Exercise-induced bronchoconstriction update-2016.

The first practice parameter on exercise-induced bronchoconstriction (EIB) was published in 2010. This updated practice parameter was prepared 5 years later. In the ensuing years, there has been increased understanding of the pathogenesis of EIB and improved diagnosis of this disorder by using objective testing. At the time of this publication, observations included the following: dry powder mannitol for inhalation as a bronchial provocation test is FDA approved however not currently available in the United States; if baseline pulmonary function test results are normal to near normal (before and after bronchodilator) in a person with suspected EIB, then further testing should be performed by using standardized exercise challenge or eucapnic voluntary hyperpnea (EVH); and the efficacy of nonpharmaceutical interventions (omega-3 fatty acids) has been challenged. The workgroup preparing this practice parameter updated contemporary practice guidelines based on a current systematic literature review. The group obtained supplementary literature and consensus expert opinions when the published literature was insufficient. A search of the medical literature on PubMed was conducted, and search terms included pathogenesis, diagnosis, differential diagnosis, and therapy (both pharmaceutical and nonpharmaceutical) of exercise-induced bronchoconstriction or exercise-induced asthma (which is no longer a preferred term); asthma; and exercise and asthma. References assessed as relevant to the topic were evaluated to search for additional relevant references. Published clinical studies were appraised by category of evidence and used to document the strength of the recommendation. The parameter was then evaluated by Joint Task Force reviewers and then by reviewers assigned by the parent organizations, as well as the general membership. Based on this process, the parameter can be characterized as an evidence- and consensus-based document.

Prevalence of allergy and asthma symptoms in recreational roadrunners.

PURPOSE: The prevalence of allergy and asthma symptoms and asthma medication use, which has been extensively studied in elite athletes, has received little attention in recreational roadrunners. METHODS: A validated questionnaire was used to determine the prevalence of allergy and asthma symptoms, the use of medication, and allergy specialty attention among recreational roadrunners. Comparison with the published prevalence of allergy and asthma symptoms in Olympic athletes was made. RESULTS: The prevalence of allergy and asthma symptoms were similar in two consecutive yearly surveys (2003, 2004). The response from 2004 was 11% (484 of 4398 runners). The study population was 60% male, 56% Caucasian, 10% non-Caucasian, and 34% undesignated. Subjects competed for 13.2 +/- 10.5 yr. Prevalence was 44% for symptoms of allergy, 31% for asthma, and 21% for both. Of those reporting allergy symptoms alone, 0.5% had prescription medications or medication before the race. Those with asthma and allergy or asthma alone were more likely to have prescription medication (allergy and asthma, 32%, P = 0.0001; asthma, 6%, P = 0.001), to take medication before the race (asthma and allergy, 27%, P = 0.0001; asthma, 5%, P = 0.007), or to seek specialty attention and medication (asthma and allergy, 39%, P = 0.0001; asthma, 7%, P = 0.004) than those with allergy symptoms alone. The comparison with results from a survey of Olympic athletes indicates that symptoms of allergy and asthma were more prevalent in recreational athletes (P = 0.0001 to 0.007), but roadrunners were less likely to be taking prescription medication (P = 0.025). CONCLUSION: These results suggest that the recreational roadrunner is more likely to report symptoms of allergy and/or asthma but less likely to have prescription medication than the Olympic athlete.

Anaphylaxis to latex in patients without identified risk factors for latex allergy.

We describe a representative patient diagnosed with anaphylaxis to latex occurring during elective surgery in the absence of any previous risk factors for latex allergy. Latex allergy was identified by skin prick testing and confirmed by serological diagnosis testing. We review our experience screening patients for latex allergy in Connecticut over the period 1995-present. Patients without known risk factors for latex allergy in a highly atopic population had a low rate (approximately 1%) of positive skin tests to latex when screened using an allergenic extract characterized for latex allergen by serological diagnosis at 200-500 AU/ml. Our experience suggests that skin prick test screening with serological diagnosis standardized latex extracts can be used to rapidly screen and identify individuals with latex allergy although the cost-effectiveness, sensitivity and safety of screening remains to be determined. Clinicians should consider the diagnosis of latex allergy in all cases of anaphylaxis without identified causes, even in patients without identified risk factors for latex allergy.

Allergic rhinitis and asthma in the athlete.

The pathogenesis, epidemiology, presentation, diagnosis, and management of allergic rhinitis and asthma in the recreational and elite athlete are discussed in this study. There is an increased prevalence of allergic rhinitis and asthma in the elite athlete related to the enhanced ventilation with entrainment of inhalants including allergens as well as irritants such as pollutants in the urban athlete, chlorine in the swimmer, and cold air in the hockey player in the training environment. The history as well as objective exercise challenge and skin-prick tests to inhalants or in vitro allergen testing are essential in conjunction with a comprehensive physical exam to diagnosis of allergic rhinitis and/or asthma in the athlete. This is particularly necessary for the elite or competitive athlete who often has poor insight into the symptoms. Management is with appropriate inhaled steroids and/or leukotriene antagonists for the upper (nasal) and lower airways with avoidance of inhaled allergens and/or appropriate immunotherapy where relevant. The optimal management of the athlete results in minimum medication with minimum adverse side effects and optimal outcome. Proper adherence to antidoping regulations and application for use exemption in competitive athletes is recommended. The athlete should be encouraged to pursue the selected sports activity without limitations.

Characterization of an anaphylactoid reaction to omalizumab.

BACKGROUND: The novel humanized murine monoclonal antibody omalizumab prevents binding of human IgE to its high-affinity receptor. A contraindication to therapy with omalizumab is allergy to the medication or previous immediate-type hypersensitivity or anaphylaxis to omalizumab or similar medications. OBJECTIVE: To determine whether a 32-year-old woman with asthma, allergic rhinitis, and idiopathic chronic urticaria and angioedema with anaphylactoid reactions to omalizumab could tolerate the medication in a desensitization protocol. METHODS: Omalizumab was administered after pretreatment with nonsteroidal anti-inflammatory drugs (ibuprofen, 600 mg) while the patient was closely monitored in an intensive care unit. RESULTS: Omalizumab was well tolerated using this protocol, but a serum sickness-like reaction developed that required discontinuation of the medication after the seventh dose. CONCLUSIONS: Our experience suggests that some patients with anaphylactoid reactions to omalizumab can tolerate the medication when pretreated with nonsteroidal anti-inflammatory drugs but that a serum sickness-like illness may develop, requiring discontinued use of the medication.