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ORIGINAL ARTICLE HIGHLIGHTS FROM THIS ISSUE
Impact of Asthma Exacerbations and Asthma Triggers on Asthma-related Quality of Life in Patients with Severe or Difficult-to-Treat Asthma Luskin et al 544 What is already known about this topic? Although the association between asthma triggers and asthma exacerbations is well established, few studies have quantified the impact of these variables on asthma-related quality-of-life (QoL) or the impact of asthma exacerbation severity on QoL. What does this article add to our knowledge? The greater severity and numbers of asthma exacerbations were significantly associated with decreases in asthma-related QoL. Poorer QoL and greater asthma exacerbation severity and frequency were significantly associated with higher numbers of asthma triggers at baseline. How does this study impact current management guidelines? Avoidance of asthma triggers may be an effective treatment strategy to reduce exacerbation rates and improve asthma-related QoL in patients with severe or difficult-to-treat asthma, although formal interventional trials would be required to confirm this. Fluticasone FuroateeeVilanterol 100-25 mcg Compared with Fluticasone Furoate 100 mcg in Asthma: A Randomized Trial Bleecker et al 553 What is already known about this topic? Once-daily dosing could improve adherence to asthma, thereby potentially improving disease control. Once-daily fluticasone furoate (FF) alone and once-daily vilanterol (VI) have been shown to significantly improve lung function compared with placebo in asthma. What does this article add to our knowledge? This study provides further evidence that once-daily FF (100 mcg), alone and in combination with VI (25 mcg) significantly improves FEV1 compared with placebo. The effect of FF-VI versus FF alone on FEV1 was not statistically different. How does this study impact current management guidelines? Once-daily dosing of FF and of FF-VI is an acceptable option in asthma management, with the potential for improving treatment adherence. Measurements of asthma control are improved with once-daily FF and FF-VI compared with placebo. Sleep Duration, Sleep Hygiene, and Insomnia in Adolescents with Asthma Meltzer et al
562
What is already known about this topic? Sleep disruption due to nocturnal asthma symptoms is common. Poor sleep quality and short sleep duration may contribute to increased daytime asthma symptoms. What does this article add to our knowledge? Compared with adolescents with mild or no asthma, more adolescents with severe asthma have insufficient sleep, poorer sleep hygiene, more symptoms of insomnia, and more daytime sleepiness. How does this study impact current management guidelines? Clinical providers should inquire about adolescent sleep habits, encourage good sleep hygiene and increased sleep duration, and refer when necessary for the treatment of insomnia. Asthma Exacerbation Rates in Adults Are Unchanged Over a 5-Year Period Despite High-Intensity Therapy Schatz et al 570 What is already known about this topic? Prior asthma exacerbations increase the short-term risk of subsequent asthma exacerbations. What does this article add to our knowledge? For patients on high-intensity pharmacologic treatment, the risk of exacerbations does not change over time, and prior exacerbations increase the risk of subsequent asthma exacerbations over a several-year period, in spite of therapy. How does this study impact current management guidelines? New therapeutic options are needed for patients who experience asthma exacerbations in spite of high-intensity pharmacologic treatment.
10A
J ALLERGY CLIN IMMUNOL PRACT VOLUME 2, NUMBER 5
Nonprescription Racemic Epinephrine for Asthma Mondal et al
11A
575
What is already known about this topic? There is little information on the relative efficacy of racepinephrine and albuterol for patients with asthma. What does this article add to our knowledge? It indicates that nebulized racepinephrine has less bronchoprotective effect than albuterol. How does this study impact current management guidelines? Racepinephrine should not be used in place of albuterol to treat acute asthma. Exhaled Breath Condensate pH Does Not Discriminate Asymptomatic Gastroesophageal Reflux or the Response to Lansoprazole Treatment in Children with Poorly Controlled Asthma Fitzpatrick et al 579 What is already known about this topic? Exhaled breath condensate (EBC) pH has been identified as an emerging biomarker of interest for asthma clinical trials and may allow for identification of acute acid reflux events. What does this article add to our knowledge? The results of this study demonstrated that EBC pH is not associated with asymptomatic gastroesophageal reflux or characteristics of asthma in school-age children. How does this study impact current management guidelines? Although other EBC constituents may prove to be of value in asthma therapeutic monitoring, we concluded that measurements of EBC pH have limited predictive utility in the long-term assessment of childhood asthma. The Impact of Dietary Therapy on Clinical and Biologic Parameters of Pediatric Patients with Eosinophilic Esophagitis Colson et al 587 What is already known about this topic? Three dietary regimens have been shown to be effective in children diagnosed with eosinophilic esophagitis (EoE): the strict use of an amino-acid formula, dietary restriction based on eliminating the most likely food antigens, dietary restriction based on multimodality allergy testing. What does this article add to our knowledge? In children with EoE, after 2 months of a dietary therapy that combined both types of elimination diet with an amino-acid formula as a replacement for dairy products, the nutritional status was mildly affected by EoE and not worsened by the 2-month dietary therapy. How does this study impact current management guidelines? Dietary therapy with an amino-acid formula as a replacement for dairy products is nutritionally adapted to the treatment of EoE. Rituximab and Immune Deficiency: Case Series and Review of the Literature Kaplan et al
594
What is already known about this topic? As the indications and use of rituximab continue to expand, the reports of longterm effects of anti-CD20emediated B-cell depletion on immune function accumulate. What does this article add to our knowledge? We report a group of patients with persistent immune dysfunction that required immunoglobulin replacement therapy after rituximab use. B-cell phenotype data were notable for a significant decrease in switched and memory B cells and a predominance of naive B cells. How does this study impact current management guidelines? Routine baseline serum immunoglobulin levels and B-cell numbers are required to help distinguish preexistent primary immunodeficiency disease from secondary rituximabinduced immune suppression. Periodic monitoring of B-cell numbers and serum immunoglobulins is prudent to identify immune recovery of patients treated with rituximab. Double-Blind Placebo-Controlled Trial of Dapsone in Antihistamine Refractory Chronic Idiopathic Urticaria Morgan et al
601
What is already known about this topic? Chronic idiopathic urticaria (CIU) is a common disease with a large societal impact. Although H1 antihistamines are the mainstay of treatment, many patients will have an incomplete response and face limited options. What does this article add to our knowledge? Quality evidence is lacking for many of the medications used in antihistamine refractory CIU. This trial lends more credible evidence that dapsone is an efficacious tool for CIU for patients who tolerate it. How does this study impact current management guidelines? This trial supports the role of dapsone as a viable medication in antihistamine refractory CIU.
12A
J ALLERGY CLIN IMMUNOL PRACT SEPTEMBER/OCTOBER 2014
Use of Leukotriene Receptor Antagonists Are Associated with a Similar Risk of Asthma Exacerbations as Inhaled Corticosteroids Wu et al 607 What is already known about this topic? Results of randomized clinical trials found that inhaled corticosteroids have greater efficacy than leukotriene receptor antagonists to prevent exacerbations of childhood asthma under controlled circumstances. Few studies compared the effectiveness of these controller medication regimens under real-life conditions. What does this article add to our knowledge? This study found that the risk of emergency department visits, hospitalizations, and oral corticosteroids did not differ between children who initiated leukotriene antagonist and those who initiated inhaled corticosteroid in 5 health plans and a state Medicaid population. These findings may be explainable by leukotriene antagonist having similar effectiveness as inhaled corticosteroid in real-life usage. How does this study impact current management guidelines? Analysis of the results of this study suggests that current national asthma management guidelines are not being followed.
Impact of Asthma Exacerbations and Asthma Triggers on Asthma-related Quality of Life in Patients with Severe or Difficult-to-Treat Asthma Luskin et al 544 What is already known about this topic? Although the association between asthma triggers and asthma exacerbations is well established, few studies have quantified the impact of these variables on asthma-related quality-of-life (QoL) or the impact of asthma exacerbation severity on QoL. What does this article add to our knowledge? The greater severity and numbers of asthma exacerbations were significantly associated with decreases in asthma-related QoL. Poorer QoL and greater asthma exacerbation severity and frequency were significantly associated with higher numbers of asthma triggers at baseline. How does this study impact current management guidelines? Avoidance of asthma triggers may be an effective treatment strategy to reduce exacerbation rates and improve asthma-related QoL in patients with severe or difficult-to-treat asthma, although formal interventional trials would be required to confirm this. Fluticasone FuroateeeVilanterol 100-25 mcg Compared with Fluticasone Furoate 100 mcg in Asthma: A Randomized Trial Bleecker et al 553 What is already known about this topic? Once-daily dosing could improve adherence to asthma, thereby potentially improving disease control. Once-daily fluticasone furoate (FF) alone and once-daily vilanterol (VI) have been shown to significantly improve lung function compared with placebo in asthma. What does this article add to our knowledge? This study provides further evidence that once-daily FF (100 mcg), alone and in combination with VI (25 mcg) significantly improves FEV1 compared with placebo. The effect of FF-VI versus FF alone on FEV1 was not statistically different. How does this study impact current management guidelines? Once-daily dosing of FF and of FF-VI is an acceptable option in asthma management, with the potential for improving treatment adherence. Measurements of asthma control are improved with once-daily FF and FF-VI compared with placebo. Sleep Duration, Sleep Hygiene, and Insomnia in Adolescents with Asthma Meltzer et al
562
What is already known about this topic? Sleep disruption due to nocturnal asthma symptoms is common. Poor sleep quality and short sleep duration may contribute to increased daytime asthma symptoms. What does this article add to our knowledge? Compared with adolescents with mild or no asthma, more adolescents with severe asthma have insufficient sleep, poorer sleep hygiene, more symptoms of insomnia, and more daytime sleepiness. How does this study impact current management guidelines? Clinical providers should inquire about adolescent sleep habits, encourage good sleep hygiene and increased sleep duration, and refer when necessary for the treatment of insomnia. Asthma Exacerbation Rates in Adults Are Unchanged Over a 5-Year Period Despite High-Intensity Therapy Schatz et al 570 What is already known about this topic? Prior asthma exacerbations increase the short-term risk of subsequent asthma exacerbations. What does this article add to our knowledge? For patients on high-intensity pharmacologic treatment, the risk of exacerbations does not change over time, and prior exacerbations increase the risk of subsequent asthma exacerbations over a several-year period, in spite of therapy. How does this study impact current management guidelines? New therapeutic options are needed for patients who experience asthma exacerbations in spite of high-intensity pharmacologic treatment.
10A
J ALLERGY CLIN IMMUNOL PRACT VOLUME 2, NUMBER 5
Nonprescription Racemic Epinephrine for Asthma Mondal et al
11A
575
What is already known about this topic? There is little information on the relative efficacy of racepinephrine and albuterol for patients with asthma. What does this article add to our knowledge? It indicates that nebulized racepinephrine has less bronchoprotective effect than albuterol. How does this study impact current management guidelines? Racepinephrine should not be used in place of albuterol to treat acute asthma. Exhaled Breath Condensate pH Does Not Discriminate Asymptomatic Gastroesophageal Reflux or the Response to Lansoprazole Treatment in Children with Poorly Controlled Asthma Fitzpatrick et al 579 What is already known about this topic? Exhaled breath condensate (EBC) pH has been identified as an emerging biomarker of interest for asthma clinical trials and may allow for identification of acute acid reflux events. What does this article add to our knowledge? The results of this study demonstrated that EBC pH is not associated with asymptomatic gastroesophageal reflux or characteristics of asthma in school-age children. How does this study impact current management guidelines? Although other EBC constituents may prove to be of value in asthma therapeutic monitoring, we concluded that measurements of EBC pH have limited predictive utility in the long-term assessment of childhood asthma. The Impact of Dietary Therapy on Clinical and Biologic Parameters of Pediatric Patients with Eosinophilic Esophagitis Colson et al 587 What is already known about this topic? Three dietary regimens have been shown to be effective in children diagnosed with eosinophilic esophagitis (EoE): the strict use of an amino-acid formula, dietary restriction based on eliminating the most likely food antigens, dietary restriction based on multimodality allergy testing. What does this article add to our knowledge? In children with EoE, after 2 months of a dietary therapy that combined both types of elimination diet with an amino-acid formula as a replacement for dairy products, the nutritional status was mildly affected by EoE and not worsened by the 2-month dietary therapy. How does this study impact current management guidelines? Dietary therapy with an amino-acid formula as a replacement for dairy products is nutritionally adapted to the treatment of EoE. Rituximab and Immune Deficiency: Case Series and Review of the Literature Kaplan et al
594
What is already known about this topic? As the indications and use of rituximab continue to expand, the reports of longterm effects of anti-CD20emediated B-cell depletion on immune function accumulate. What does this article add to our knowledge? We report a group of patients with persistent immune dysfunction that required immunoglobulin replacement therapy after rituximab use. B-cell phenotype data were notable for a significant decrease in switched and memory B cells and a predominance of naive B cells. How does this study impact current management guidelines? Routine baseline serum immunoglobulin levels and B-cell numbers are required to help distinguish preexistent primary immunodeficiency disease from secondary rituximabinduced immune suppression. Periodic monitoring of B-cell numbers and serum immunoglobulins is prudent to identify immune recovery of patients treated with rituximab. Double-Blind Placebo-Controlled Trial of Dapsone in Antihistamine Refractory Chronic Idiopathic Urticaria Morgan et al
601
What is already known about this topic? Chronic idiopathic urticaria (CIU) is a common disease with a large societal impact. Although H1 antihistamines are the mainstay of treatment, many patients will have an incomplete response and face limited options. What does this article add to our knowledge? Quality evidence is lacking for many of the medications used in antihistamine refractory CIU. This trial lends more credible evidence that dapsone is an efficacious tool for CIU for patients who tolerate it. How does this study impact current management guidelines? This trial supports the role of dapsone as a viable medication in antihistamine refractory CIU.
12A
J ALLERGY CLIN IMMUNOL PRACT SEPTEMBER/OCTOBER 2014
Use of Leukotriene Receptor Antagonists Are Associated with a Similar Risk of Asthma Exacerbations as Inhaled Corticosteroids Wu et al 607 What is already known about this topic? Results of randomized clinical trials found that inhaled corticosteroids have greater efficacy than leukotriene receptor antagonists to prevent exacerbations of childhood asthma under controlled circumstances. Few studies compared the effectiveness of these controller medication regimens under real-life conditions. What does this article add to our knowledge? This study found that the risk of emergency department visits, hospitalizations, and oral corticosteroids did not differ between children who initiated leukotriene antagonist and those who initiated inhaled corticosteroid in 5 health plans and a state Medicaid population. These findings may be explainable by leukotriene antagonist having similar effectiveness as inhaled corticosteroid in real-life usage. How does this study impact current management guidelines? Analysis of the results of this study suggests that current national asthma management guidelines are not being followed.