Pearls from the European Academy of Allergy and Clinical Immunology (EAACI) Congress, 2025
The European Academy of Allergy and Clinical Immunology (EAACI) Congress 2025, held in Glasgow, Scotland, United Kingdom from June 13 to 16, centred on the overarching theme of “Breaking boundaries in Allergy, Asthma, and Clinical Immunology: Integrating Planetary Health for a Sustainable Future.” Indeed, this year’s theme emphasized the intersection of environmental health and allergic diseases. The vibrant congress featured several presentations on immunological diseases in both adult and pediatric populations, along with breakthroughs in clinical and translational domains. Key topics included asthma, allergy, chronic spontaneous urticaria, and current global challenges such as pollution and climate change. This report highlights several key studies, organized under three main themes: pediatric studies, biologics in combined airways disease, and biomarkers.
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Venom Immunotherapy in 2025: Practical Insights for Community Allergists
Hymenoptera venom allergy (HVA), caused by stings from bees, wasps, hornets, and yellow jackets, is one of the most common identifiable causes of anaphylaxis in adults. While local reactions are common, systemic responses can be fatal. Venom immunotherapy (VIT) offers long-term protection and is often curative. Introduced in the 1920s, VIT remains the only disease-modifying treatment for HVA.
Updates on the Treatment and Management of Urticaria in 2025
Chronic spontaneous urticaria (CSU) is increasingly recognized as a complex immune-mediated disorder, driven by interactions among T cells, mast cells, and inflammatory mediators. This paper summarizes the latest advances in urticaria treatment and management, incorporating new targeted therapies and evidence-based clinical guidelines.
An Update on Biologics in Pediatric Asthma: A Canadian Perspective
Asthma is one of the most common chronic diseases in Canada, affecting approximately 11% of Canadians. Severe asthma, estimated to affect 5–10% of patients with asthma, is associated with a significant burden of disease‑related morbidity. In adults, typical management strategies include using combinations of inhaled corticosteroids, long-acting beta agonists, leukotriene receptor antagonists, long-acting muscarinic antagonists, and oral corticosteroids. However, in pediatric cases, particularly young children, our medication options are more limited. Although inhaled corticosteroids are effective for the majority of mild-to-moderate asthma cases, their efficacy in non-atopic asthma is limited. Furthermore, using inhaled corticosteroids at moderate-to-high doses can impair linear growth and lead to adrenal suppression. Given our growing recognition of asthma as a heterogenous disease, with multiple disease endotypes driven by distinct inflammatory pathways, there is an increasing demand for targeted therapies, particularly for patients with ongoing, uncontrolled disease (Figure 1). Type 2 (T2) high inflammation, characterized by elevated levels of IgE, interleukin (IL)-4, IL-5, and IL-13, alongside eosinophilia and atopy, remains the most well-defined endotype in school-age children and youth. With the advent of biologic medications, targeting T2‑high inflammatory pathways has become a critical component for managing uncontrolled, moderate‑to-severe asthma in children. This approach aims to improve treatment response and reduce adverse effects. This review will explore the biologic therapies currently available in Canada for moderate-to-severe pediatric asthma, discuss key considerations in selecting the optimal biologic, and outline future research directions to inform the optimal timing for initiating and discontinuing biologic treatments.
The Evolving Therapeutic Landscape for Hereditary Angioedema in Canada: Clinical Advances and Unmet Needs
Hereditary angioedema (HAE) is a rare genetic disorder characterized by recurrent, potentially life‑threatening episodes of swelling due to bradykinin overproduction. Advances in the understanding of molecular pathophysiology, coupled with the development of innovative therapies, are transforming the management of HAE. This underscores the need for strategic planning to incorporate emerging treatment modalities into the Canadian therapeutic framework for HAE.
Use of the Rema Score to Distinguish Individuals with Systemic Mastocytosis From Those with Hereditary Alpha-tryptasemia
Background: Systemic mastocytosis (SM) and hereditary alpha-tryptasemia (HαT) may present with overlapping clinical manifestations of mast cell activation, making them difficult to distinguish on clinical grounds. Diagnosing SM requires a bone marrow or tissue biopsy whereas HαT can be diagnosed with a buccal swab for genetic testing. Another potential method to differentiate SM from HαT is through a validated scoring system. For example, the Spanish Network on Mastocytosis, Red Española de Mastocitosis (REMA) score has been validated as a predictor of mast cell clonality in SM by using basal serum tryptase levels, clinical symptoms, and sex. This study aims to determine whether REMA scores can differentiate sufficiently between individuals with SM and HαT, thereby confidently ruling in or out the need for more invasive investigations such as bone marrow or tissue biopsy. Methods: A retrospective chart review was conducted on 39 patients with SM and 24 patients with HαT to calculate their individual REMA scores. A two-sample Wilcoxon test was conducted to assess the difference in median REMA scores between patients with SM and those with HαT. Within the SM cohort, subgroup analysis was performed to compare REMA scores based on the KIT D816V mutation and SM subtype. The area under the curve was calculated to evaluate the discriminatory property of the REMA score. Results: The Median REMA score within the SM cohort was 2 (0.50, 4.00) compared to -1 (-1.50 0.00) within the HαT cohort (p <0.001). REMA scores in patients with SM did not differ based on the KIT mutation status. A REMA score cut-off of 0.5 was able to distinguish SM and HαT with a specificity of 83.3% (67%,96%). Conclusion: This novel comparison of REMA scores in patients with SM and HαT highlights a potential role for the calculated REMA score in informing decisions about the need for invasive testing for patients presenting with symptoms of mast cell activation. However, larger comparative studies are needed before incorporating REMA scoring into routine care.
Epinephrine is the first line treatment for anaphylaxis, which is a serious allergic reaction that can rapidly progress and may cause death. As a nonselective adrenergic agonist, epinephrine rapidly works to increase vasoconstriction and peripheral vascular resistance, increase cardiac output, reverse bronchoconstriction and mucosal edema, and inhibit the release of mediators of inflammation from mast cells and basophils. The anaphylaxis guidelines developed by the Joint Task Force on Practice Parameters (JTFPP) in 2020, the World Allergy Organization (WAO) in 2020, and the European Academy of Allergy and Clinical Immunology (EAACI) in 2021 advise clinicians to prescribe self-injectable epinephrine to individuals at risk of anaphylaxis and educate them on when and how to administer it. In 2023, the JTFPP updated its anaphylaxis practice parameter to address seven key topic areas, including multiple questions and recommendations related to epinephrine prescription and use. The practice parameter authors graded each recommendation as conditional or strong, based in part on the certainty of the supporting evidence. We provide an overview of key recommendations and discuss their applications in the Canadian context. It is important to note that in Canada, EpiPen® autoinjectors are currently the sole epinephrine delivery devices available with premeasured doses of epinephrine for the emergency treatment of allergic reactions. These autoinjectors should be administered intramuscularly into the anterolateral thigh. Additional epinephrine devices may become available in the future, including the first epinephrine nasal spray (neffy®). There is a wider variety of epinephrine devices available in the United States, including multiple brands of epinephrine autoinjectors (Adrenaclick®, Auvi-Q®, EpiPen®/EpiPen® Jr., and generic versions). Additionally, there is one brand of epinephrine prefilled syringe (Symjepi™) and one brand of nasal spray (neffy®). Although the anaphylaxis practice parameter update was published before the U.S. Food and Drug Administration had approved neffy®, we believe its recommendations for epinephrine prescription and use may be appropriately extended to include epinephrine nasal spray where it is available.
Emerging Biologics in the Management of Atopic Dermatitis
Atopic dermatitis (AD) is a chronic, relapsing and remitting inflammatory skin disease marked by intense pruritus that significantly impacts the daily activities and quality of life of those affected. Topical therapies such as topical corticosteroids (TCS) and topical calcineurin inhibitors (TCI) have been the mainstay of treatment and may offer symptomatic relief. However, their efficacy is often suboptimal, they carry the potential for adverse effects, application adherence can be challenging, and they are not suitable for more widespread disease. Conventional systemic agents such as methotrexate and cyclosporine are used off-label for AD. However, these medications are associated with off-target toxicities and are generally unsuitable for long-term use due to safety concerns. Advances in understanding the immunopathogenesis of AD (Figure 1) have led to the development of multiple new therapies. These include biological agents that target these pathways by neutralizing specific cytokines or their receptors. This paper will review the therapies that have been recently approved or are currently in various stages of development.
Real-world Experience with Advanced Long-term Prophylaxis Agents to Treat Hereditary Angioedema in Canada
Hereditary angioedema (HAE) is a rare genetic disorder caused by a deficiency or dysfunction in the serine protease inhibitor of C1, which results in an accumulation of the vasodilator bradykinin. Angioedema is a type of temporary swelling that can be histaminergic (mast cell-mediated) or non-histaminergic (bradykinin-mediated), of which HAE is an example. The prevalence of HAE is approximately 1:50,000 individuals, and no major differences in prevalence between ethnicities or sex have been reported for the most common subtypes I and II. There are three categories of HAE; type I is the most prevalent and is characterized by low C1-inhibitor (C1-INH) levels, type II ischaracterized by normal levels but low activity of C1-INH (dysfunctional C1-INH), and patients with the nC1-INH subtype have normal C1-inhibitor levels and function. This last subtype has an unknown prevalence, but is less commonly observed than type I and II. The dysfunction or deficit in C1-INH results in accumulation of the vasodilator bradykinin. C1-INH is involved in inhibiting proteins in the bradykinin pathway, such as factor XIIa and kallikrein. Due to the overproduction of bradykinin, vascular permeability increases, resulting in recurrent episodes of potentially severe angioedema in various body parts (HAE attacks). HAE management includes acute attack management, and potentially short-term and/or long-term prophylaxis (LTP). This article will discuss disease burden, patient unmet needs, challenges with conventional treatments, and clinical trial and real-world experience with the newer LTP agents lanadelumab, berotralstat, and garadacimab, with a particular emphasis on Canadian experience with these newer drugs.
At-home Management of Food-induced Anaphylaxis
Anaphylaxis is an acute, potentially life-threatening, systemic reaction characterized by the involvement of two or more body systems. The National Institute of Allergy and Infectious Diseases and Food Allergy and Anaphylaxis Network (NIAID/FAAN) have well-established criteria for the clinical definition of anaphylaxis. Anaphylaxis is a severe allergic reaction that occurs suddenly after contact with an allergy-causing substance (e.g., peanuts), insect venom or medications (e.g., antibiotics). Anaphylaxis criteria include an acute onset of symptoms (within minutes to several hours) involving the skin, mucosal tissue, or both, which may present with generalized hives, pruritus or flushing, or swollen lips, tongue, and uvula. In addition, one or more of the following must be present: respiratory compromise, reduced blood pressure, or associated symptoms of end-organ dysfunction. Anaphylaxis results in a sudden release of mediators, including, but not limited to, histamine from activated mast cells and basophils following the cross-linking of specific immunoglobulin E. Together with downstream mediators, such as prostaglandin D2, platelet activating factor, and leukotrienes, this reaction manifests clinically through peripheral vasodilation, bronchoconstriction, and increased vascular permeability, presenting as a multi-organ emergency requiring immediate intervention. It is estimated that up to 5% of the population has experienced anaphylaxis, although fatality rates are very low at approximately 0.3% and occur most commonly with drug-induced anaphylaxis. Older age, often consistent with pre-existing comorbidities, and delayed epinephrine administration, pose the most significant risk factors for anaphylaxis fatality. While the global rates of anaphylaxis appear to be on the rise, case fatalities fortunately do not seem to follow this trend.
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Pearls from the 2024 European Respiratory Congress
The European Respiratory Congress 2024, held from September 7th to 11th, 2024, in Vienna, Austria, featured several presentations on airway diseases, interstitial lung diseases, bronchiectasis, and critical care, with a focus on emerging therapies, particularly on asthma and chronic obstructive pulmonary disease (COPD).
Treatment and Management of Chronic Cough in Children
Chronic cough (CC) in children is common and most often post-viral in nature. CC in children should be comprehensively evaluated and the underlying etiology treated to prevent irreversible lung damage. Refractory chronic cough (RCC) is proposed as a distinct clinical entity in children, which is defined by a persistent cough that does not resolve after comprehensive evaluation and adherence to systematic, guideline-based treatments. RCC may involve a heightened cough reflex sensitivity or altered neural regulation influenced by genetic, environmental, or immunologic factors. This review focuses on the definition, diagnostic approach, and evidence-based management of pediatric RCC, emphasizing the need for a multidisciplinary approach and highlighting research gaps for future targeted therapies.
Occupational asthma is defined as asthma that is caused by work exposures, accounting for approximately 10-15% of all new-onset adult asthma. Typically, this is a new-onset of asthma in workers with no previous history of asthma. However, the diagnosis may also be made in individuals who had previous childhood asthma that cleared, then recurred as an adult due to work exposure. In contrast, work-exacerbated asthma is defined as asthma that is exacerbated but not caused by work exposures. Occupational asthma can be caused by different mechanisms (Figure 1). It is most often due to a workplace sensitizer, which is a high- or low-molecular weight agent that causes asthma from an immunologic response. Asthma symptoms do not occur on the first exposure. Instead, they require a period ranging from days to years for sensitization. Once sensitized, subsequent exposures, even to very low levels of exposure, will trigger asthma. When this response is due to high-molecular weight sensitizers, which are typically proteins or glycoproteins, it is associated with specific IgE antibodies. In addition, specific IgE-antibodies are also associated with the response to some low molecular-weight sensitizers (chemical sensitizers) such as complex platinum salts and other metal salts. However, for most low-molecular weight sensitizers, the immune mechanism is unclear.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed for pain management and inflammation. Acetylsalicylic acid (ASA) is a commonly used treatment for cardiovascular diseases including acute coronary syndromes. Reactions to NSAIDs can vary widely, ranging from exacerbation of underlying cutaneous and respiratory conditions to anaphylaxis and delayed hypersensitivity reactions (DHRs). A thorough clinical history is essential for diagnosing NSAID hypersensitivity, with a focus on the systems involved, reaction timing, and the presence and control of comorbid allergic conditions. Although commonly referred to as an allergy, the mechanisms behind these reactions are not solely IgE-mediated. As such, the authors will primarily use the term “hypersensitivity reactions” in concordance with the latest American Academy of Allergy, Asthma and Immunology (AAAAI) drug allergy practice parameter. While NSAID hypersensitivity reactions may cross-react among cyclooxygenase-1 (COX-1) inhibitors, reactions to selective cyclooxygenase-2 (COX-2) inhibitors are rare and they are typically well tolerated as alternative agents.
Pollen Cross-Reactivity: A Primer for Allergy Specialists
There are over 400,000 land-based plant species that comprise our biodiverse habitat. Only a small subset of those plant species satisfies Thommen’s postulates, classifying them as allergens. The number of allergenic species, however, remains so vast that it is prohibitive to both test and treat for all relevant species within a geographical region. Allergy specialists have a valuable tool that can be used to help simplify the management of allergic patients: cross-reactivity. Cross-reactivity is the ability for an allergen to induce an IgE-mediated response, regardless of previous exposure. Allergens are a complex milieu of proteins, some of which have allergic potential while others do not. A number of proteins are conserved across allergen species. When exposure to these conserved proteins occurs, the immune system recognizes them in a similar manner. For homologous or cross-reactive allergenic proteins, this conserved molecular recognition initiates the allergic cascade. Allergen characterization is critical to the understanding of cross-reactivity. Characterization, in this context, refers to the protein make-up of a particular allergen. The process of allergen characterization began in 1962 with the discovery of antigen E, the first identified allergenic protein. Antigen E, commonly known as Amb a 1, is an allergenic protein in ragweed, and is the primary sensitizing protein for ragweed allergy sufferers. These primary sensitizers are referred to as major allergens and can be defined as such when >50% of the allergic patient population is sensitized to them. An entire branch of research arose from this discovery, which has allowed for major advances to be made in the understanding of cross‑reactive relationships among allergen species. Cross‑reactivity is not limited to homologous major allergen expression. Rather, minor allergens and panallergens, though less clinically relevant, play a similar role in cross‑reactive relationships. This primer will explore the science behind cross‑reactivity, as well as provide a general overview of the cross‑reactive relationships that have been defined for plant allergens found across North America.
Allergen Immunotherapy and Atopic Dermatitis: Updated Guidance
Atopic dermatitis (AD), also commonly referred to as atopic eczema, is the most common chronic inflammatory skin disease. Research over the past 30 years has revealed that it affects approximately 13% of children and 7% of adults worldwide. Among the growing number of treatment options for AD, the role of allergy to aeroallergens, such as house dust mite (HDM) pollens or animal dander, in driving this condition has remained uncertain for a long time. Consequently, so too has been the therapeutic role of allergen immunotherapy (AIT) for AD. The American Academy of Allergy, Asthma & Immunology (AAAAI)/American College of Allergy, Asthma and Immunology (ACAAI) Joint Task Force (JTF) on Practice Parameters recently updated their AD guidelines. This update included a systematic review of the effectiveness and safety of AIT, including subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) versus no AIT for patients with AD. This article summarizes the systematic review findings, guideline update, and future directions.
Abstract Presentation Highlights from the 2024 EAACI Annual Meeting
Many oral abstracts, posters and case reports were presented at The European Academy of Allergy and Clinical Immunology (EAACI) Annual Meeting which was held in June 2024 in Valencia, Spain. We have selected the following 13 articles due to their relevance to Canadian allergy and immunology clinical practice and research.
Understanding and Managing Adenotonsillar Hypertrophy in Pediatric Otolaryngology
Adenotonsillar hypertrophy (ATH) is a common pediatric condition marked by the growth of lymphoid tissues within the Waldeyer’s ring, which includes adenoids, palatine tonsils, and lingual tonsils. These tissues surround the upper airway and food passage, and play an immunological role, enlarging until about age 12, before gradually reducing during adolescence and adulthood. Untreated or poorly managed ATH can severely impact multiple health aspects of children. It is the primary cause of upper airway obstruction and obstructive sleep apnea (OSA) syndrome in children, which disrupts sleep and can severely impair cognitive development, school performance and behaviour. Chronic mouth breathing from ATH can alter dental arches and facial growth, known as adenoid facies. More severe outcomes include increased pulmonary pressures and the potential development of pulmonary hypertension and cor pulmonale due to chronic hypoxia and CO2 retention. As a result, tonsillectomy, with or without adenoidectomy (T&A), has become one of the most frequently performed surgeries in North America, with over 530,000 operations performed annually on children under age 15. This paper discusses the significant impact of ATH on pediatric health and the frequent need for surgical intervention. It covers the immunophysiology, influence of atopy, community-based assessments prior to specialist referrals, and an overview of available medical and surgical treatment options. Additionally, it outlines general indications for referring patients to otolaryngology.
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to extrinsic causes, such as a medication or an acquired disease process, resulting in decreased immunoglobulin production or increased immunoglobulin loss. Most published reports of SHG refer to IgG hypogammaglobulinemia and data on isolated IgA or IgM hypogammaglobulinemia is limited. The common causes of SHG include medications, hematological malignancies, and conditions associated with protein loss. Hypogammaglobulinemia can increase the risk of infection, morbidity and mortality, particularly in patients who may already be immunocompromised due to their associated condition or use of immunosuppressive therapies. With growing use of immunosuppressive or immunomodulatory treatments that affect B-cells, it is increasingly important to assess and monitor for SHG. Treatment of the underlying condition or removal of the extrinsic factor often results in resolution of the SHG. A subset of patients presenting with autoimmune or malignant conditions can have a primary immunodeficiency (PID) or primary immune regulatory disorder. It is therefore important to consider both primary and secondary causes when assessing hypogammaglobulinemia. This article will review these common causes and discuss an approach to assessment and management of SHG.
Shared Decision Making in Asthma Treatment: Using Motivational Communication to Elevate Your Consultations
The extent to which patients are adherent to their medication regimen is critical for achieving good asthma control, preventing exacerbations, and optimizing the likelihood that patients can lead full and productive lives. Knowing this, physicians might perceive that their role is to convince their patients to comply with their prescribed medicines using educational or persuasive advice-giving strategies that focus on the health benefits of treatment compliance and the negative health consequences of non-compliance. However, evidence suggests that evoking fear of negative consequences is a poor motivator for both the adoption, and long-term maintenance, of good health behaviors such as medication adherence. In an effort to make the maladaptive behavior the ‘less desirable choice’, physicians often inadvertently become associated with the fear messages they share (through classical conditioning) and the negative emotions they elicit (through operant conditioning). This may result in physicians themselves becoming aversive to their patients, leading to patients disengaging from the therapeutic relationship and becoming resistant to treatment recommendations. In fact, treatment success depends not on the imperative to convince and control patient behavior (which defines compliance), but on the willingness to collaborate with the patient to co-construct a treatment plan that they agree with and want to follow (which defines adherence). The key takeaway is to recognize that non-collaborative communication is ineffective for behavior change and may actually be counterproductive, if not harmful.
Adult Obstructive Sleep Apnea: A Practical Guide for the Allergist
Obstructive sleep apnea (OSA) is a common sleep disorder, affecting 15-30% of males and 10-15% of females in North America. OSA is characterized by the recurrent obstruction of the upper airway during sleep resulting in apneas and hypopneas. OSA can be diagnosed using a home sleep apnea test (i.e., a level 3 sleep study) or a polysomnogram (PSG) (i.e., a level 1 study or PSG) in a supervised sleep laboratory which quantifies the number of apneas and hypopneas per hour using the apnea-hypopnea index (AHI). In broad terms, the diagnosis is made when an individual with symptoms or cardiac risk factors has an AHI of ≥5, or an asymptomatic individual has an AHI of ≥15. Continuous Positive Airway Pressure (CPAP) is considered the first-line treatment of OSA. Other treatment options include an oral appliance called a mandibular advancement device, or multilevel surgery of the upper airway, especially uvulopalatopharyngoplasty (UPPP). Herein we review OSA in the context of conditions commonly observed in the allergy clinic, namely asthma, chronic rhinosinusitis, rhinitis, and contact dermatitis.
Surgical Management of Allergic Rhinitis
The inferior turbinate is composed of a central bony structure surrounded by ciliated pseudostratified columnar epithelium. Underneath the epithelium, there are mucous glands, goblet cells and venous sinusoids in the submucosa, The inferior turbinate is supplied by the inferior turbinate branch of the posterior lateral nasal artery from the sphenopalatine artery. The inferior turbinates humidify the air, trap particles and direct airflow throughout the nasal cavity. Due to these functions, the inferior turbinates are often the first point of contact for allergens in the inspired air. With immune responses prompted by a cascade of inflammatory mediators such as immunoglobulin E, mast cells, histamine, and leukotrienes, mucous glands become stimulated and the vasculature within the inferior turbinate engorges. This results in inferior turbinate hypertrophy, leading to increased nasal discharge and nasal obstruction. For individuals refractory to medical therapy for nasal obstruction, surgical inferior turbinate reduction techniques can be employed to help alleviate the symptoms. For those with rhinorrhea refractory to medical therapy, surgical management aimed at reducing parasympathetic innervation to the nasal cavity to reduce nasal discharge production can be also option.
Berotralstat: A data review of a novel oral medication for the treatment of hereditary angioedema
The treatment of hereditary angioedema (HAE) has progressed significantly over the last decade. HAE is an autosomal dominant condition that is bradykinin mediated and affects approximately 1 in 50,000 people. This condition continues to challenge allergists/immunologists (A/I) in promptly managing the disease to reduce attacks of potentially life-threatening angioedema, while improving quality of life in a population in which disease activity tends to increase with age. Notably, delays in diagnosis may reach up to 8 years from initial presentation. The impact of HAE extends beyond the patient, and can affect their caregivers, owing to the fear of acute attacks, which can lead to absenteeism both at school and in the workplace and ultimately negatively impact quality of life and career productivity.
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Over generations of health care providers, the approach to medicine has predominantly been reactive in nature, addressing symptoms as they arise. With advancements in medical research that explore the underlying mechanisms of disease, associated comorbidities, and improved therapeutic options, the objectives of medicine are transforming. While managing active symptoms remains crucial, there is a growing focus on altering the future trajectory of a disease which will result in new avenues to improve the quality of life of patients. In this evolving landscape, the atopic march emerges as a promising area for disease modification.
Epinephrine auto-injectors in Canada: A review of available products and clinical proposals
Anaphylaxis is a severe reaction with significant associated morbidity and mortality that necessitates prompt on-demand management for patients. Epinephrine administered intramuscularly at a dose of 0.01 mg/kg of body weight, up to a maximum single dose of 0.5 mg at one time, is the first-line treatment for anaphylaxis. Epinephrine auto-injectors (EAIs) are devices designed to deliver a predetermined dose of epinephrine rapidly and reliably into the vastus lateralis muscle of the mid-anterolateral thigh for treatment of anaphylaxis. All commercially available auto-injectors in Canada are fixed-dose delivery systems, therefore titration of epinephrine dose based on patient weight is not possible. In Canada, there are several manufacturers of EAIs, providing treating physicians and patients with a variety of options to treat anaphylaxis in the community. However, as these devices all contain the same medication, physicians may not realize that specific EAIs may be of greater utility in certain clinical circumstances. This scientific review aims to describe all currently available EAIs in Canada, with detailed discussion on the differences between products and the nuances of a patient-centred approach to prescription in a market filled with seemingly “one size fits all” devices.
Hydrogen and methane breath testing for abdominal bloating of small intestinal origin
Abdominal bloating with or without excessive gas production and with or without abdominal distention is common, very bothersome for patients, and is poorly understood. Bloating can be associated with gastrointestinal disorders, nutrient malabsorption, and systemic illnesses. The origin of abdominal bloating is often unclear, though it is usually associated with food intake and bowel motility dysfunction. Often, food allergies, food intolerance, or food poisoning are considered by the patient or physician as potential causes for bloating. A common concern in the patient’s mind is that healthcare professionals will dismiss or misdiagnose their complaint. The limited understanding of the pathophysiology of bloating leads to current empirical management, and bloating is often characterized as a “functional” disorder. Bloating carries a heavy clinical, psychological, and economic burden. Proper diagnosis will provide the patient with peace of mind and lead to effective treatment. This review focuses on the mechanisms and management of abdominal bloating associated with different small intestinal disorders identified by non-invasive hydrogen and methane breath tests.
Allergic conjunctivitis: Treatment updates and long-term monitoring
Allergic conjunctival diseases have a significant impact on the ocular surface, affecting the conjunctiva, cornea, and eyelids. Estimates indicate that approximately 35% of North Americans are affected by these diseases. Seasonal and perennial allergic conjunctivitis are the most common and mildest forms of ocular allergic disease, affecting 15–20% of the population. More severe conditions of ocular allergenic diseases include atopic keratoconjunctivitis (AKC), vernal keratoconjunctivitis (VKC), and giant papillary conjunctivitis (GPC). This article will review allergic conjunctivitis classifications, ocular sequelae, and a simplified treatment algorithm.
IgG plays multiple roles in the immune system. Best known as an effector molecule in host defence, infusions of polyclonal IgG have been employed as the mainstay of treatment for patients with immunodeficiency diseases affecting the humoral immune system. IgG preparations are fractionated from pools of several hundred to several thousand donors or more and therefore contain a broad spectrum of antibodies, capable of providing protection against many bacterial and viral diseases. Preparations of human IgG are available for intravenous (IVIG) or subcutaneous (SCIG) administration, allowing individuals with both primary and secondary immune defects to have significantly fewer infections, decreased hospitalizations and overall improved quality of life (QOL). Moreover, IVIG has been employed as a regulator of a large number of autoimmune and inflammatory conditions since the 1980s.
Vaccination is one of the most impactful and cost-effective interventions for improving global health. Routine immunization has reduced mortality and morbidity resulting from numerous types of infectious diseases. The widespread use of any reagent is always associated with the risk of adverse reactions, including expected and common side effects, as well as those that are unexpected or idiosyncratic. Mild, local injection site reactions such as redness, tenderness, swelling, or constitutional symptoms such as fever and malaise, are common after vaccination and are not contraindications to further vaccination; they are generally manifestations of the physiologic response to vaccination. Uncommon reactions can vary; they may manifest as delayed hypersensitivity to vaccine components causing injection site nodules or severe, rare anaphylactic reactions. Anaphylaxis occurs at approximately one per million doses administered. The extremely rare Arthus reaction, a type of local Type 3 hypersensitivity reaction, resulting in local immune complex deposition due to the presence of pre-existing IgG antibodies, is typically limited in duration and is not a contraindication to further tetanus vaccination. Allergists are often seen as stewards of information regarding many of these reactions, although most of these reactions are not allergic in nature. It can be difficult to distinguish between a true allergic reaction to a vaccine and other clinical manifestations that may occur during or acutely after vaccination, such as anxiety, vasovagal responses, and pronounced local reactions. Patients who have had adverse reactions to vaccines may be unnecessarily advised to avoid subsequent immunization, which can put them at risk of morbidity or mortality. The importance of making this clinical distinction has become particularly significant during the ongoing COVID-19 pandemic. The allergist plays an important role in investigating adverse reactions to vaccines and ensuring that patients who are eligible can be safely vaccinated following appropriate investigation. For those patients with true immediate-onset allergic reactions, allergists are able to provide safe revaccination following established protocols.
Aeroallergen Avoidance: Updated Evidence and How to Advise Patients
Allergic rhinitis (AR) is highly prevalent in Canada, affecting approximately 20–25% of the population. Asthma is estimated to affect approximately three million Canadians, and between 12% and 25% of Canadian children. Approximately two-thirds of individuals with asthma are allergic to aeroallergens, and these allergens act as triggers for asthma exacerbations. Overall, approximately 7.7 million individuals were affected by aeroallergens in Canada in 2016. High concentrations of ambient aeroallergens, including tree pollen and fungal spores have been associated with increased risk of premature birth, myocardial infarction (MI) and asthma-related Emergency Department visits and hospitalizations in cities across Canada. This demonstrates that nation-wide aeroallergen counts are associated with severe signs and symptoms. Children exposed to various indoor allergens are placed at an increased risk of developing asthma in later life, with sensitization in these individuals being a strong predictor of disease morbidity. Common indoor exposures for infants include house dust mite, pet, cockroach, mould, and rodent allergens. Sensitization to at least one indoor allergen has been demonstrated to be present in nine of every ten children hospitalized with asthma. It has been noted that more than 90% of children worldwide breathe polluted air. While the impact of climate change on aeroallergen exposure is not fully understood, there is increasing evidence that it may have an impact on outdoor aeroallergens and, by extension, asthma control in children. Global warming has been projected to influence the duration and intensity of pollen seasons, and may lead to increased pollen production, prolonged pollen seasons, and increased pollen protein allergenicity. The changing weather patterns including rainfall and wind may cause pollen species to reach environments in which they had not previously been present, contributing to a shift in geographic pollen distributions.