[GUIMIT 2019, Mexican Guideline on Immunotherapy. Guideline on the diagnosis of IgE-mediated allergic disease and immunotherapy following the ADAPTE approach]. / GUIMIT 2019, Guía Mexicana de Inmunoterapia. Guía de diagnóstico de alergia mediada por IgE e inmunoterapia aplicando el método ADAPTE.

BACKGROUND: In Mexico, allergen immunotherapy (AIT) and immunotherapy with hymenoptera venom (VIT) is traditionally practiced combining aspects of the European and American school. In addition, both types of extracts (European and American) are commercially available in Mexico. Moreover, for an adequate AIT/VIT a timely diagnosis is crucial. Therefore, there is a need for a widely accepted, up-to-date national immunotherapy guideline that covers diagnostic issues, indications, dosage, mechanisms, adverse effects and future expectations of AIT (GUIMIT 2019). METHOD: With nationwide groups of allergists participating, including delegates from postgraduate training-programs in Allergy/Immunology-forming, the guideline document was developed according to the ADAPTE methodology: the immunotherapy guidelines from European Academy of Allergy and Clinical Immunology, German Society for Allergology and Clinical Immunology, The American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma, and Immunology were selected as mother guidelines, as they received the highest AGREE-II score among international guidelines available; their evidence conforms the scientific basis for this document. RESULTS: GUIMIT emanates strong or weak (suggestions) recommendations about practical issues directly related to in vivo or in vitro diagnosis of IgE mediated allergic diseases and the preparation and application of AIT/VIT and its adverse effects. GUIMIT finishes with a perspective on AIT modalities for the future. All the statements were discussed and voted on until > 80 % consensus was reached. CONCLUSIONS: A wide and diverse group of AIT/VIT experts issued transculturized, evidence-based recommendations and reached consensus that might improve and standardize AIT practice in Mexico.

Antecedentes: En México, la inmunoterapia con alérgenos (ITA) y con veneno de himenópteros (VIT) se practica tradicionalmente combinando criterios de las escuelas europea y estadounidense; los dos tipos de extractos están comercialmente disponibles en México. Para una ITA adecuada es crucial un diagnóstico oportuno. Objetivo: Presentar GUIMIT 2019, Guía Mexicana de Inmunoterapia 2019, de base amplia, actualizada, que abarca temas de diagnóstico, indicaciones, dosificación, mecanismos, efectos adversos de la ITA y expectativas con esta modalidad de tratamiento. Método: Con la participación de múltiples grupos mexicanos de alergólogos, que incluían los centros formadores universitarios en alergia e inmunología, se desarrolló el documento de la guía según la metodología ADAPTE. Las guías de inmunoterapia de la European Academy of Allergy and Clinical Immunology, The American Academy of Allergy, Asthma and Immunology, German Society for Allergology and Clinical Immunology y del American College of Allergy, Asthma, and Immunology se seleccionaron como guías fuente, ya que recibieron la puntuación AGREE-II más alta entre las guías internacionales disponibles; su evidencia conforma la base científica de GUIMIT 2019. Resultados: En GUIMIT 2019 se emiten recomendaciones fuertes o débiles (sugerencias) acerca de temas directamente relacionados con el diagnóstico in vivo o in vitro de las enfermedades alérgicas mediadas por IgE, la preparación y aplicación de ITA o VIT y sus efectos adversos; se incluye la revisión de las modalidades de ITA para el futuro. Todos los argumentos que se exponen fueron discutidos y votados con > 80 % de aprobación. Conclusión: Un grupo amplio y diverso de expertos en ITA y VIT emitió recomendaciones transculturizadas basadas en evidencia, que alcanzaron consenso; con ellas se pretende mejorar y homologar la práctica de la inmunoterapia en México.

[Antihistamines for the treatment of urticaria in Mexico]. / Antihistamínicos en el tratamiento de la urticaria en México.

There are four types of histamine receptors. Allergic symptoms, especially those in rhinoconjunctivitis and urticaria, are mainly caused by activation of histamine receptor 1 (H1). Consequently, oral H1-antihistamines form and integral part of the treatment of these diseases. Antihistamines are inverse agonists that stabilize the non-active configuration of the histamine receptor. First generation H1-antihistamines cause a variety of adverse effects via several mechanisms: sedation (accumulation in the central nervous system), dry mouth, urinary retention, weight gain (low selectivity: stimulation of serotonin/muscarinic/alpha-adrenergic receptors) and drug interactions (substrate of CYP450-3A4). Generally second generation H1-antihistamines have a better safety profile. New guidelines on allergic rhinitis and urticaria recommend second generation H1-antihistamines as first line drugs, with -if necessary- four-times updosing to obtain control in urticaria. The enhanced efficacy of quadruple doses in urticaria, while maintaining a good safety profile, has been shown for bilastine, desloratadine and levocetirizine (rupatadine). For ebastine and fexofenadine only the safety of quadruple doses has been shown till now. Extreme precaution should be taken with astemizol and terfenadine that never should be up-dosed, as high serum concentrations can cause potentially fatal ventricular tachycardia. First generation antihistamines are not recommended as first line treatment and updosing is not safe.

Existen cuatro tipos de receptores histaminérgicos. Los síntomas de alergia, especialmente rinoconjuntivitis alérgica y urticaria, son principalmente causados por activación del receptor H1; por ende, los antihistamínicos H1 orales (anti-H1) forman parte integral del tratamiento de estas enfermedades. Los antihistamínicos son agonistas inversos, porque estabilizan la forma inactiva del receptor. Los antihistamínicos H1 de primera generación producen efectos adversos por varios mecanismos: sedación (fijación a receptores H1 cerebrales), boca seca, retención urinaria, aumento de peso (baja selectividad: estimulación de los receptores de serotonina, muscarina y alfa-adrenérgicos) e interacciones medicamentosas (con sustrato de citocromo P450-3A4). Los antihistamínicos H1 de segunda generación son generalmente más seguros. Las nuevas guías de tratamiento de la rinitis alérgica y urticaria recomiendan como manejo de primera intención a los antihistamínicos H1 de segunda generación. En urticaria se recomienda hasta cuadruplicar su dosis en caso necesario. El aumento de la eficacia en el control de la urticaria con cuádruple dosis, sin que se afecte la seguridad, se ha documentado para bilastina, desloratadina y levocetirizina (rupatadina). Respecto de ebastina y fexofenadina, hasta ahora, sólo se comprobó la seguridad de cuádruple dosis. Una rigurosa excepción son astemizol y terfenadina, que a concentraciones séricas elevadas pueden causar taquicardia ventricular. No se recomiendan los antihistamínicos H1 de primera generación y aumentar su dosis no es seguro.

[Mexican guidelines on the diagnosis and treatment of urticaria]. / Guía Mexicana para el Diagnóstico y el Tratamiento de la Urticaria.

BACKGROUND: Urticaria is a disease that a fifth of the population shallsuffer once in a lifetime. Recent clinical guidelines have proposed some fundamental changes in the diagnosis and treatment of urticaria, making the development of a national, multidisciplinary guideline, with wide acceptability among different professional groups -both specialists and primary health care workers-, necessary in Mexico. MATERIAL AND METHOD: Internationally recognized tools for guidelinedevelopment were used. An interdisciplinary group of clinical experts (some of them knowledgeable in methodology of guideline development) determined the objectives and scope of the Evidence Based Clinical Practice Guideline with SCOPE. It was decided to adapt and transculturize international guidelines on the diagnosis and treatment of urticaria. With AGREE-II three high-quality guidelines (Zuberbier 2014, Sánchez-Borges 2012, Powell 2007) were selected to function as basic guidelines (BG). A set of Clinical Questions was formulated that lead to recommendations/suggestions, based on these BG, taking into account the cultural and economic background of Mexico, according to GRADE recommendation development. RESULTS: By a formal process of discussion and voting during several working-sessions, experts and first level healthcare physicians determined the wording of the final guideline, taking particularly care of developing a document, adjusted to the reality, values and preferences of the Mexican patients. The use of oral second generation, non-sedating antihistamines as first line treatment is emphasized. CONCLUSION: This document is an Evidence Based Clinical Practice Guideline for the diagnosis and treatment of acute and chronic urticaria, based on three, high quality, international guidelines. It was developed by a multidisciplinary group. Tables and algorithms make the guideline user-friendly for both, first line health care physicians and specialists.

Antecedentes: la urticaria es una enfermedad que padece una quinta parte de la población en algún momento de su vida. Las guías internacionales recientes han propuesto unos cambios de fondo en su diagnóstico y tratamiento, por lo que había la necesidad de crear una guía nacional y multidisciplinaria, con base amplia en los gremios de especialistas y médicos de primer contacto en México. Material y método: un grupo interdisciplinario de expertos clínicos y algunos expertos en metodología determinó los objetivos y alcances de la Guía de Práctica Clínica Basada en Evidencia con el instrumento SCOPE. Se decidió llevar a cabo la adaptación y transculturización de guías internacionales para el diagnóstico y tratamiento de urticaria. Con el instrumento AGREE-II se seleccionaron las tres guías de alta calidad, como guías base (Zuberbier 2014, Sánchez-Borges 2012, Powell 2007) para formular y contestar la preguntas clínicas clave, en el contexto cultural y económico mexicano, según el método de desarrollo de recomendaciones GRADE. Resultados: mediante un proceso formal de discusión y votación durante varias juntas de expertos, se terminó la redacción de la forma final de la guía, con especial cuidado de lograr un ajuste a las realidades, valores y preferencias de los pacientes de México. Se hace hincapié en la administración de antihistamínicos vía oral de segunda generación, como tratamiento de primera elección. Conclusión: este documento es una Guía de Práctica Clínica Basada en Evidencia para el diagnóstico y tratamiento de urticaria aguda y crónica, basada en tres guías internacionales de alta calidad. Se desarrolló por un grupo multidisciplinario. Los cuadros y algoritmos hacen a la guía amigable para su uso por médicos de primer contacto y por especialistas.

[Mexican clinical practice guidelines of immunotherapy 2011]. / Guía Mexicana de Práctica Clínica de Inmunoterapia 2011.

BACKGROUND: Several international guidelines on immunotherapy exist, but they only apply partially in Mexico. The Mexican guideline of immunotherapy dates from 1998. OBJECTIVES: To establish clinical recommendations and suggestions for Allergy residents and specialists for skin testing and allergen immunotherapy based on evidence and Mexican expert opinion, according to the GRADE system. METHODS: The guidelines were developed following the methodology of a guideline for clinical practice starting with the formulation of clinical questions, in the context of Mexican environmental conditions and morbidity, with the participation of allergists from all regions of the country. External validation was obtained. Its development followed three steps: 1. formulation of 24 clinical questions. 2. Search for consensus on the answers among members of the Regional chapters of both Mexican Colleges of Allergists (CMICA and COMPEDIA) during regional meetings. 3. Literature search for articles related to the questions and grading of its quality according to GRADE. RESULTS: Based on the regional consensus, 116 articles and the safety, patient acceptance/ comfort and cost clinical recommendations and suggestions were developed on basic aspects of skin testing, subcutaneous and sublingual immunotherapy (patient preparation, vial preparation and application schedules) and the treatment of eventual adverse reactions. CONCLUSIONS: A clinical guideline was developed respecting particular methodology, validated by CMICA and COMPEDIA for its implementation among Mexican allergists. Several aspects deserve further study to improve scientific evidence. KEYWORDS: Allergen immunotherapy, subcutaneous immunotherapy, sublingual immunotherapy, skin testing, allergy diagnosis, rhinitis, asthma, atopic dermatitis, house dust mite, pollens, anaphylaxis, adrenaline, Mexico.

Nasal allergies in the Latin American population: results from the Allergies in Latin America survey.

Allergies in Latin America is the first cross-national survey that describes the symptoms, impact, and treatment of nasal allergies (NAs) in individuals >or=4 years old in Latin America (LA). In total, 22,012 households across the Latin American countries of Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, Peru, and Venezuela were screened for children, adolescents, and adults with a diagnosis of NA and either symptoms or treatment in the past 12 months. A total of 1088 adults and 457 children and adolescents were included and the sample was probability based to ensure valid statistical inference to the population. Approximately 7% of the LA population was diagnosed with NAs with two of three respondents stating that their allergies were seasonal or intermittent in nature. A general practice physician or otolaryngologist diagnosed the majority of individuals surveyed. Nasal congestion was the most common and bothersome symptom of NAs. Sufferers indicated that their symptoms affected productivity and sleep and had a negative impact on quality of life. Two-thirds of patients reported taking some type of medication for their NAs, with a roughly equal percentage of patients reporting taking over-the-counter versus prescription medications. Changing medications was most commonly done in those reporting inadequate efficacy. The most common reasons cited for dissatisfaction with current medications were related to inadequate effectiveness, effectiveness wearing off with chronic use, failure to provide 24-hour relief, and bothersome side effects (e.g., unpleasant taste and retrograde drainage into the esophagus). Findings from this cross-national survey on NAs have confirmed a high prevalence of physician-diagnosed NAs and a considerable negative impact on daily quality of life and work productivity as well as substantial disease management challenges in LA. Through identification of disease impact on the LA population and further defining treatment gaps, clinicians in LA may better understand and treat NAs, thus leading to improvements in overall patient satisfaction and quality of life.

Tratamiento de la rinitis alergica con Ketotifeno: estudio doble ciego vs. placebo / Treatment of allergic rhinitis with ketotifen: a double-blind study vs. placebo

Se incluyeron en un estudio doble ciego comparativo contra placebo 29 pacientes de ambos sexos con Rinitis Alérgica, 15 de los cuales recibieron ketotifeno 1 mg cada 12 horas durante 3 meses y 14 placebo de apariencia idéntica al principio activo. Al final de tratamiento se observó una disminución en la frecuencia de la sintomatología en el grupo Ketotifeno, la cual fue estadísticamente significativa (p<0.001), permaneciendo el grupo placebo sin cambio a lo largo del estudio. La intensidad de la rinorrea, prurito y obstrucción nasal, así como la frecuencia de estornudos y tos, descendieron en el grupo Ketotifeno, siendo la diferencia con el grupo placebo estadísticamente significativa. Se observaron efectos secundarios tales como somnolencia y cefalea en 5 y 2 pacientes del grupo Ketotifeno, siendo leves y de carácter transitorio; en el grupo placebo se observó somnolencia y cefalea leves y transitorios en 6 casos. Se concluye que el Ketotifeno es un medicamento útil para el tratamiento de la rinitis alérgica