ASTHMA

Dosing adjustment of inhaled glucocorticoids — A meta-analysis of the dose response to inhaled glucocorticoids in children with mild-to-moderate persistent asthma suggests that there is little additional benefit (as measured by beta-agonist use, asthma symptom score, forced expiratory volume in one second, and peak expiratory flow) in increasing the dose from low to moderate levels (≤200 mcg/day versus 300 to 400 mcg/day beclomethasone-equivalent).

Spacers — The use of a spacer or valved holding chamber is recommended for all children in whom proper breath and actuation coordination is difficult (particularly those who are younger than five to six years), and whenever an inhaled corticosteroid is being administered via a pressurized metered dose inhaler (MDI). In a study comparing spacers, children two to seven years of age who used spacers without facemasks had inhalation volumes nearly double the expected tidal volumes. Two tidal breaths were sufficient for the smaller volume spacers (149 mL Aerochamber Plus and 225 mL Funhaler) and a 500 mL modified plastic soft drink bottle, but three tidal breaths were required for the larger volume spacer (750 mL Volumatic). Additional tidal breaths did not significantly increase drug delivery. Drug delivery was otherwise equivalent between the four devices.

Acetaminophen and asthma risk — The Melbourne Atopy Cohort Study examined the relationship between paracetamol use during early childhood and the risk of asthma in 620 children with a family history of allergic disease. To reduce the risk of confounding bias, frequent prospective documentation of paracetamol use and its indications were obtained. After adjustment for the frequency of respiratory infections, no association was found between paracetamol use and parental report of asthma at age six or seven.

COPD

Inhaled glucocorticoids and pneumonia — Among 6353 patients with COPD hospitalized at US Veterans Affairs hospitals for pneumonia, the use of outpatient inhaled glucocorticoids was not associated with increased mortality at 30 and 90 days compared with those not taking inhaled glucocorticoids.

EOSINOPHILIC ESOPHAGITIS

Maintenance therapy with budesonide — Many patients with eosinophilic esophagitis respond to initial therapy, but subsequently relapse once therapy is stopped. A randomized controlled trial found that patients who received low-dose budesonide maintenance therapy had a significantly higher rate of clinical remission after 50 weeks compared with patients who received placebo. Budesonide may be an option for patients with eosinophilic esophagitis who require maintenance therapy.

FOOD ALLERGY

Food allergy guidelines — The US National Institute of Allergy and Infectious Diseases, in conjunction with 34 professional organizations, federal agencies, and patient advocacy groups, developed clinical guidelines for the diagnosis and management of food allergy. Medically supervised food challenge is recommended to confirm that a food allergy has resolved, as in vitro and skin tests can remain positive in patients who achieve clinical tolerance, and conversely, tests can become negative in patients who still react upon ingestion, although the latter situation is uncommon.

Risk of sesame or coconut allergy in patients with peanut or tree nut allergy — There are limited data on the rate of co-allergy to sesame and coconut in patients with peanut and tree nut allergy. In one retrospective survey, children who had a positive skin test to peanut or tree nuts were more likely to also test positive to sesame. However, there was no systematic evaluation of the clinical outcomes (eg, whether there was a significant risk of clinical allergy to sesame). In contrast, children with peanut and tree nut sensitization or allergy were not more likely to be sensitized or allergic to coconut.

IMMUNOTHERAPY

Updated practice parameters for allergen immunotherapy — Practice parameters for allergen immunotherapy have been updated by the Joint Task Force (a panel of experts from three American professional allergy organizations). Most recommendations are similar to the 2007 version. Changes include the addition of atopic dermatitis as a condition that may respond to immunotherapy and the use of venom immunotherapy to prevent recurrent and bothersome large local reactions to insect stings.

American studies of oral immunotherapy demonstrate possible efficacy — Oral immunotherapy has been used for decades in Europe for the treatment of allergic rhinitis and other allergic disorders and is safer and more convenient compared with subcutaneous injection immunotherapy. However, oral immunotherapy products have not been approved by the US Food and Drug Administration because rigorous studies showing benefit in the American population, whose patterns of allergic sensitization can differ from those of European populations, were lacking. Two large randomized trials of adults and children in the United States, most of whom were sensitized to multiple allergens in addition to grass pollen, have now demonstrated positive clinical outcomes. In both studies, combined daily symptom plus medication score improved between 20 and 26 percent compared to placebo-treated groups, and serious treatment-related adverse events and anaphylaxis were not reported. Multiple allergen allergic patients failed to respond to oral immunotherapy.