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PHARMACY PRACTICE TRAINING
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Allergic Respiratory Disease
Allergic respiratory disease can manifest
as asthma and/or allergic rhinitis (AR) and is
the result of allergic sensitisation of the upper and/or lower airways to inhaled airborne allergens.
In Australia, the allergen most commonly associated with
triggering asthma and AR is the house dust mite (HDM),1
a tiny scavenger that feeds on skin flakes that are continuously
shed from humans. The HDM allergen is a digestive protease that
persists in the faecal pellets of the mite causing an IgE-mediated allergic reaction in sensitive individuals.2
What are the symptoms of asthma and AR?
While the symptoms of asthma and AR are distinct (asthma
presenting as wheezing, shortness of breath, coughing and chest
tightness; AR presenting as sneezing, watery rhinorrhoea, nasal itching and nasal congestion), these two conditions often co-exist. In a study looking at patients with AR and/or asthma tested for allergic causality, 48% were sensitised to HDM.3 Therefore finding a way to minimise the impact of HDM exposure on those with HDM-sensitive asthma and AR is important.
HDM allergen minimisation is the first step in preventing an HDM allergic response, however HDM allergen minimisation strategies are often complicated and expensive and there are no validated methods for identifying which patients are likely to derive clinical benefit.4
Pharmacotherapy
Pharmacotherapy plays an important role in controlling the symptoms of
AR and asthma and can often successfully control symptoms of one or both conditions. Recommended symptomatic medications include oral, intranasal and ocular antihistamines, intranasal or inhaled corticosteroids, decongestants and leukotriene receptor antagonists. Nevertheless despite optimal pharmacotherapy, adherence and inhaler device technique, in some cases HDM- induced AR and/or asthma can be difficult to treat due to difficulties faced in minimising exposure to the HDM allergen. Suboptimal management of asthma and/or AR can have a significant negative impact on a person’s quality of life; work productivity, school performance, social interactions and sleep.5 As a result a high proportion of patients are disappointed with pharmacotherapy. 6 The next line of treatment to consider is Allergen Immunotherapy (AIT).
Allergen Immunotherapy
Allergen immunotherapy or AIT is currently the only available treatment that can alter the natural history of allergic respiratory disease.7 AIT is effective in patients with moderate to severe AR and allergic asthma who haven’t responded sufficiently to symptomatic drug therapy.8-10
Recently, the AIT sublingual tablet ‘Acarizax’ (12 SQ-HDM oral lyophilisate) has become available on prescription in Australia.10 Taken once daily it works by modifying the immune response to the HDM allergens providing specific desensitisation. The tablets contain an allergen extract from HDM formulated
into a rapidly dissolving tablet that is held under
the tongue until completely dissolved. After the
first supervised administration, Acarizax is suitable for “at home” administration. Swallowing should
be avoided for approximately 1 minute and food and beverage should not be consumed for the following 5 minutes. Acarizax can be taken in conjunction with symptomatic medications. The most commonly reported adverse effects include irritation of the throat, swelling and/or itching of
the mouth and nasopharyngitis. In most cases, adverse events are transient and mild to moderate in severity and can be managed with non-sedating oral antihistamines.10
References
1. Matheson M, Abramson M, Dharmage S, Forbes A, Raven J, Thien F et al. Changes in indoor allergen and fungal levels predict changes in asthma activity among young adults. Clin Exp Allergy. 2005;35:907–13.
2. Calderon MA et al. Respiratory allergy caused by house dust mites: What do we really know? J Allergy Clin Immunol 2015;136:38–48.
3. Zureik M, Neukirch C, Leynaert B, Liard R, Bousquet J, Neukirch F. Sensitisation to airborne moulds and severity of asthma: cross sectional study from European Community respiratory health survey. BMJ 2002;325:411–4.
4. Sheikh A, Hurwitz B, Shehata Y. House dust mite avoidance measures for perennial allergic rhinitis. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD001563.
5. Pawankar R, Bunnag C, Khaltaev N, Bousquet J. Allergic Rhinitis and Its Impact on Asthma in Asia Pacific and the ARIA Update 2008. World Allergy Organization Journal. 2012;5(Suppl 3):S212.
6. Frati F et al. Evaluation of house dust mite allergy in real life: patients’ characteristics and satisfaction with treatment. Eur Ann Allergy Clin Immunol 2014:46(1):17–21
7. Calderon MA et al. House dust mite respiratory allergy: an overview of current therapeutic strategies. J Allergy Clin Immunol Pract 2015;3:843–55.
8. Lin E and Nicholls K. A clinical approach to allergic rhinitis. Medicine Today 2014;15:16–24.
9. Demoly P et al. Severity and disease control before house dust mite immunotherapy initiation: ANTARES a French observational survey. Allergy Asthma Clin Immunol. 2016; 12:13.
10. ACARIZAX Product Information, 1 Aug 2016.
This article was supported by an educational grant from Seqirus.
32 Australian Pharmacist January 2017 I ©Pharmaceutical Society of Australia Ltd.