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What's new in allergy and immunology

What's new in allergy and immunology
Literature review current through: Jan 2024.
This topic last updated: Dec 19, 2023.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ASTHMA AND COPD

Tapering inhaled corticosteroids in asthma patients responding to biologics (December 2023)

Strategies for tapering other asthma therapies, such as inhaled corticosteroids (ICS), for patients who achieve good asthma control with biologics has not been well studied. In an open-label, randomized trial of 168 adults with a history of severe eosinophilic asthma and good control on benralizumab and high-dose ICS, 43 patients were assigned to an ongoing high-dose ICS-formoterol regimen and 125 patients were assigned to a 32-week taper protocol (medium-, low-, and as-needed dosing of ICS-formoterol) [1]. In the tapering arm, 92 percent of patients achieved lower doses of ICS, with only 9 percent experiencing exacerbations. However, significant decreases in FEV1 and increases in fraction of exhaled nitric oxide occurred in patients using the least amount of as-needed ICS-formoterol after their taper. These data suggest that most patients well-controlled on biologics may be successfully tapered to regimens containing medium- or low-dose ICS with long-acting bronchodilators. However, the safety and efficacy of tapering to as-needed ICS-formoterol requires further study. (See "Treatment of severe asthma in adolescents and adults", section on 'Tapering therapy'.)

Long distance effect of wildfire smoke on asthma symptoms (October 2023)

Wildfire fine particulate matter (PM2.5) has been shown to affect respiratory health; however, previous work has focused on populations residing near and directly affected by wildfires. In June 2023, smoke from wildfires in Canada drifted hundreds of miles to New York City, resulting in increased ambient PM2.5. During smoke waves, emergency department visits for asthma in both pediatric and adult patients increased to 261 per day (reference during nonsmoke periods, 181.5 per day; incidence rate ratio 1.4) [2]. Wildfires have health effects far from their source and are particularly hazardous to those with underlying lung disease. (See "Climate emergencies", section on 'Changing wildfire exposure'.)

FOOD ALLERGY AND INTOLERANCE

Low awareness of meat allergy caused by "alpha-gal syndrome" (September 2023)

Allergy to galactose-alpha-1,3-galactose, a carbohydrate allergen found in all mammalian meat except that of primates, causes allergic reactions to meats like beef, pork, and lamb, as well as to an array of other products, medications, and medical devices made with mammalian tissues. This allergy, first reported in 2009 and termed "alpha-gal syndrome," develops following the bites of certain ticks and causes reactions that are uncharacteristically delayed (ie, several hours after ingestion). A common presentation is anaphylaxis developing in the middle of the night after a meat-containing evening meal. Although the prevalence is increasing worldwide, a web-based survey of 1,500 health care professionals in the United States revealed that 42 percent had never heard of the disorder [3]. This lack of awareness can delay diagnosis for decades. (See "Allergy to meats", section on 'In whom to suspect the diagnosis'.)

IMMUNODEFICIENCY

Newborn screening for severe combined immunodeficiency (August 2023)

Historically, best outcomes after hematopoietic cell transplantation (HCT) for severe combined immunodeficiency (SCID) occur in younger recipients without infection at the time of transplant. In a multicenter, longitudinal study, from 2010 to 2018, five-year overall survival after HCT was higher for children identified with SCID by newborn screening (93 percent) compared with those identified by family history or clinical presentation (80 and 85 percent, respectively) [4]. In multivariable analysis, younger age and absence of active infection at the time of HCT, both of which are improved by identification through newborn screening, were strongly associated with overall survival. Expanded use of newborn screening for SCID in public health programs worldwide could lead to additional improvement in survival after HCT wherever available. (See "Hematopoietic cell transplantation for severe combined immunodeficiencies", section on 'Newborn screening'.)

VACCINES AND VACCINE HYPERSENSITIVITY

ACIP recommendations for 2023-24 seasonal influenza vaccination (September 2023)

The Advisory Committee on Immunization Practices (ACIP) issued new recommendations for seasonal influenza vaccination in August 2023 (table 1) [5]. The antigenic composition has been updated. In addition, the ACIP now states that egg allergy alone no longer necessitates additional safety measures for influenza vaccination, including with egg-based vaccines, beyond those recommended for any recipient of any vaccine, regardless of severity of previous reaction to egg. All vaccines should be administered in settings where personnel and equipment needed for prompt recognition and treatment of acute hypersensitivity reactions are available. This is consistent with our previous guidance. (See "Seasonal influenza vaccination in adults", section on 'Antigenic composition'.)

OTHER GENERAL ALLERGY AND IMMUNOLOGY

Efficacy and side effects of gefapixant treatment for refractory chronic cough (September 2023)

P2X3 inhibitors decrease sensitivity of airway sensory nerve fibers and are under investigation for the treatment of refractory chronic cough. In a recent meta-analysis of over 2000 patients receiving 45 mg twice daily of the P2X3 inhibitor gefapixant or placebo, the gefapixant group demonstrated greater reduction in 24-hour cough frequency (66 versus 50 percent) and improved cough quality of life (4- versus 3-point improvement on a 19-point scale), but nearly one-third of patients developed a taste disturbance [6]. The modest benefit compared with significant risk of adverse side effects continues to be a barrier to regulatory approval and widespread use of this agent. (See "Evaluation and treatment of subacute and chronic cough in adults", section on 'P2X3 antagonists'.)

Oral baricitinib for atopic dermatitis in children (August 2023)

Baricitinib is an oral JAK1/2 selective inhibitor approved for adults with atopic dermatitis in Europe but not in the United States. A multicenter randomized trial evaluated the efficacy and safety of once-daily oral baricitinib combined with topical corticosteroids in 483 children aged 2 to <18 years with moderate to severe atopic dermatitis [7]. At 16 weeks, more patients in the 4 mg (high dose) baricitinib group achieved an Investigator Global Assessment score of clear/almost clear compared with those in the placebo group (42 versus 16 percent). Low-dose and medium-dose baricitinib (1 and 2 mg, respectively) were no more effective than placebo. Treatment-emergent adverse events included abdominal pain, acne, and headache. While baricitinib appears to be effective with a good safety profile for the short-term treatment of atopic dermatitis in children, larger and longer duration studies are needed to evaluate its efficacy and safety in the pediatric population. (See "Treatment of atopic dermatitis (eczema)", section on 'Baricitinib'.)

  1. Jackson DJ, Heaney LG, Humbert M, et al. Reduction of daily maintenance inhaled corticosteroids in patients with severe eosinophilic asthma treated with benralizumab (SHAMAL): a randomised, multicentre, open-label, phase 4 study. Lancet 2023.
  2. Chen K, Ma Y, Bell ML, Yang W. Canadian Wildfire Smoke and Asthma Syndrome Emergency Department Visits in New York City. JAMA 2023; 330:1385.
  3. Carpenter A, Drexler NA, McCormick DW, et al. Health Care Provider Knowledge Regarding Alpha-gal Syndrome - United States, March-May 2022. MMWR Morb Mortal Wkly Rep 2023; 72:809.
  4. Thakar MS, Logan BR, Puck JM, et al. Measuring the effect of newborn screening on survival after haematopoietic cell transplantation for severe combined immunodeficiency: a 36-year longitudinal study from the Primary Immune Deficiency Treatment Consortium. Lancet 2023; 402:129.
  5. Grohskopf LA, Blanton LH, Ferdinands JM, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2023–24 Influenza Season. MMWR Recomm Rep 2023; 72:2.
  6. Kum E, Patel M, Diab N, et al. Efficacy and Tolerability of Gefapixant for Treatment of Refractory or Unexplained Chronic Cough: A Systematic Review and Dose-Response Meta-Analysis. JAMA 2023; 330:1359.
  7. Torrelo A, Rewerska B, Galimberti M, et al. Efficacy and safety of baricitinib in combination with topical corticosteroids in paediatric patients with moderate-to-severe atopic dermatitis with an inadequate response to topical corticosteroids: results from a phase III, randomized, double-blind, placebo-controlled study (BREEZE-AD PEDS). Br J Dermatol 2023; 189:23.
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