What is the most effective treatment approach for managing the allergic march?

Managing the Allergic March: Treatment Approaches

Allergen-specific immunotherapy (AIT) is the most effective treatment approach for managing the allergic march, as it can both control symptoms and potentially prevent disease progression from allergic rhinitis to asthma. 1, 2

Understanding the Allergic March

The allergic march refers to the natural progression of allergic diseases that typically follows this sequence:

• Begins with atopic dermatitis and food allergies in infancy
• Progresses to allergic asthma in childhood
• Culminates in allergic rhinitis in later childhood and adolescence

This progression is driven by multiple factors including:

• Genetic predisposition
• Environmental allergen exposure
• Skin barrier dysfunction
• Type 2 inflammation
• Oxidative stress 3, 4

Treatment Algorithm for Managing the Allergic March

Step 1: Early Intervention for Atopic Dermatitis and Food Allergy

• Maintain skin barrier function with moisturizers
• Control inflammation with topical corticosteroids as needed
• For food allergies:
  • Implement dietary avoidance of confirmed allergens
  • Consider early introduction of potential allergenic foods (particularly peanut) in high-risk infants 1

Step 2: Management of Allergic Rhinitis

• First-line treatment: Intranasal corticosteroids for moderate-to-severe persistent symptoms 5
• Second-line options:
  • Oral or intranasal antihistamines for mild intermittent symptoms
  • Combination therapy with intranasal corticosteroids and antihistamines for inadequate response
  • Leukotriene receptor antagonists as add-on therapy 1

Step 3: Prevention of Asthma Development

• Implement allergen-specific immunotherapy for patients with:
  • Moderate-to-severe allergic rhinitis not adequately controlled with pharmacotherapy
  • Demonstrable specific IgE antibodies to relevant allergens 1, 2
• Options include:
  • Subcutaneous immunotherapy (SCIT)
  • Sublingual immunotherapy (SLIT) - better tolerated in children 2

Step 4: Management of Established Asthma

• Daily anti-inflammatory treatment with inhaled corticosteroids (ICS) as cornerstone therapy
• For inadequate control:
  • Medium-dose ICS or
  • Low-dose ICS plus long-acting β-agonist (LABA)
• For allergic asthma in patients ≥12 years with elevated IgE:
  • Consider anti-IgE therapy (omalizumab) for moderate-to-severe persistent asthma 1

Evidence for Disease-Modifying Potential

The most compelling evidence supports allergen-specific immunotherapy as the only current treatment that can potentially modify the natural course of allergic disease:

1. Prevention of new sensitizations: AIT can reduce the development of new allergen sensitizations 1

2. Reduction of asthma risk: Studies show that children with allergic rhinitis treated with AIT have a reduced risk of developing asthma 1, 2

3. Long-term efficacy: Three-year immunotherapy with standardized allergen extracts has demonstrated long-term clinical effects and preventive effects on asthma development in children with seasonal rhinoconjunctivitis 1

4. Precision approach: Molecular diagnosis (PAMD@) can help create more precise immunotherapy regimens tailored to the patient's specific allergic profile [@10@]

Important Considerations and Caveats

• Early identification of high-risk patients is crucial for timely intervention
• Sublingual immunotherapy is generally well-tolerated in children [@8@]
• Patient and family education is essential for successful management [@8@]
• Environmental control measures should be implemented based on identified allergens [@7@]
• Treatment efficacy should be monitored by assessing impact on quality of life, sleep quality, and daily activities [@7@]

The evidence strongly supports that only allergen-specific immunotherapy has the potential to alter the natural history of the allergic march by preventing the development of new allergen sensitizations and reducing the risk for subsequent development of asthma [@1@, @8@, @11