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1.  CSACI position statement: epinephrine auto-injectors and children < 15 kg 
Epinephrine (adrenaline) is the treatment of choice for anaphylaxis. While other medications, including H1-antihistamines, H2-antihistamines, corticosteroids, and inhaled beta-2 agonists are often used to treat anaphylaxis in the emergency setting, none of these medications has been shown to reverse anaphylaxis. Fatal anaphylaxis is related to the delayed use of epinephrine. In community settings, epinephrine is available as an auto-injector in two doses, 0.15 mg and 0.3 mg. The recommended dose for children is 0.01 mg per kilogram. For infants at risk of anaphylaxis in the community, there are few options with regard to providing an optimal epinephrine dose for first-aid treatment. The Canadian Society of Allergy and Immunology (CSACI) therefore recommends, for the child weighing less than 15 kg, given the lack of a suitable alternative, prescribing the 0.15 mg epinephrine autoinjector. Adverse effects of an epinephrine dose of 0.15 mg given intramuscularly in infants or children weighing less than 15 kg are expected to be mild and transient at the plasma epinephrine concentrations achieved; therefore, these effects need to be measured against the consequences of not receiving epinephrine at all, which can include fatality.
doi:10.1186/s13223-015-0086-9
PMCID: PMC4485331  PMID: 26131015
Epinephrine; Anaphylaxis; Infant; CSACI position statement; Allergy
2.  CSACI position statement: systemic effect of inhaled corticosteroids on adrenal suppression in the management of pediatric asthma 
Asthma is a chronic inflammatory disease of the airways that affects a growing number of children and adolescents. Inhaled corticosteroids (ICS) are the mainstay of treatment in persistent asthma, with a stepwise approach to increasing doses of ICS depending on asthma severity and control. ICS have known local and systemic side effects, of which adrenal suppression is still under-recognized. The latter is associated with chronic exposure and higher doses, although it has rarely been reported in children receiving low doses for a short period of time. The Canadian Society of Allergy and Clinical Immunology (CSACI) therefore recommends that physicians screen for adrenal suppression in children receiving high doses for more than 6 months and to consider screening those on medium dose if the risk is deemed higher by factors that increase an individual’s systemic corticosteroid exposure. Morning serum cortisol level can be used as a screening tool and abnormal results or normal results with a high index of suspicion should be confirmed with low-dose ACTH stimulation tests.
doi:10.1186/s13223-015-0075-z
PMCID: PMC4369840  PMID: 25802532
Asthma; Inhaled corticosteroids; Fluticasone; Adrenal suppression
3.  A retrospective study of the clinical benefit from acetylsalicylic acid desensitization in patients with nasal polyposis and asthma 
Background
Aspirin-exacerbated respiratory disease (AERD), also known as Samter’s triad, is a clinical syndrome which consists of aspirin (ASA) intolerance, chronic rhinosinusitis with nasal polyposis, and intrinsic bronchial asthma (Press Med 119:48-51, 1922). ASA challenge is the gold standard for diagnosing AERD (Curr Allergy Asthma 9:155-163, 2009). The practice of ASA challenge and desensitization in Canada is infrequently utilized, which may explain its omission as a viable therapeutic option in the latest Canadian clinical practice guidelines for acute and chronic rhinosinusitis (AACI 7:1-38, 2011).
Methods
This retrospective study assessed 111 patients who underwent ASA desensitization in the Allergy and Immunology clinic at St. Joseph’s Healthcare (SJHC) in London, Ontario. The mean age was 50.7 years, and 52.5% (n = 58) were male. Sixty-one percent (n = 68) claimed prior, significant reactions to ASA, and all patients had features of AERD.
Results
Seventy-three percent (n = 81) claimed symptom improvement after achieving maintenance dosing on the desensitization protocol. Of this population, 21.6% (n = 24) improved in all 3 areas of interest (sense of taste or smell, upper respiratory symptoms and lower respiratory symptoms). Twenty-six percent (n = 29) had adverse effects, mostly in the way of gastrointestinal upset, but no severe adverse events were seen.
Conclusions
ASA desensitization helps improve symptoms in patients with AERD. Further, it allows patients to tolerate additional ASA and other non-steroidal anti-inflammatories (NSAIDs) when needed for supplemental analgesia or for cardio-protection. This is of particular benefit in those who require these medications for improved quality of life, and for reduced morbidity and mortality, such as those with cardiovascular disease or chronic pain. There should be further studies conducted in Canada as well as consideration for ASA desensitization to be included in the next clinical practice guidelines.
doi:10.1186/s13223-014-0064-7
PMCID: PMC4267150  PMID: 25516728
Aspirin desensitization; Nasal polyposis; Rhinosinusitis; Asthma; Aspirin-exacerbated respiratory disease
6.  Efficacy and safety of ragweed sublingual immunotherapy in Canadian patients with allergic rhinoconjunctivitis 
Background
Currently accepted therapies for ragweed allergy in North America consist of pharmacotherapy and subcutaneous allergen immunotherapy injections to treat symptoms. Allergen immunotherapy not only reduces symptoms and the need for pharmacotherapy but has also been shown to have disease-modifying potential. Recently, ragweed immunotherapy administered via sublingual allergen tablet has been approved in North America for treatment of allergic rhinitis with and without conjunctivitis.
Methods
This was an analysis of pooled data for a prespecified subgroup of Canadian subjects from two multicentre, randomized, double-blind placebo-controlled trials of ragweed sublingual tablet (SLIT-T; 6 and 12 Amb a 1-U of Ambrosia artemisiifolia) in patients aged ≥18y, with ragweed-induced allergic rhinoconjunctivitis (AR/C) with or without asthma. Randomized subjects used once-daily ragweed SLIT-T or placebo for at least 12 weeks before the ragweed season and for up to 52 weeks post-randomization. The primary efficacy endpoint was the total combined score (TCS) based on the sum of AR/C daily symptom score (DSS) and daily medication score (DMS) averaged over the peak season. Treatment effects on TCS, DSS, and DMS in the entire season were also assessed. Adverse events (AEs) were monitored to assess safety.
Results
337 Canadian subjects were randomized in the two trials. During the peak season, ragweed SLIT-T 6 and 12 Amb a 1-U significantly reduced TCS by 26% (difference, -2.46 score point; p = .0009) and 40% (difference, -3.75 score point; p < .0001), respectively. In the overall population (N = 961), TCS reductions with 6 and 12 Amb a 1-U were 20% and 23%, respectively (both p < .001). Clinically meaningful reductions in entire-season TCS in Canadians were similar to those during peak ragweed season. Dose-dependent reduction of DSS and DMS was also observed for ragweed SLIT-T 6 and 12 Amb a 1-U during the peak season and the entire season. Ragweed SLIT-T was well tolerated in Canadian subjects and the overall population. Adverse events were generally mild to moderate and transient, occurring early in treatment; no systemic allergic reaction/anaphylaxis was noted.
Conclusion
Ragweed SLIT-T is an effective form of immunotherapy that provides symptomatic efficacy of AR/C with a favorable risk profile in Canadian and overall populations.
Trial registration
Clinicaltrials.gov identifiers NCT00783198 and NCT00770315.
doi:10.1186/1710-1492-10-55
PMCID: PMC4363352  PMID: 25788949
Allergic rhinitis; Conjunctivitis; Ragweed pollen; Allergen immunotherapy; Sublingual immunotherapy Tablet; SLIT
7.  The efficacy and safety of the Timothy grass allergy sublingual immunotherapy tablet in Canadian adults and children 
Background
The effect of sublingual Timothy grass immunotherapy tablet 2800 BAU (grass SLIT-T) has been evaluated in three North American trials in adults and children who have allergic rhinitis with or without conjunctivitis (AR/C). This paper examines the effects of grass SLIT-T in Canadians.
Methods
Data for grass-allergic Canadians in three randomized, placebo-controlled, double-blind trials were analyzed post hoc: 1) adults ≥18 y, grass-pollen season [GPS] 2009; 2) children 5– <18 y, 2009; and 3) adults 18–65 y and children 5– <18 y, GPS 2012. Data from the GPS 2009 trials were pooled to provide a more precise estimate of treatment effects than the individual studies would provide. In every trial, participants received once-daily grass SLIT-T or placebo approximately 12 weeks before and continuing throughout the GPS. Participants used daily electronic diaries to record AR/C symptoms and medication use for treatment of symptoms. The therapeutic effect of grass SLIT-T was measured as a total combined score (TCS = daily symptom score + daily medication score) averaged over the entire GPS. Safety was assessed by monitoring adverse events (AEs).
Results
In the three trials, 386 Canadian participants were randomized; the overall population had 2284 participants. Canadian participants treated with grass SLIT-T in the pooled adult-pediatric 2009 trials showed a 38% mean TCS reduction relative to placebo (-2.06 difference [95% CI: -3.72, -0.39]; 3.32 vs. 5.37). Participants treated with grass SLIT-T in the adult-pediatric 2012 trial showed a 37% median TCS reduction relative to placebo (-1.53 difference [95% CI: -2.1, -0.3]; 2.58 vs. 4.11). Similar efficacy findings were observed over the peak GPS. Approximately 90% of treatment-related AEs were mild or moderate in severity. Two Canadian participants had moderate systemic allergic reactions (skin, respiratory, abdominal symptoms) to grass SLIT-T; symptoms resolved within 1 hour without medical intervention or treatment. No serious or life-threatening treatment-related AEs occurred.
Conclusion
The 2800 BAU Timothy grass SLIT-T significantly improved AR/C induced by Timothy grass pollen in adults and children ≥5 y in Canadians, which was consistent with the robust efficacy observed in the overall trial population. The treatment was generally well tolerated.
Trial registration
Clinicaltrials.gov identifiers NCT00562159, NCT00550550, NCT01385371.
doi:10.1186/1710-1492-10-53
PMCID: PMC4326370  PMID: 25685162
Allergic rhinitis; Conjunctivitis; Timothy grass pollen; Sublingual immunotherapy tablet
11.  A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy 
Systemic corticosteroids play an integral role in the management of many inflammatory and immunologic conditions, but these agents are also associated with serious risks. Osteoporosis, adrenal suppression, hyperglycemia, dyslipidemia, cardiovascular disease, Cushing’s syndrome, psychiatric disturbances and immunosuppression are among the more serious side effects noted with systemic corticosteroid therapy, particularly when used at high doses for prolonged periods. This comprehensive article reviews these adverse events and provides practical recommendations for their prevention and management based on both current literature and the clinical experience of the authors.
doi:10.1186/1710-1492-9-30
PMCID: PMC3765115  PMID: 23947590
Adverse events; Adrenal suppression; Corticosteroids; Cushing’s syndrome; Hyperglycemia; Glaucoma; Glucocorticoids; Glucocorticoid-induced osteoporosis; Side effects; Systemic
15.  Asthma 
Asthma is the most common respiratory disorder in Canada. Despite significant improvement in the diagnosis and management of this disorder, the majority of Canadians with asthma remain poorly controlled. In most patients, however, control can be achieved through the use of avoidance measures and appropriate pharmacological interventions. Inhaled corticosteroids (ICSs) represent the standard of care for the majority of patients. Combination ICS/long-acting beta2-agonists (LABA) inhalers are preferred for most adults who fail to achieve control with ICS therapy. Allergen-specific immunotherapy represents a potentially disease-modifying therapy for many patients with asthma, but should only be prescribed by physicians with appropriate training in allergy. Regular monitoring of asthma control, adherence to therapy and inhaler technique are also essential components of asthma management. This article provides a review of current literature and guidelines for the appropriate diagnosis and management of asthma.
doi:10.1186/1710-1492-7-S1-S2
PMCID: PMC3245435  PMID: 22165976
16.  Allergic rhinitis 
Allergic rhinitis is a common disorder that is strongly linked to asthma and conjunctivitis. It is usually a long-standing condition that often goes undetected in the primary-care setting. The classic symptoms of the disorder are nasal congestion, nasal itch, rhinorrhea and sneezing. A thorough history, physical examination and allergen skin testing are important for establishing the diagnosis of allergic rhinitis. Second-generation oral antihistamines and intranasal corticosteroids are the mainstay of treatment. Allergen immunotherapy is an effective immune-modulating treatment that should be recommended if pharmacologic therapy for allergic rhinitis is not effective or is not tolerated. This article provides an overview of the pathophysiology, diagnosis, and appropriate management of this disorder.
doi:10.1186/1710-1492-7-S1-S3
PMCID: PMC3245436  PMID: 22166009
17.  Allergen-specific immunotherapy 
Allergen-specific immunotherapy is a potentially disease-modifying therapy that is effective for the treatment of allergic rhinitis/conjunctivitis, allergic asthma and stinging insect hypersensitivity. However, despite its proven efficacy in these conditions, it is frequently underutilized in Canada. The decision to proceed with allergen-specific immunotherapy should be made on a case-by-case basis, taking into account individual patient factors such as the degree to which symptoms can be reduced by avoidance measures and pharmacological therapy, the amount and type of medication required to control symptoms, the adverse effects of pharmacological treatment, and patient preferences. Since this form of therapy carries the risk of anaphylactic reactions, it should only be prescribed by physicians who are adequately trained in the treatment of allergy. Furthermore, injections must be given under medical supervision in clinics that are equipped to manage anaphylaxis. In this article, the authors review the indications and contraindications, patient selection criteria, and the administration, safety and efficacy of allergen-specific immunotherapy.
doi:10.1186/1710-1492-7-S1-S5
PMCID: PMC3245438  PMID: 22166078
18.  Anaphylaxis 
Anaphylaxis is an acute, potentially fatal systemic reaction with varied mechanisms and clinical presentations. Although prompt recognition and treatment of anaphylaxis are imperative, both patients and healthcare professionals often fail to recognize and diagnose early signs and symptoms of the condition. Clinical manifestations vary widely, however, the most common signs are cutaneous symptoms, including angioedema, urticaria, erythema and pruritus. Immediate intramuscular administration of epinephrine into the lateral thigh is first-line therapy, even if the diagnosis is uncertain. The mainstays of long-term management include specialist assessment, avoidance measures, and the provision of an epinephrine auto-injector and an individualized anaphylaxis action plan. This article provides an overview of the causes, clinical features, diagnosis and acute and long-term management of this serious allergic reaction.
doi:10.1186/1710-1492-7-S1-S6
PMCID: PMC3245439  PMID: 22166113
19.  Adrenal suppression: A practical guide to the screening and management of this under-recognized complication of inhaled corticosteroid therapy 
Inhaled corticosteroids (ICSs) are the most effective anti-inflammatory agents available for the treatment of asthma and represent the mainstay of therapy for most patients with the disease. Although these medications are considered safe at low-to-moderate doses, safety concerns with prolonged use of high ICS doses remain; among these concerns is the risk of adrenal suppression (AS). AS is a condition characterized by the inability to produce adequate amounts of the glucocorticoid, cortisol, which is critical during periods of physiological stress. It is a proven, yet under-recognized, complication of most forms of glucocorticoid therapy that can persist for up to 1 year after cessation of corticosteroid treatment. If left unnoticed, AS can lead to significant morbidity and even mortality. More than 60 recent cases of AS have been described in the literature and almost all cases have involved children being treated with ≥500 μg/day of fluticasone.
The risk for AS can be minimized through increased awareness and early recognition of at-risk patients, regular patient follow-up to ensure that the lowest effective ICS doses are being utilized to control asthma symptoms, and by choosing an ICS medication with minimal adrenal effects. Screening for AS should be considered in any child with symptoms of AS, children using high ICS doses, or those with a history of prolonged oral corticosteroid use. Cases of AS should be managed in consultation with a pediatric endocrinologist whenever possible. In patients with proven AS, stress steroid dosing during times of illness or surgery is needed to simulate the protective endogenous elevations in cortisol levels that occur with physiological stress.
This article provides an overview of current literature on AS as well as practical recommendations for the prevention, screening and management of this serious complication of ICS therapy.
doi:10.1186/1710-1492-7-13
PMCID: PMC3177893  PMID: 21867553

Results 1-20 (20)