Comparison of Old and New Systemic Treatments for Moderate to Severe Atopic Dermatitis.

PURPOSE OF REVIEW: Historically, systemic treatments for atopic dermatitis (AD) primarily consisted of immunosuppressive agents such as corticosteroids and Disease Modifying Antirheumatic Drugs (DMARDS), which provided symptomatic relief but often had long-term adverse effects. Newer treatments have shown significant efficacy with less side effects in clinical trials. This review discusses and compares conventional and newer systemic treatments for AD. RECENT FINDINGS: Newer medications for AD including dupilumab, tralokinumab, lebrikizumab, and oral JAK inhibitors have been shown to be safe and efficacious. High dose cyclosporine and dupilumab were more effective than methotrexate and azathioprine in improving clinical signs of AD. High-dose upadacitinib was shown in another meta-analysis to be most effective in the measured outcomes but had the highest frequency of adverse events. Targeted biologic treatments are increasingly favored over traditional immunosuppressive treatments of AD. Treatment can be individualized based on potency, adverse side effects, mechanism of action, and administration preference. Ongoing research continues to expand treatment options for AD.

Recent advances in immunomodulators for atopic dermatitis.

PURPOSE OF REVIEW: Conventional treatments of atopic dermatitis have been inadequate, especially in patients with moderate-to-severe disease. RECENT FINDINGS: In the past 5 years, four immunomodulators have been approved for the treatment of atopic dermatitis in children. These include dupilumab, ruxolitinib, upadacitinib, and abrocitinib. The review summarizes the pivotal phase 3 trials of these medications. SUMMARY: The newer immunomodulators have transformed the treatment of atopic dermatitis, particularly in patients with moderate-to-severe disease. Dupilumab targets IL-4 and IL-13, which are the main causes of allergic inflammation, resulting in great efficacy and few side effects. Upadacitinib and abrocitinib are alternative systemic medications for adolescents who have failed or are unable to tolerate dupilumab. Ruxolitinib cream is the latest addition to the current topical therapy. It is indicated for children 12 years and older with mild-to-moderate atopic dermatitis. Further studies are needed to confirm its safety and efficacy for younger children and for patients with more severe disease.

The Need for Required Stock Epinephrine in All Schools: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee.

Epinephrine is the first line of treatment for anaphylaxis that can occur outside a medical setting in community environments such as schools. Patients with diagnosed IgE-mediated food allergy at risk of anaphylaxis are prescribed self-injectable epinephrine and given an individualized anaphylaxis action plan. As students, such patients/families provide their school with completed medication forms, a copy of their anaphylaxis plan, and additional student-specific epinephrine. However, students approved to self-carry prescribed self-injectable epinephrine may forget to do so or have other reasons for lacking prescribed epinephrine such as familial inability to fill the prescription due to cost or other access barriers. Undiagnosed students lacking prescribed epinephrine may also experience anaphylaxis at school. The presence of non-student-specific school stock epinephrine allows school nurses and other staff the ability to treat anaphylaxis onsite while awaiting Emergency Medical Services. Notably, not all states legally mandate K-12 schools to stock epinephrine. In states with laws only voluntarily allowing schools to stock epinephrine, it provides the ability to opt-out. Herein, we present a comprehensive review of barriers to school stock epinephrine, related improvement strategies, and workgroup recommendations supporting the need for mandated stock epinephrine in all schools in every state. Proposed solutions include ensuring legal immunity from liability for prescribers; advocacy for legislation to stabilize cost of self-injectable epinephrine; educational initiatives to schools promoting merits and safety of epinephrine and related anaphylaxis training; and partnerships between patient advocacy groups, medical and nursing organizations, public health departments and other health professionals to promote laws and district policies addressing need for stock epinephrine and school nurses to train and supervise school staff.

Ensuring equitable access to guideline-based asthma care across the lifespan: Tips and future directions to the successful implementation of the new NAEPP 2020 guidelines, a Work Group Report of the AAAAI Asthma, Cough, Diagnosis, and Treatment Committee.

The most recent recommendations from the 2020 National Asthma Education and Prevention Program Update and Global Initiative for Asthma 2021 guide evidence-based clinical decision making. However, given the present state of health disparities by age, income, and race, the equitable implementation and dissemination of these guidelines will be unlikely without further guidance. This work group report reviews the current state of the new asthma guideline implementation; presents updated evidence-based therapeutic options with attention to specific patient populations; and addresses barriers to the implementation of these guidelines in minoritized, historically marginalized, and underresourced communities. Allergists and immunologists can use practical ways to accomplish the goals of improved asthma care access and advanced asthma care across the life span, with specific considerations to historically marginalized populations. Modifiable barriers to guideline implementation include financial barriers, environmental factors, and allergy subspecialty access and care coordination. Various programs to improve access to guideline-based asthma care include community programs, school-based asthma programs, and digital health solutions, with an emphasis on reducing disparities by race.

Improving epinephrine autoinjector usability and carriage frequency among patients at risk of anaphylaxis: a quality improvement initiative.

Although epinephrine autoinjectors (EAIs) are crucial for the management of anaphylaxis, patient carriage frequency of EAI is as low as 57% and usage of EAIs is erroneous 35%-43% of the time. Our objective was to improve patient carrying frequency of EAI and understanding of EAI usage.We implemented a quality improvement initiative using consistent closed-loop education, redesigned clinic workflow, electronic medical record reminder-based interventions, and educational materials to improve patient EAI carriage compliance and understanding of EAI indications and proper technique.The percentage of our patients who carried the EAI at all times increased from 55% to 93% in 6 months. Participants knowledge of EAI indications also improved from 22% to 91%. Patient demonstration scores of the EAI device improved from 21% to 91% as well.Our quality improvement interventions demonstrated a significant improvement>80% in EAI carriage frequency, knowledge of indications, and proper device technique.

Peripheral Airway Impairment and Dysanapsis Define Risk of Uncontrolled Asthma in Obese Asthmatic Children.

BACKGROUND: Factors that determine the relationship between obesity and poor outcomes in asthmatic children are not well understood. Dysanapsis and peripheral airway impairment (PAI) could provide an explanation in the obese asthmatic patient. OBJECTIVES: To determine the effect of obesity on increased dysanapsis and PAI and establish the effect of obesity, dysanapsis, and PAI on increased risk of uncontrolled asthma. METHODS: We evaluated 206 children with moderate to severe asthma, aged 4-18 years, to determine the relationship of body mass index (BMI) to increased dysanapsis and PAI, using reference values. We examined the probability of obesity, dysanapsis, and PAI increasing the risk of uncontrolled asthma by BMI categorically and BMI z scores using generalized linear model analyses. RESULTS: Compared with normal-weight children, overweight and obese children had increased forced vital capacity % predicted and obesity increased odds of dysanapsis by 2.32 (P = .04), while PAI showed an age-dependent effect, with increased odds of 2.09 for children younger than 12 years (P = .08) and 54.14 for those 12 years and older (P = .003). For each unit increase in BMI z score, there was an increased odds ratio of 1.57 for dysanapsis (P = .009), greater in males, OR of 3.10, P = .009, and of 1.39 for PAI for those younger than 12 years (P = .042) and of 4.60 for those 12 years and older (P = .002). Obesity's relationship to uncontrolled asthma was indirect, as not significant when adjusted for the direct effect of dysanapsis and PAI, which were highly significant predictors, with increased odds of 28.01 for dysanapsis for those younger than 12 years (P < .001) and of 3.09 for PAI (P = .005). CONCLUSIONS: Overweight and obesity significantly increase odds of dysanapsis and PAI, in an age and gender-specific manner, increasing the probability of uncontrolled asthma.

A case of delayed maculopapular eruption to ibuprofen and acute urticaria to acetaminophen.

We present the unique case of a 33-year-old male referred to our clinic in search of analgesic options who was found to have a delayed hypersensitivity reaction to ibuprofen manifesting as a maculopapular rash and acute urticaria to acetaminophen. Non-steroidal anti-inflammatory drugs are associated with predictable reactions as well as immunoglobulin E-mediated reactions or T-cell mediated reactions. This case highlights the importance of knowledge of the different types of reactions to non-steroidal anti-inflammatory agents as well as the risk of cross reactivity. Delayed reaction to a single non-steroidal agent is rare; urticaria to acetaminophen is very rare. This is the first report we have found in the literature where one individual has a delayed reaction manifesting as rash to ibuprofen as well as urticaria to acetaminophen. We challenged our patient to aspirin which helped identify that his delayed reaction was only to ibuprofen and urticaria only to acetaminophen. The case also highlights the importance of an oral provocation challenge when no contraindications exist which helped us find that he could take celecoxib and avoid narcotics as initial therapy.

Effect of omalizumab on outcomes in patients with aspirin-exacerbated respiratory disease.

Background: The current treatment for patients with aspirin-exacerbated respiratory disease (AERD) who have uncontrolled asthma or chronic rhinosinusitis is aspirin desensitization. For patients who are unable to undergo or do not benefit from aspirin desensitization, treatment with biologics is an option, although efficacy data for AERD is scarce. Objective: We reported a series of patients with AERD who were started on omalizumab and measured the outcomes to assess improvement. Methods: Adult patients with AERD who were initiated on omalizumab from January 2007 to January 2018 were included. We compared outcomes 6-12 months before initiating biologic therapy and during the last 6-12 months while they were on biologic therapy. Our study investigated the number of oral steroid courses, short-acting beta-agonists (SABA), antibiotics for sinusitis or pneumonia, emergency department visits, hospitalizations, pulmonary function tests, and changes in controller medications. Results: Twenty-nine patients were placed on omalizumab. Sixty-two percent demonstrated a reduction in the number of steroid courses (p = 0.0014) and number of SABA canisters used (p = 0.0005) during their last 12 months while on omalizumab. Eighty-six percent of the patients with AERD and on omalizumab demonstrated either a decrease in the number of steroid courses or number of SABA canisters used in the last year of the study. The patients with AERD and with concomitant immunoglobulin E (IgE) mediated respiratory disease showed a statistically significant reduction in the number of steroid courses and number of SABA canisters used while on omalizumab for 1 year (p = 0.002 and p = 0.005, respectively), whereas those without concomitant IgE-mediated respiratory disease did not have a substantial reduction in steroids or SABA canisters used. Conclusion: Our case series reported that omalizumab could effectively be used as an adjunct treatment for AERD, but additional larger and longitudinal studies are needed to corroborate these findings.

Development of a pediatric asthma predictive index for hospitalization.

BACKGROUND: Variation in emergency department (ED) management for asthma exacerbation leads to disparities in care. Current asthma severity scores are insufficient to be used for hospitalization decisions. OBJECTIVE: To develop and internally validate an asthma predictive index for hospitalization (APIH) to guide practitioners in their admission decision for children with asthma exacerbations. METHODS: Data were collected from 12,066 children between 5 and 18 years old diagnosed with asthma exacerbation in the ED. Epidemiologic findings, number of inhaled corticosteroid canisters, short-acting ß-blocker canisters, oral steroids, coexisting atopy, family history of atopy, insurance, and prior asthma ED visits or hospitalizations were compared between patients hospitalized and discharged. We used univariate analysis and multivariate analysis to determine the best predictor variables for hospitalization. Our study internally validated the prediction index to estimate future performance of the prediction rule. RESULTS: The highest risk factors associated with asthma hospitalization from the ED are oxygen saturation less than 94%, respiratory rate greater than 31/min, history of pneumonia, and asthma ED visits in past 12 months. With a reduced predictive model that combined these risk factors, the odds ratio was 44.9 (95% CI, 32.8-61.4), which is extremely significant. Our C index of discrimination of 0.77 was similar to the validation C index of 0.78, which confirms a solid prediction model. CONCLUSION: We have developed and internally validated a pediatric hospitalization prediction index for acute asthma exacerbation in the ED. Further studies are needed to externally validate the APIH before its implementation into clinical practice.