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ALLSA Conference 2022 Report Back Part 1

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Oncology Optometry Optometry

ALLSA Conference 2022 Report

The Allergy Society of South Africa’s annual conference took place in Durban from 15 to 17 September. With the theme, Allergies: Behind the Mask, it was the first in-person get-together of South Africa’s allergy community since the start of the Covid-19 pandemic more than two years ago.

This report is one of three by Medical Writer, Peter Wagenaar that reviews a few of the highlights.

ALLSA Conference 2022: Report Back Part 1

A breakfast symposium hosted by Glenmark saw a quartet of key opinion leaders discuss four diverse hot topics.

Atopic dermatitis – more than meets the eye

Thulja Trikamjee

Atopic dermatitis (AD) is a very common condition with a 1.5-5% prevalence worldwide and this is predicted to increase further. More than 50% of patients self-report their condition as moderate to severe. It affects all age groups. Diagnosis can be challenging and missed or delayed diagnosis is common. “There is indeed much more to atopic dermatitis than meets the eye. When dealing with a skin condition’s clinical presentation, you tend to see the surface but not what is going on inside. AD carries an emotional and mental burden too, and needs to be managed holistically, as skin is very important to an individual’s self-image. One has only to look at how much is spent on skincare products and cosmetics,” explained Dr Thulja Trikamjee, specialist Paediatrician and Allergologist from the University of Cape Town.

“So, the social impact is high and a leading cause of the global burden of disease. AD’s significant impact on quality of life is comparable to that of other serious chronic diseases like anxiety and depression. In the USA, it is estimated that 1.6 million patients on treatment do not have their condition under control.

“The pathogenesis is multifactorial. Epidermal barrier dysfunction, immunogenic abnormalities, host genetics and environmental factors all play a role and need to be considered when managing these patients,” Dr Trikamjee emphasised.

With regard to symptoms, itching – which is long-lasting, painful and disruptive – has the highest impact on quality of life. Sleep disturbances are another significant contributor to impaired quality of life, and also affect work productivity. Adults with AD have a high risk of depression and suicidality (almost twice that of the general population).

Is there still space for questionnaires in your practice?

Associate Professor Jonny Peter: Head of the Division of Allergy and Clinical Immunology at Groote Schuur Hospital and head of the e Allergy and Immunology Unit at the University of Cape Town Lung Institute.

Despite barriers to the use of questionnaires, most notably the time required, the answer to the question is nonetheless a resounding ‘yes’.

There are several questionnaires validated across various allergic diseases. Factors to consider include the following:

Most of these diseases are chronic and remitting

The particular symptoms and habituation to them

Transience of human recall and memory

Clinical trials of novel agents require treating to target

Funders increasingly require that questionnaires be used

Despite their importance, a number of factors discourage their use. Some questionnaires are extremely complex and require a lot of time to complete. They may be perceived as lacking accessibility, even by healthcare professionals themselves. Also, clinicians are creatures of habit and often resistant to changing their ways and the status quo.

However, small tweaks can have a big impact in this regard:

Simply have the test/questionnaire easily available

Simplicity is important

Train your team and the patients themselves to complete simple questionnaires on their own

Use an app for the more complex tests

Using an objective measure like these questionnaires allows you to reflect on clinical experiences, especially with partial responders and complex patients. “Remember that ‘even the faintest ink is better than the best memory’ and the best questionnaire is one that both clinician and patient will actually use.”

Does buffered saline make sense - and is saline nasal irrigation a ‘neglected solution’?

Prof Andre van Niekerk, Paediatrician and Paediatric Pulmonologist

All the evidence would suggest that saline nasal irrigation does make sense and that it is indeed a neglected solution. The 2015 guidelines encourage its use in both AR and acute and chronic sinusitis, especially before the use of intranasal steroids, while the EUFOREA algorithm recommends it in all patients with nasal allergies.

A 2012 study provides key evidence for its use as an adjunctive treatment. Saline nasal irrigation was associated with significantly improved nasal symptom scores, a 62% reduction in the use of other medications and a 32% improvement in both mucociliary clearance and quality of life. A Cochrane review from 2018 found significant patient-reported improvement in symptoms.

Regarding upper airway infection in children, a 2008 study found that nasal douching reduced nasal secretions during the acute phase and significantly improved nasal obstruction. After the acute phase, there was a significant reduction in the use of other treatments, including antibiotics. Symptoms resolved more quickly and there were fewer complications afterwards.

“We consider it an adjuvant and how it works is uncertain. It has been postulated that it removes mucous debris and inflammatory mediators, thus providing a physical cleansing of allergies.”

“Nasal saline is an effective solution supported by the guidelines and evidence,” Prof van Niekerk concluded.

Topical vs systemic treatment for the three As (asthma, AR and atopic dermatitis)

Dr. Ahmed Manjra, Paediatrician and Allergologist at the Paediatric Allergy and Asthma Centre at Westville Hospital

The prevalence of and burden of disease associated with these three conditions is extremely high. Many patients have both asthma and AR, and there is a link between AR and other chronic disorders, with associated problems that go beyond the nose, ears and eyes. The impact on quality of life is significant, and assessment thereof is an important factor when treating these illnesses.

What starts as AR is often the harbinger of other disease in future, and some patients even have all three conditions.

“We therefore need good treatments that reduce the need for systemic therapy as the more severe the AR, the worse the future asthma,” Dr Manjra stressed.

Common to the pathophysiology of all these type 2 inflammatory conditions is barrier dysfunction of the skin. Getting patients to use nasal sprays is often a challenge in clinical practice, and AR is often poorly controlled.

Therapeutic options include intranasal steroids, oral antihistamines and a combination of intranasal steroids and intranasal antihistamines. However, a recent study of systemic and inhaled glucocorticoid use over a period of time suggests that prolonged use of oral and inhaled steroids contributes to neuropsychiatric side effects. “The effect on the brain is profound and includes a decrease in white matter. The immune system is also impacted.

“We need to look closely at the guidelines and the doses we use. Not all intranasal steroids are the same, so choice is very important. With regard to topical treatments, these allow a greater concentration of the agent in question as well as a faster onset of action.”

A new class of drugs, the biologics, shows promise as they are disease-modifying treatments and don’t just control symptoms. But they are currently very expensive and few patients can afford them.

Always consider efficacy, safety, convenience and cost. Topical treatments remain the drugs of choice,” Dr Manjra concluded.

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