture expansion of towns and cities towards industrial 8. Wong TW, Lau TS, Yu TS, Neller A, Wong SL, Tam W, Pang emission sources, and the potential effect on air quality of SW Air pollution and hospital admissions for respiratory andcardiovascular diseases in Hong Kong. Occup Environ Med residential areas as a possible consequence. Enforcement of legislation and punishment of polluters is important 9. Bener A, Ehlayel M, Sabbah A. The pattern of genetics of paedi- according to type and intensity of pollution. It is good to atric extrinsic asthma risk factors in polluted environment. Allerg establish educational programs for factory managers and Immunol (Paris). 2007; 39(2):58-63.
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Eur Ann Allergy Clin Immunol VOL 41, N 3, 85-94, 2009 B. Proust1, C. Astier1, J. M. Renaudin1, E. Magueur2, D. Maurice2, C. Belcourt2, F.
T. Yen2, G. Kanny1, B. E. Bihain2, S. Jacquenet2 A murine model of cow's milk protein-inducedallergic reaction: use for safety assessment of hiddenmilk allergens 1EA 3999 "Allergic Diseases: Diagnosis and Therapeutics", Department of Internal Medicine, ClinicalImmunology and Allergology, University of Nancy, France; 2Genclis SAS, Vandoeuvre-lès-Nancy, FranceSource of support: Saint Hubert, France Key words
Summary
Background: Masked allergens in processed food products can lead to severe allergic re-
Cow's milk allergy, anaphylaxis, actions following unintentional ingestion. We sought to develop a murine model for mouse model, LOAEL, NOAEL, the detection of hidden cow's milk proteins (CMP). This study aimed to induce cow's milk allergy in mice, to characterize the anaphylaxis induced by CMP in this model,
and to validate its reliability using three margarines manufactured with (A) or with-
out (B, C) milk, sharing the same production line. Materials and Methods: Three-
week-old BALB/c mice were sensitized intragastrically with CMP plus cholera toxin
and boosted 6 times at weekly intervals. CMP-sensitization status was monitored by
skin tests, and measurement of CMP-specific IgE and IgG1 levels. On day 44, the
minimal threshold of clinical reactivity to CMP in terms of anaphylaxis was deter-
mined by performing a dose response of intraperitoneal CMP challenge. Under the
same conditions, anaphylaxis was evaluated in CMP-sensitized mice after challenge
with protein extracts of margarines A, B or C. Results: Sensitization to CMP was
demonstrated by positive skin tests and increased CMP-specific IgE and IgG1. The
minimal clinical reactivity threshold corresponding to 0.1 mg CMP elicited detectable
anaphylaxis evidenced by clinical symptoms, a decrease in breathing frequency, and in-
creased plasma histamine upon challenge. Similarly, challenges with margarine A con-
taining CMP demonstrated anaphylaxis, whereas those with B or C did not elicit any
detectable allergic reaction. Conclusion: This study shows that our murine model of
CMP-induced anaphylaxis is useful for investigating the allergenic activity and the
assessment of margarines with respect to milk.
Abbreviations: CMP: cow's milk proteins; CT: cholera toxin; i.g.: intragastrically; i.p.: intraperitoneal; LOAEL: lowest observed
adverse effect level; MOS: margin of safety; NOAEL: no-observed adverse effect level
B. Proust, C. Astier, J. M. Renaudin, et al.
(FAO)/World Health Organization (WHO) [22, 23] hasidentified a need for the development of well-defined Food allergy is an important public health problem in in- food allergy animal models that can serve as predictive dustrialized countries. To date, strict dietary avoidance is tools for the determination of the allergenic activity of the only way to manage food allergy, which implies care- finished food products.
ful labelling of manufactured products. Nevertheless, Cow's milk allergy is one of the most common food al- masked allergens in food can lead to severe accidents such lergies in infants. Most patients outgrow this by the age as fatal food-induced allergic reactions following uninten- of 5 years, but cow's milk allergy can persist in some tional ingestion [1]. The total absence of any or all aller- adults [24]. Contamination of food products with milk gen in foods is often difficult to achieve because of manu- proteins have been reported to be unsafe in children al- facturing practices. Any remaining allergens are due pri- lergic to cow's milk [1, 25]. The wide use of cow's milk marily to different products sharing the same production proteins (CMP) in various food products complicates the application of dietary avoidance. This is most notably the The relationship of any given food to allergy can be con- case for fats used as cooking oils or spreads such as mar- sidered as two main components. 1) Allergenicity is de- garines. These products are defined as foodstuffs other fined as the likelihood of a given protein to induce de no- than butter whatever their origin or their composition, vo sensitization in a non-allergic individual [2]. The de- that present the same aspect as that of butter and are in- termination of allergenicity requires models of allergic tended for the same use. Margarines are composed of sensitization primarily conducted in animals. Several two major fractions: fat (83 %) and an aqueous fraction models developed in mice [3-8] and rats [5, 9, 10] have (17 %) which includes water and/or milk, emulsifiers, been helpful in investigations of allergic sensitization and conservatives, aromas and coloring agents. Some mar- humoral immune responses. 2) Allergenic activity reflects garines therefore contain cow's milk allergens when milk the propensity of a substance to induce allergic reactions is included in their manufacturing, while others prepared in sensitized individuals [2]. This activity is usually eval- without milk can be contaminated due to manufacturing uated in allergic patients by oral challenge tests. The clinical objective is to determine whether the component This study aimed (i) to induce cow's milk allergy in mice in question induces allergic response in allergic individu- and characterize the anaphylactic reaction induced by als and to estimate the magnitude and the risk related to CMP in this model, and (ii) to validate the suitability this reaction. Several rodent [11-13] and non-rodent and the reliability of this model for the testing of mar- models such as swine [14] or canine [15] have been de- garines manufactured with or without milk, yet sharing veloped to mimic food allergies similar to those seen in the same production line.
humans. A major advantage of these models is that aprotein induces not only an immune response but, alsoclinical symptoms as well after allergenic challenge in Materials and Methods
sensitized animals. These models are useful for the inves-tigation of allergenic activities of allergens and the im- Three-week-old female BALB/c mice were purchased munopathological me-chanisms involved, as well as for from Charles River Laboratory (Lyon, France). Animals the exploration of potential immunotherapeutic ap- were maintained on milk-free chow (Harlan Teklad, proaches. Despite these interesting and valuable models, Gannat, France) under specific pathogen-free conditions none have been used for the study of the allergenic activ- on a 12 h light/dark cycle in a room maintained at a ity of finished food products before their marketing. In mean temperature of 21 ± 2°C with a relative humidity of vitro assays are commonly used to detect proteins in food 50 ± 20%. Drinking water and standard laboratory ani- products [16-21]. These tests provide information for mal food pellets were provided ad libitum. Animals were safety assessment, but do not determine the allergenic ac- handled in accordance with French State Council guide- tivity of finished products. It is clear that clinical studies lines for the use and care of laboratory animals (decree are the gold standard tests, but in practice, they cannot N° 87-848, October the 19, 1987 and decree 2001-464, be implemented on a routine basis for detection of aller- May the 29, 2001).
gens in foods. Genetically Modified Foods by the Food Commercially available powdered cow's milk (355 mg and Agricultural Organization of the United Nations CMP/g, Régilait, Saint-Martin-Belle-Roche, France) In vivo CMP detection tool for exploration of allergenic activity of margarines was used. Three margarines referred to as A, B and C (MaxiSorp, Nunc Immunoplate, Roskilde, Denmark) were provided by a manufacturer without any indication were coated overnight with CMP (0.5 µg/mL for specific on their composition. Detection antibodies for ELISAs, IgE and 1 µg/mL for specific IgG1) diluted in carbonate i.e. HRP-labeled goat anti-mouse IgE and IgG1, were buffer (50 mM, pH 9.6). Plates were incubated with di- purchased from Serotec Ldt (Kidlington, Oxford, UK) luted serum samples (1:10 for IgE; 1:5000 for IgG1) at and Southern Biotech (Southern Biotechnology Associ- 37°C for 2 h. CMP-specific IgE were detected by HRP- ates Inc., Birmingham, AL, USA), respectively. Com- labeled goat anti-mouse IgE (1:5,000). CMP-specific pound 48/80, red blood cell lysis buffer and concanavalin IgG1 were detected by HRP-labeled goat anti-mouse A were obtained from Sigma (Saint Louis, MO, USA).
IgG1 (1:1,000). Plates were developed with tetramethyl BALB/c mice were sensitized intragastrically (i.g.) with benzidine substrate (Pierce, Rockford, IL, USA) and cow's milk administered together with cholera toxin read at 450 nm with an automated microplate reader (CT) and boosted 6 times at weekly intervals. To deter- (Biorad, Hercules, CA, USA). The specificity of HRP- mine the optimal sensitizing dose, 3 groups of mice re- labeled goat anti-mouse IgE was verified in preliminary ceived 0.1, 1 or 10 mg of CMP in PBS containing 4 µg experiments. IgE detection was not modified after re- CT per mouse (200 µL per mouse) through oral admin- moving IgG from mouse pooled sera with protein-G istration. Control mice were sensitized i.g. with 4 µg CT (Sigma) (data not shown).
alone. Naive mice never exposed to CMP or CT were Anaphylactic symptoms were assessed by 2 independent used as second controls. Immediately prior to each boost- investigators within 0-45 minutes after the intraperi- ing, individual blood samples from each group of mice toneal (i.p.) challenge; this study was conducted in a were obtained from the retro-orbital venous plexus under blind manner. Disease severity was evaluated by using a isoflurane anaesthesia, centrifuged and the sera were scoring system as previously described (Proust et al., stored at - 20°C until use. Two skin tests were per- 2008) with slight modifications and scored as follows: 0, formed: an ear swelling test and an intradermal skin test no symptoms; 1, reduced activity; 2, scratching and rub- (see below). Forty four days after the initial boosting, bing around the nose, the ears and eyes, partial immobili- mice were challenged intraperitoneally with 15 mg CMP ty; 3, prostration, pilar erection, total immobility; 4, ede- in 150 µL of PBS per mouse, and anaphylaxis was as- ma around the mouth and the eyes, puffiness around the sessed by monitoring clinical symptoms, rectal tempera- eyes; 5, no activity after prodding, convulsion, and death.
ture, breathing frequency, and by measuring plasma hist- Rectal temperature was measured before and 30 minutes amine levels.
after the i.p. challenge using a thermal probe (Anritsu Ear swelling test was performed as previously described meter CO., LTD, Tokyo, Japan).
(Proust et al., 2008). Briefly, CMP (10 µL, 5 mg/mL) Breathing rate (breaths per minute, bpm) was assessed in was intradermally injected into the dorsal aspect of a conscious unrestrained mice following evaluation of ana- mouse ear and ear thickness was measured with a digi- phylactic symptoms after the i.p. challenge using a baro- matic micrometer (Mitutoyo, Japan). Ear swelling re- metric plethysmography method (EMKA Technologies, sponse was determined as the incremental increase in Paris, France).
thickness above baseline control values. Compound Blood was collected 60 minutes after the i.p. challenge 48/80 (5 mg/mL) and PBS were used as positive and and plasma histamine concentrations were measured with negative controls, res-pectively.
an ELISA kit (Immunotech, Marseille, France) accord- Intradermal skin tests were carried out as previously de- ing to the manufacturer's instructions.
scribed (Proust et al., 2008). Briefly, before testing, the Spleens were harvested from mice allergic to CMP after abdominal skin was shaved. Evan's blue dye (100 µL, challenge under sterile conditions. After lysis of red 0.25 %) was intravenously injected and five minutes later, blood cells with buffer (Sigma) and several washes, CMP (10 µL, 2.5 mg/mL) was injected intradermally splenocytes were resuspended in complete culture medi- under isoflurane anaesthesia. Compound 48/80 (30 um (RPMI-1640 plus 10 % fetal calf serum, 1 % peni- µg/mL) and PBS were used as positive and negative con- cillin/streptomycin and 1 % L-Glutamine). Cells were trols, respectively. A blue wheal with a diameter > 0.3 cm incubated in 24-well plates (4 x 106 cells/mL) in the appea-ring within 5 minutes after the injection of aller- presence or absence of CMP (5 µg/mL) or Concanavalin gen was considered as positive.
A (2 µg/mL, positive control) for 72 h at 37°C (5 % CMP-specific antibodies were assayed by ELISA. Plates CO2). Supernatants were then removed and stored at - B. Proust, C. Astier, J. M. Renaudin, et al.
80°C until use. Levels of IL-4, IL-5 and IFN-γ were as-sayed using CytoSetsTM kits (BioSource International Figure 1 - CMP-sensitization following oral exposure to CMP
Europe, Nivelles, Belgium) according to the manufactur- plus CT (A) Ear swelling response after CMP intradermal injec- er's instructions. The limits of detection for IL-4, IL-5 tion at day 42 post-sensitization. Forty minutes after intradermalinjection of PBS, compound 48/80 or CMP (10 µL, 5 mg/mL), and IFN-γ were < 5 pg/mL, 3 pg/mL and 1 pg/mL, re- increase of ear thickness (mm) was measured in CMP-sensitized mice and control (naive and CT alone). Results are expressed as To determine the clinical reactivity threshold in CMP- mean ± SEM of 6 mice per group. ***p < 0.001: CMP or com- sensitized and -challenged mice, i.e. the minimal dose of pound 48/80 versus PBS treatment for each group. NS: non signi- CMP leading to anaphylactic symptoms, mice sensitized ficant. Sera CMP-specific IgE (B) and IgG1 (C). Pooled sera from with the optimal sensitizing dose of CMP as previously each group of mice (n=6 mice/group) as indicated were obtained determined, as well as CT mice, were blind challenged weekly just before each boosting. CMP-IgE and IgG1 levels were intraperitoneally at day 44 either with 0, 0.01, 0.1, 1, 5 or assessed by ELISA. Results are expressed as mean ± SEM of 6 mi- 15 mg CMP per mouse.
ce per group. *p < 0.05, **p < 0.01, ***p < 0.001: CMP-sensitized Protein extracts of each of the margarines (A, B and C) versus naive or CT mice. #p < 0.05, ##p < 0.01, ###p < 0.001 versus were freshly prepared by treating 10 g melted margarine 0.1 mg CMP + CT. +p<0.05, +++p < 0.001 versus 10 mg CMP + with di-isopropyl ether. Samples were mixed for 30 min CT. NS: non significant at room temperature on a circular rotator (30 rpm) andthen centrifuged 5 min at 2500 rpm. The aqueous phasewas collected and organic solvent was evaporated byN2(g). A negative internal control, i.e. PBS alone, wasprepared similarly and simultaneously with the differentsamples of protein extracts. Mice sensitized to CMP, aswell as CT mice were blind challenged by i.p. injectionwith 150 µL of protein extracts of either margarines A, Bor C or with 150 µL PBS alone in order to determine forpresence of CMP in margarines.
Margarine extracts were prepared as described in the pre-vious paragraph. CMP content of these extracts wasmeasured by sandwich ELISA using polyclonal antibod-ies directed against all CMP (Neogen, Ayr, Scotland).
Results are expressed as mean ± SEM. Statistical analyseswere determined using Student's t test and one-wayANOVA. A p value < 0.05 was considered as statisticallysignificant.
To characterize the relationship between the dose ofCMP administered and sensitization status, we per-formed skin tests (ear swelling and intradermal skintests) and monitored sera CMP-specific IgE. On day 42,signi-ficant increases in ear thickness in response to in-tradermal injection of CMP were observed with all sensi-tizing doses of CMP (Figure 1A). No increase in earthickness was obtained in control mice (naive and CTalone). Similarly, positive skin responses with intradermalskin test were observed in all CMP-sensitized mice ascompared to control mice (data not shown). Animals In vivo CMP detection tool for exploration of allergenic activity of margarines sensitized with 0.1, 1 and 10 mg CMP plus CT pro- plateau with higher doses. Figure 3 also revealed that a duced significant increase in CMP-specific IgE and dose of 1 mg CMP induced a maximal decrease in body IgG1 levels from 35 and 28 days, respectively, after the temperature (Figure 3B) and in breathing frequency initial boosting in contrast to control mice (Figures 1B, (Figure 3C). Although relatively less pronounced, both 1C). On day 42, both 1 and 10 mg doses of CMP plus parameters remained significantly modified at higher CT induced an increase in levels of CMP-specific IgEthat were significant, but lower than that observed for0.1 mg CMP plus CT (Figure 1B). CMP-specific IgG1 Figure 2 - Anaphylactic response depending on the amount of
levels were significantly increased on day 42 at the dose CMP used for oral sensitization CMP-sensitized (n = 6/group), of 1 mg CMP plus CT, but lower than that observed for naive (n = 6/group) and CT (n = 6/group) mice were challenged 0.1 and 10 mg CMP plus CT (Figure 1C).
intraperitoneally with 15 mg CMP at day 44 post-sensitization.
We next evaluated the anaphylactic reaction in CMP- (A) anaphylactic symptoms, (B) change in body temperature and sensitized mice at day 44 upon an i.p. challenge of 15 mg (C) change in breathing frequency were evaluated after i.p. challen- CMP per mouse. CMP-sensitized mice expressed severe ge. Data are given as mean ± SEM. *p<0.05, **p < 0.01, ***p < anaphylactic symptoms reaching a clinical score of 4 to 5 0.001: CMP-sensitized versus naive or CT mice after CMP chal- irrespective of the sensitizing dose (Figure 2A). Howev- lenge. #p < 0.05, ##p < 0.01 versus 10 mg CMP + CT. NS: non si-gnificant er, the dose of 10 mg CMP elicited a more consistentanaphylactic response in all CMP-sensitized mice ascompared to those sensitized to lower doses of CMP. Incontrast, control mice obtained a clinical score of 0 (Fig-ure 2A). Measurement of changes in body temperatureand breathing frequency were consistent with clinicalscore and provided an assessment of anaphylactic re-sponses that was significantly more pronounced in micesensitized with 10 mg CMP plus CT (Figures 2B andC). We therefore selected 10 mg CMP plus CT as theoptimal sensitizing dose for BALB/c mice. This dose wasused in the remainder of the study.
We next determined the production of Th1 and Th2 cy-tokines by spleen cells stimulated in vitro with CMP andcollected from BALB/c mice (sensitized with 10 mgCMP plus CT) allergic to CMP. Seventy-two hourspost-culture, Th2 cytokine production was significantlyincreased in CMP-stimulated cultures, 8 ± 0.6 pg/mL(p<0.01) and 140 ± 35.8 pg/mL (p<0.001) for IL-4 andIL-5, respectively, when compared to unstimulated cells(undetectable). In contrast, IFN-γ levels in CMP-stimu-lated and unstimulated spleen cells (35 ± 3.4 pg/mL and31 ± 2.9 pg/mL, respectively) were essentially the same(non significant). IL-4, IL-5 and IFN-γ levels for con-canavalin A were 28 ± 1.1 pg/mL, 547 ± 15.4 pg/mL and695 ± 1.6 pg/mL, respectively.
At day 44, CMP-sensitized BALB/c were challenged in-traperitoneally either with 0, 0.01, 0.1, 1, 5 or 15 mgCMP, respectively in order to determine the clinical reac-tivity threshold. CMP-sensitization status was also con-firmed. Dose response curve of Figure 3A shows that asignificant increase in anaphylactic clinical score was ob-ser ved with 0.1 mg CMP challenge and reached a B. Proust, C. Astier, J. M. Renaudin, et al.
Figure 3 - Threshold of clinical reactivity to CMP in CMP-sensitized mice. Sensitized mice with 10 mg CMP plus CT (n = 6/group) and
CT mice (n = 4/group) were challenged intraperitoneally either with 0, 0.01, 0.1, 1, 5 and 15 mg CMP per mouse at day 44 post-sensitiza-
tion. The clinical reactivity threshold for CMP was determined by monitoring (A) anaphylactic symptoms, (B) change in body temperatu-
re, (C) change in breathing frequency and measuring (D) plasma histamine concentrations, after i.p. challenge. Data are expressed as mean
± SEM. *p < 0.05, **p < 0.01, ***p < 0.001: CMP-sensitized versus CT mice after CMP challenge. #p < 0.05, ##p < 0.01, ###p < 0.001 ver-
sus 1 mg CMP. NS: non significant
challenge doses (5 and 15 mg CMP). Histamine release garine A led to anaphylaxis with a clinical score in a was significantly increased with a challenge dose of 1 mg range of 3 to 4 associated with a statistically significant but further increased with 5 mg CMP (Figure 3D).
1) drop in body temperature, 2) decrease in breathing Therefore, the minimal dose of 0.1 mg CMP elicited frequency and 3) release of plasma histamine (Figure 4).
clinically detectable allergic reaction. However, a dose of Margarines B or C failed to induce any detectable ana- 1 mg was necessary to obtain objective measures of ana- phylactic reactions. These results indicated that only phylactic reaction.
margarine A contained CMP in quantity sufficient to BALB/c mice sensitized with 10 mg CMP plus CT lead- provoke an allergic reaction. We next estimated the con- ing to positive skin tests and significant increase of centration of proteins in the extracts of margarines A, B CMP-specific IgE in serum were blind challenged in- and C. Immunobiochemical analysis revealed that CMP traperitoneally at day 44 either with protein extracts from concentrations of extracts of margarines A, C and B were margarines (A, B, or C) or PBS. CT mice treated either 10.5 µg/µL, 0.0035 µg/µL and undetectable, respectively.
with PBS or protein extracts of margarines did not de- Consequently, we estimated the quantity of CMP ad- velop anaphylactic reactions in terms of clinical symp- ministered intraperitoneally per mouse in a final volume toms, decrease in body temperature and in breathing fre- of 150 µL to be 1.6 mg and 525 ng per mouse for mar- quency (Figures 4A, B and C). Among the 3 tested mar- garines A and C, respectively.
garines in CMP-sensitized mice, the extract from mar- In vivo CMP detection tool for exploration of allergenic activity of margarines Figure 4 - In vivo assessment of allergenic activity of margarines. On day 44 post-sensitization, mice sensitized with 10 mg CMP plus CT
and CT mice were challenged intraperitoneally either with protein extracts of margarines (A, B, C) (Sens n = 6, CT n = 4 per margarine)
or with PBS (Sens n = 6, CT n = 4 per margarine) used as the negative internal control. (A) anaphylactic symptoms, (B) change in body
temperature, (C) change in breathing frequency and (D) plasma histamine concentrations were evaluated after i.p. challenge. Data are gi-
ven as mean ± SEM. *p<0.05, **p<0.01, ***p < 0.001: protein extract versus PBS challenge within each group. #p < 0.05, ###p < 0.001:
CMP-sensitized versus CT mice after challenge with protein extract. NS: non significant
levels and positive skin tests to CMP demonstrated sen-sitization to CMP in BALB/c mice. In the context of This is the first report of the application of animal model providing a sensitive model for the detection of CMP, towards detection of the allergenic activity of hidden the i.p. route was used for allergenic challenge to elicit milk allergens extracted from food using a murine model anaphylaxis [26, 28]. This route offers the advantage of of cow's milk-induced allergy. However, this is not the minimizing variations of allergen bioavailability. Indeed, first description of CMP-induced anaphylaxis. Previous we demonstrated recently that this route was much more interesting and valuable models of CMP-induced allergy sensitive than the i.g. route in terms of anaphylactic re- have been reported [12, 27], but none of them have de- sponse [28]. The determination of the threshold clinical termined the clinical reactivity threshold doses to CMP reactivity to CMP is based on the assessment of anaphy- in order to define the lowest observed adverse effect level lactic reaction by monitoring the clinical symptoms and (LOAEL) and the no-observed adverse level (NOAEL).
quantifiable parameters (body temperature, breathing Similarly to the experimental approach reported in these frequency, histamine). In our model, the LOAEL was studies, mice were sensitized using several oral exposures found to be 0.1 mg CMP. This dose was demonstrated to of milk plus CT. Increased CMP-specific IgE and IgG1 be favourable towards eliciting a detectable allergic reac- B. Proust, C. Astier, J. M. Renaudin, et al.
tion including anaphylactic symptoms scored in a range due to the fact that 525 ng CMP per mouse is largely be- of 3 to 4 associated with a significant decrease in breath- low the LOAEL and the NOAEL, nor did margarine B ing frequency and increased release of plasma histamine due to the absence of any detectable protein. The compared to 0.01 mg CMP. This latter dose that failed LOAEL described in human varies between 0.6 and 180 to lead to anaphylactic reaction corresponds to the mg CMP, whereas no NOAEL for milk has been report- threshold CMP dose below which no adverse effects oc- ed [33]. Interesting and valuable existing in vitro assays cur and thus is defined as the NOAEL in our model are more sensitive for protein detection, but their major [29]. As shown in our study, the 1 mg CMP dose was inconvenience is lack of information on the allergenic ac- necessary to obtain objective measures of anaphylactic re- tivity of food products in contrast to in vivo detection action including body temperature, breathing frequency tools [16-21]. The application of our model to mar- and plasma histamine release. In case of 0.1 mg CMP garines confirms the fact that this murine model of dose, no global significant change in body temperature CMP-induced anaphylaxis may be used as a tool to as- was observed suggesting that the temperature is related sess the safety of a finished food product for people with to the variability of response in mice. Indeed for this cow's milk allergy. Mice did not exhibit allergic reactions dose, a marked decrease in body temperature was only with 525 ng CMP in margarine C, which is 1150 times recorded in some individuals (n = 2 mice/6) indicating below the human LOAEL. The harmlessness of the mar- that a drop in body temperature is nevertheless a sign of garine C is confirmed with a margin of safety (MOS) > disease severity [30-32]. According to our results, clinical 100, which is established from the mouse NOAEL [29].
tests were required to evaluate the allergenic activity of Since a MOS > 100 is considered to be without risk for milk allergens in terms of anaphylaxis, because they human subjects [29]. Thus, this margarine could be con- clearly evidenced a severe sign of anaphylactic shock.
sidered as being of no risk to CMP-allergic patients.
Moreover, the combination of these clinical tests with a CMP detected in margarine C are most likely contami- biologic assay such as the measurement of plasma hista- nants resulting from the use of CMP on the same pro- mine release is important in order to confirm the in- duction line. On the other hand, the margarine A would volvement of mast cells in CMP-specific anaphylaxis.
be prohibited to patients allergic to CMP because of the In practice, the reliability of our model as CMP detec- wide overlap between the murine and human LOAEL tion tool was tested by assessing the allergenic activity of values. The knowledge of a NOAEL for milk obtained 3 different margarines A, B and C sharing the same pro- from animal studies could provide the food industry with duction line, manufactured with or without milk. Indeed, a much needed MOS to establish good manufacturing only CMP-sensitized mice challenged with margarine A practices and allergenic risk control programs. This mod- exhibited an anaphylactic reaction similar to that ob- el could be used as a supplement to the biochemical tests served with CMP challenge, indicating the presence of in order to investigate a potential allergenic activity when CMP at levels sufficient to provoke anaphylaxis. On the a biochemical risk with respect to milk has been detected other hand, no anaphylactic reaction was developed with in a food product intended for allergic consumers before margarines B and C, suggesting that either the finished its marketing.
margarines did not contain CMP, the concentration ofCMP was below the limit of detection, or that the mar-garines contained proteins without allergenic activity. We then evaluated the levels of CMP in the margarine ex-tracts that led to the appearance of anaphylactic symp- We report here the development and characterization of toms in order to compare these clinical data to the a BALB/c model of CMP-induced anaphylaxis that rep- murine LOAEL or NOAEL. This allowed us to evaluate resents a potential in vivo CMP detection tool for the the feasibility of this model as a tool for determining the safety assessment of finished food products such as mar- allergenic risk of the analyzed margarines. The lack of al- garines. Additional studies are required to determine the lergenic activities of margarines B or C was supported by capacity of our model to evaluate the CMP allergenic ac- the immunobiochemical evaluation of the CMP amounts tivity of other finished food products, i.e. to analyze in the extracts of margarines. Indeed, in contrast to mar- whether the food product contains specific CMP aller- garine A (1.6 mg CMP per mouse), under the same con- gens at levels that could potentially induce an allergic re- ditions, margarine C did not lead to anaphylaxis probably action in sensitized individuals.
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Eur Ann Allergy Clin Immunol VOL 41, N 3, 95-96, 2009 Preventable Injuries from Life-Saving Epinephrine Auto-In-
The researchers therefore note that additional information is jectors on the Rise
needed "about the lost dose hazard and its implications for ana-phylaxis morbidity or mortality and about the indications for, and ARLINGTON HEIGHTS, Ill., April 6, 2009 – Researchers find timing of, a second injection of epinephrine in this situation." an increased rate of unintentional injection of epinephrine from Although inadvertent injuries from epinephrine auto-injectors auto-injectors for anaphylaxis (severe allergic reactions) and urge sometimes cause extreme discomfort, they generally have a fa- people who may need to administer the life-saving drug to them- vorable outcome.
selves or others in an allergic emergency to receive regular coaching Authors conclude, "Health care professionals should maintain in its proper use. The report is published this month in Annals of vigilance about training and regular coaching of those at risk for Allergy, Asthma & Immunology, the scientific journal of the anaphylaxis in the community and the caregivers of children at American College of Allergy, Asthma and Immunology (ACAAI).
risk in the correct and safe use of epinephrine auto-injectors, More than 50 million Americans suffer from some type of aller- ideally at yearly intervals." gy. While an allergy often makes people miserable, it's rarelydangerous, unless it results in an anaphylactic reaction, an aller-gic emergency. Fast-acting, self-administered epinephrine (adrenaline) auto-injectors are commonly prescribed for people People who have allergies and/or asthma and a history of severe who are at risk of anaphylaxis.
allergic reaction are at increased risk, but anyone can have an Systematically reviewing 26 reports published in peer-reviewed journals during the past 20 years, F. Estelle R. Simons, M.D., The most common triggers of a anaphylaxis are food (especially Department of Pediatrics and Child Health, Faculty of Medicine, peanut, tree nuts – almonds, pecans, cashews, walnuts – fish, University of Manitoba, Winnipeg, Manitoba, Canada, and col- shellfish, cow's milk and egg), insect stings, medications (most leagues in the United States, found that most of the 69 incidents commonly penicillin) and latex. Its symptoms include: of unintentional injection of epinephrine reported to date in the • Hives, itching and redness of the skin, lips, eyelids, or other parts medical literature have occurred during the past 6 years.
of the body, and/or itching of the throat, tongue, and mouth The true rate of occurrence of unintentional injection of epi- • Wheezing and/or difficulty breathing nephrine from auto-injectors is unknown, but the authors note • Swelling of the tongue, throat and nose that the previously projected rate of 1 in 50,000 injections has • Nausea, vomiting, diarrhea, or cramping pain in the abdomen been seriously underestimated.
• Dizziness and fainting or loss of consciousness, which can "An increased rate of occurrence is likely, paralleling the in- lead to shock and heart failure creased rate of occurrence of anaphylaxis in the community and Patient information on allergic diseases including the free the increased dispensing rates for epinephrine auto-injectors," brochure, titled Be S.A.F.E Managing Allergic Emergencies they stated.
(Anaphylaxis), is available by calling the ACAAI toll free num- Although approximately 10 percent of the injuries occurred ber at (800) 842-7777 or visiting its Web site at HYPERLINK while first aid treatment was being administered to another per- "http://www.acaai.org" www.acaai.org. For food allergy patient son, no information about the outcomes of anaphylaxis in the information or support, call the Food Allergy and Anaphylaxis person for whom the epinephrine was intended was found in Network (FAAN) at (800) 929-4040 or visit online at HY- the articles reviewed.
News release issued by the American College of Allergy,
News release issued by the American College of Allergy,
Asthma and Immunology (ACAAI)
Asthma and Immunology (ACAAI)
Caregivers of Asthmatic Children Fail to Use Albuterol
Health Care Use is Higher in Adult Asthma Patients, Inac-
tivity and Obesity Contributing Factors
ARLINGTON HEIGHTS, Ill., June 10, 2009 - Nearly one third ARLINGTON HEIGHTS, Ill., June 10, 2009 - Health care use of caregivers in low-income, urban areas used albuterol improperly is higher in adult asthmatic patients when compared with non- in the home when treating children for acute asthma symptoms, asthmatic patients, and inactivity and obesity are contributing to according to a report published this month in Annals of Allergy, this increase, according to a report published this month in Annals Asthma & Immunology, the scientific journal of the American of Allergy, Asthma & Immunology, the scientific journal of the College of Allergy, Asthma and Immunology (ACAAI).
American College of Allergy, Asthma and Immunology Jane M. Garbutt, MB, ChB, FRCP (C), associate professor of medicine and pediatrics, medical director of Washington Universi- Shilpa Dogra, MSc, of the Lifespan Health and Performance ty Pediatric/Adolescent Ambulatory Research Consortium, Wash- Laboratory at York University in Toronto, Ontario, Canada, and ington University School of Medicine, St. Louis, Mo., and col- colleagues, also found that overnight hospital stays were more leagues, report that 32 percent of 114 caregivers in the interven- common in inactive asthmatic patients regardless of body mass in- tion group of a randomized trial to reduce emergent care for low- dex (BMI), whereas both BMI and physical activity were impor- income urban children used albuterol inappropriately (over-treat- tant determinants of physician consultations.
ment or under-treatment).
Investigators analyzed self-reported data of an adult population of "Albuterol is the most effective treatment for providing prompt 6,835 with asthma and 78,051 without asthma from the 2005 relief from worsening asthma systems and is recommended for Canadian Community Health Survey (CCHS), a nationally rep- home use, guided by an asthma action plan," note the authors.
resentative population-based cross-sectional survey. Their findings The caregivers completed a structured telephone interview with an asthma nurse to evaluate home management of their child´s acute Patients with asthma were 2.25 times more likely to have an asthma symptoms. Albuterol use for worsening asthma symptoms overnight hospital stay, 1.48 times more likely to have four or was categorized as appropriate for only 68 percent of caregivers, more overnight hospital stays, and 2.43 times more likely to have and was more likely if the children had an emergency department three or more physician consultations compared with patients visit or hospitalization for asthma in the prior year.
without asthma.
Reportedly having an asthma action plan, or a recent primary care Inactive patients with asthma were 1.68 times more likely to have physician visit to discuss asthma maintenance care, did not in- an overnight hospital stay and 1.23 times more likely to have three crease the likelihood that albuterol use was appropriate.
or more physician consultations than active patients with asthma.
"Caregivers reported that they would use albuterol to treat their Inactive/obese patients with asthma were 2.35 times more likely to child´s worsening asthma symptoms, but many described inappro- have an overnight hospital stay and 2.76 times more likely to have priate use," the authors conclude. "Detailed evaluation of proper three or more physician consultations than active/ normal weight albuterol use at home may provide insight into how health care patients with asthma.
professionals can better educate and support parents in their man- "The most important thing to take from this study is that asth- agement of acute exacerbations and more effective use of asthma matics, whether obese or normal weight, can benefit greatly from action plans." adopting and maintaining an active lifestyle," said Ms. Dogra.
The National Asthma Education and Prevention Program "Health care professionals working with asthmatics should inform (NAEPP) guidelines recommend early treatment of acute asthma their patients of the benefits of an active lifestyle, and the various symptoms with albuterol and oral corticosteroids.
ways in which they can overcome asthma specific barriers to phys- Citation: Garbutt JM, et al. Home use of albuterol for asthma ex- ical activity, such as exercise-induced asthma. Higher activity levels acerbations. Ann Allergy Asthma Immunol 2009;102:504-509.
not only help the individual with asthma, but also have the poten-tial to relieve some of the burden being placed on the healthcaresystem."

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