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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; 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
Asthma: A Global Health Concern
Asthma affects approximately 300 million people in the world,1 and is estimated to affect 400 million people by 2025.1
During your 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. Asthma usually presents as one or more of the following symptoms:1
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.
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.8 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.8
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.9
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, skin prick testing 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.10,11
Specific IgE Testing Improves Accuracy of Results vs Patient History Alone7
Up to 80% of patients with allergies are sensitized to more than one allergen.12
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.5
Each patient has a different level of IgE antibodies at which he or she will show symptoms. Until the symptom threshold is reached, the patient will not show symptoms. However, when these allergens add up they have a cumulative effect, pushing the patient over his or her symptom threshold.5 By reducing exposure to certain triggers, symptoms can be avoided.5
Before exposure reduction
After exposure reduction
References for charts4,5,13
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.13 Patients with asthma and allergy, who subsequently develop a respiratory viral infection, are at increased risk of hospital admission.14
Allergens are the trigger of asthma symptoms for the majority of patients.15 These may include perennial allergens, such as dust mites and pets, and seasonal allergens, such as pollen.4,5,15
Patients with asthma and allergic triggers can be at increased risk of severe conditions:
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.19 More than 80% 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.20-24 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.20
In a UK general practice survey of adults with asthma and comorbid allergic rhinitis (n=4,611), versus patients with asthma alone (n=22,692), the presence of concomitant allergic rhinitis with asthma increases the following: 22
Allergic Rhinitis Impact on Asthma25
0.45% Patients with asthma (n=22,692)
0.76% Patients with asthma + allergic rhinitis (n=4611)
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.
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.
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.
Eggleston PA. Control of environmental allergens as a therapeutic approach. lmmunol Allergy Clin North Am. 2003;23(3):533-547.
Wickman M. When allergies complicate allergies. Allergy. 2005;60 (suppl 79):14-18.
Kim H, Bouchard J, Renzix P. The link between allergic rhinitis and asthma: A role for antileukotrienes? Can Resp J. 2008;15(2):91-98.
Egan M, Bunyavanich S. Allergic rhinitis: the “Ghost Diagnosis” in patients with asthma. Asthma Research Pract. 2015;1:8. doi:10.1186/s40733-015-0008-0.
National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma: summary report 2007. J Allergy Clin Immunol. 2007;120:Suppl:S94-S138
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.
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.
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.
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
Busse WW, Lemanske RF, Gern JE. The Role of Viral Respiratory Infections in Asthma and Asthma Exacerbations. Lancet. 2010;376(9743):826-834. doi:10.1016/S0140-6736(10)61380-3.
Green RM, Custovic A, Sanderson G, Hunter J, Johnston SL, Woodcock A. Synergism between allergens and viruses and risk of hospital admission with asthma: case-control study. BMJ. 2002; 324:763. [PubMed: 11923159]
Baxi SN, Phipatanakul W. The role of allergen exposure and avoidance in asthma. Adolesc Med State Art Rev. 2010;21(1):57-71.
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.
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.
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.
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.
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.
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.
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.
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.
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.