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Allergic Asthma: Overview, Diagnosis, and Treatment

Symptoms
Diagnosis
Management
Practice Parameters
Testing Information

About Allergies and Asthma

Asthma, the chronic and complex inflammatory disorder that narrows the airways, is a serious public health problem that affects both children and adults. Approximately 250,000 people worldwide die each year from asthma, and almost all of these deaths are avoidable.1

Exposure to allergens or irritants to which patients are sensitized may increase asthma symptoms and precipitate asthma exacerbations in patients who have asthma.2

Identifying and managing allergic triggers, in addition to pharmacological management, can have a significant impact on control.3-5 When managing asthma, it is important to identify and provide appropriate advice to help your patient reduce exposure to their confirmed triggers.3

Allergy-induced asthma can be fatal. Allergens are the trigger of asthma symptoms for the majority of patients.6 These may include perennial allergens, such as dust mites and pets, and seasonal allergens, such as pollen.4-6 Patients with asthma and allergic triggers can be at increased risk of severe conditions:

  • Children with asthma and concomitant food allergy have a seven times higher risk for life-threatening asthma exacerbations.7,8
  • Patients with asthma, allergen exposure, and viral infection face a nearly 20-fold increased risk for hospitalization compared to patients with allergies alone.9
  • Patients with asthma plus an allergy to peanuts or tree nuts are at an increased risk for fatal anaphylaxis.10

It is also important to identify and treat allergic comorbidities. For example, both allergic rhinitis and non-allergic rhinitis are risk factors for the development of asthma.11 More than 80 percent of people with asthma also suffer from rhinitis,1 suggesting the concept of “one airway, one disease.” The presence of allergic rhinitis commonly exacerbates asthma, increasing the risk of asthma attacks, emergency visits, and hospitalizations for asthma.12-16 It is not clear whether allergic rhinitis represents an earlier clinical manifestation of allergic disease in atopic patients who will later develop asthma, or whether rhinitis itself is causative for asthma.12

400 million by 2025

Asthma affects approximately 300 million people in the world and is estimated to affect 400 million people by 2025.1

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A variety of triggers can cause asthma symptoms.

Symptoms may occur in connection with allergen exposure, exercise, cold air, dry air, and airway infections. Other irritants, such as strong scents or cigarette smoke, can also trigger an exacerbation. To manage your patient's asthma, it is important to identify and minimize his or her exposure to triggers.

Asthma usually presents as one ore more of the following symptoms:1

  • Wheezing
  • Coughing
  • Shortness of breath
  • Chest tightness

 

Identifying and managing allergic triggers, in addition to pharmacological management, can have a significant impact on control.3-5 When managing asthma, it is important to identify and provide appropriate advice to help your patient reduce exposure to their confirmed triggers.3

Allergic asthma: Refining differential diagnosis with testing

During an allergy-focused patient history and physical exam, you will likely find several variable and recurring symptoms that are the characteristics of asthma. You may detect airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation.

Following a diagnosis of asthma, guidelines recommend that factors that trigger or exacerbate asthma must be elicited routinely and documented in the medical records and action plans of all patients with asthma.17 Diagnosing underlying allergy in asthma starts with a physical examination and an allergy-focused patient history. A few key questions will provide you with a detailed history and help you create an effective management plan for your patient. With allergic asthma, history is often not enough to make an accurate diagnosis. For example, a patient can present with a history indicative of house dust mite or cat allergy but actually not be sensitized.18

Guided by the allergy-focused patient history, the most appropriate next step may be specific IgE tests. Specific IgE blood tests, skin-prick tests (SPT), or both, are important diagnostic tools. When added to an allergy-focused patient history, SPT and specific IgE measurements can help you rule in or rule out allergen sensitization, which may give you the ability to correctly diagnose and improve clinical management.19,20


Who should be tested?

Up to 90 percent of children and 60 percent of adults with asthma suffer from allergies,23,24 and guidelines recommend factors that trigger or exacerbate asthma be identified routinely and documented in the medical records and personal asthma action plans of all patients with asthma.25 Reducing exposure to one or more allergic triggers can help reduce symptoms and the need for medication.22

Allergic Asthma Algorithms
View Allergic Asthma Algorithms

Adapted from the National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 200722 and Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report.26

Why test for allergen sensitizations?

Most patients with asthma have multiple allergic sensitizations (e.g., perennial and seasonal aeroallergens) contributing to their allergen load.4,21 These allergen sensitizations can add to the patient’s trigger load, eventually resulting in asthma exacerbations—even from other, non-allergic, triggers.4,5 In patients with asthma and aeroallergy, in addition to pharmaceutical strategies, reducing exposure to sensitized allergens can alleviate or reduce symptoms.23, 24, 27-29

Specific IgE Testing Improves
Accuracy of Results vs. Patient History Alone18

Allergens add up to symptoms

Up to 80 percent of patients with allergies are sensitized to more than one allergen.21 The effect of is cumulative: An individual patient may have a number of triggers, which combined may lead to symptoms.4,5 The allergen symptom threshold is the point at which the cumulative allergen load leads to symptoms.4,21

Identifying the relevant sensitizing allergens will help you outline a comprehensive exposure reduction plan to keep your patient below his or her symptom threshold. Identifying and reducing exposure to allergens to which patients are sensitized, particularly house dust mite, can reduce the risk of induced asthma exacerbations.2 In patients with asthma, allergies and respiratory viral infections act synergistically—pushing the patient over their symptom threshold—to increase the risk of a severe exacerbation.2 Patients with asthma and allergy, who subsequently develop a respiratory viral infection, are at increased risk of hospital admission.2

Common allergens to test for:22

  • Pollens
  • Foods
  • Pets
  • Molds
  • Dust mites
  • Other animals

Testing Confidence

Testing Increases Diagnostic Confidence

Adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis to 90 percent.i,ii Conventionally, a diagnosis of allergic or autoimmune disease relies on the case history and a physical examination. However, adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis.i,ii Diagnostic testing can also help to improve the patient’s quality of life and productivity, reduce costs associated with absenteeism, and optimize use of medication, in addition to decreasing unscheduled healthcare visits.iii,iv 

i. Duran-Tauleria E, Vignati G, Guedan MJ, et al. The utility of specific immunoglobulin E measurements in primary care. Allergy. 2004;59 (Suppl78):35-41.
ii. NiggemannB, Nilsson M, Friedrichs F. Paediatric allergy diagnosis in primary care is improved by in vitro allergen specific IgE testing. Pediatr Allergy Immunol. 2008;19:325-331
iii. Welsh N, et al. The Benefits of Specific Immunoglobulin E Testing in the Primary Care Setting. J Am Pharm Assoc. 2006;46:627.
iv. Szeinbach SL, Williams B, Muntendam P, et al. Identification of allergic disease among users of antihistamines. J Manag Care Pharm. 2004; 10 (3): 234-238

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Get scientific information on more than 550 allergens.

Allergen Encyclopedia

Management and care of patients with allergic asthma

Asthma is a major chronic respiratory disease due to its prevalence and its impact on quality of life.30 Asthma has been shown to negatively impact patients’ physical health (e.g., obesity, physical limitations), psychological health (e.g., anxiety, depression, self-esteem), and social health (e.g., social interaction, peer acceptance) and adversely affect their health-related quality of life (HRQoL).31,32

Patients with asthma can have both short-term treatment for asthma exacerbations and long-term treatment to obtain and maintain asthma control. Emergency treatment of asthma exacerbations is frequently, and sometimes almost exclusively, used by many asthma patients.30

In addition, atopic sensitization and comorbidities are present in a large percentage of asthmatics. Indoor and seasonal allergies are very common, and many asthmatics have more than one type of allergic sensitization.30 Allergens are the trigger of asthma symptoms for the majority of patients.33 These may include perennial allergens, such as pets and dust mites, and seasonal allergens, such as pollen.30,33

Practice parameters have been developed to classify and manage treatment of asthma and guideline-directed management has been shown to improve disease control.34

Practice Parameters

Practice parameters and guidelines

for allergic asthma:

Guidelines for the Diagnosis and Management of Asthma (EPR-3)

Guidelines for the Diagnosis and Management of Asthma (EPR-3)

Global Initiative for Asthma (GINA) Report

Global Initiative for Asthma (GINA) Report

EULAR Recommendations for the Management of Antiphospholipid Syndrome

EULAR Recommendations for the Management of Antiphospholipid Syndrome

Management Acute Loss Asthma Control

Management of acute loss of asthma control in the yellow zone: A practice parameter

Exercise Induced Bronchoconstriction Practice Parameter 2016

Exercise-induced bronchoconstriction update—2016

International Guidelines Asthma

International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma

Respiratory Interpretation Guide

Respiratory Interpretation Guide

Read Patient Case Studies
References

 

  1. Pawankar R, Holgate S, Canonica G, at el. World Allergy Organization. White Book on Allergy (WAO). 2011. http://www.worldallergy.org/UserFiles/file/WAO-White-Book-on-Allergy_web.pdf. Accessed December 2017.
  2. Murray CS, Foden P, Sumner H, et al. Preventing Severe Asthma Exacerbations in Children. A Randomized Trial of Mite-Impermeable Bedcovers. Am J Respir Crit Care Med. 2017;196(2):150-158.
  3. Janssens T, Ritz T. Perceived Triggers of Asthma: Key to Symptom Perception and Management. Clin Exp Allergy. 2013;43(9):1000-1008. doi:10.1111/cea.12138.
  4. Eggleston PA. Control of environmental allergens as a therapeutic approach. lmmunol Allergy Clin North Am. 2003;23(3):533-547. 
  5. Wickman M. When allergies complicate allergies. Allergy. 2005;60 (suppl 79):14-18.
  6. Baxi SN, Phipatanakul W. The role of allergen exposure and avoidance in asthma. Adolesc Med State Art Rev. 2010;21(1):57-71.
  7. Roberts G, Patel N, Levi-Schaffer F, et al. Food allergy as a risk factor for life-threatening asthma in childhood: a case-controlled study. J Allergy Clin Immunol. 2003;112:168-174.
  8. Liu AH, Jaramillo R, Sicherer SH, et al. National prevalence and risk factors for food allergy and relationship to asthma: results from the National Health and Nutrition Examination Survey 2005-2006. J Allergy Clin Immunol. 2010;126(4):798-806 e13.
  9. Murray CS, Poletti G, Kebadze T, et al.Study of modifiable risk factors for asthma exacerbations: virus infection and allergen exposure increase the risk of asthma hospital admissions in children. Thorax. 2006;61:376-382.
  10. Lomas JM, Järvinen KM. Managing nut-induced anaphylaxis: challenges and solutions. J Asthma. 2015;8:115-123.
  11. Scadding GK, Durham SR, Mirakian R, et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy. 2008;38:19-42. 

  12. Bousquet J, Van Cauwenberge P, Khaltaev N, et al. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol. 2001;108(suppl 5):S147-S334.
  13. Thomas M, Kocevar VS, Zhang Q, et al. Asthma-Related Health Care Resource Use Among Asthmatic Children With and Without Concomitant Allergic Rhinitis. Pediatrics. 2005;15:129-134.
  14. Price D, Zhang Q, Kocevar VS, et al. Effect of a concomitant diagnosis of allergic rhinitis on asthma-related health care use by adults. Clin Exp Allergy. 2005;35:282-287. 
  15. Crystal-Peters J, Neslusan C, Crown WH, et al. Treating allergic rhinitis in patients with comorbid asthma: the risk of asthma-related hospitalizations and emergency department visits. J Allergy Clin Immunol. 2002;109(1):57-62.
  16. Valovirta E. Managing Co-Morbid Asthma With Allergic Rhinitis: Targeting the One-Airway With Leukotriene Receptor Antagonists. World Allergy Organ J. 2012;5:S210-S211.
  17. Royal College of Physicians. Why Asthma Still Kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry Report. London, RCP, 2014. www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-report.pdf. Accessed January 2018.
  18. Smith HE, Hogger C, Lallemant C, et al. Is structured allergy history sufficient when assessing patients with asthma and rhinitis in general practice? J Allergy Clin Immunol. 2009;123:646-650.
  19. Duran-Tauleria E, Vignati G, Guedan MJ, et al. The utility of specific immunoglobulin E measurements in primary care. Allergy. 2004;59 (Suppl 78):35-41.
  20. Niggemann B, Nilsson M, Friedrichs F. Paediatric allergy diagnosis in primary care is improved by invitro allergen specific IgE testing. Pediatr Allergy Immunol. 2008;19:325-331.
  21. Ciprandi G, Alesina R, Ariano R, et al. Characteristics of patients with allergic polysensitization: the POLISMAIL study. Eur Ann Allergy Clin Immunol. 2008;40(3):77-83
  22. NIH Guidelines for the Diagnosis and Management of Asthma, 2007
  23. Allen-Ramey F, et al. J Am Board Fam Pract.  2005;18(5):434-439.
  24. Host A, Halken S. Allergy. 2000;55:600-608.
  25. National Review of Asthma Deaths (NRAD). Why Asthma Still Kills: Confidential Enquiry Report. London: RCP; 2014.
  26. NIH Guidelines for the Diagnosis and Management of Food Allergy.
  27. Morgan WJ, et al. N Engl J Med. 2004;351:1068-80.
  28. Zethraeus N, et al. Italian Journal of Pediatrics. 2010;36:61.
  29. Janson, et al. J Allergy Clin Immunol. 2009;123:840-6.
  30. Nunes C, Pereira AM, Morais-Almeida M. Asthma costs and social impact. Asthma Res Pract. (2017) 3:1.
  31. Cui W, MS, Zack MM, Zahran HS. Health-Related Quality of Life and Asthma among United States Adolescents. J Pediatr. 2015 February ; 166(2): 358–364. 
  32. Juniper EF. Quality of life in adults and children with asthma and rhinitis. Allergy. 1997: 52;971-977.
  33. Baxi SN, Phipatanakul W. The role of allergen exposure and avoidance in asthma. Adolesc Med State Art Rev. 2010;21(1):57-71.
  34. Shiffman RN et al. Bridging the Guideline Implementation Gap: A Systematic, Document-Centered Approach to Guideline Implementation. J Am Med Inform Assoc. 2004;11:418–426.