Management of Refractory Allergic Asthma and Rhinitis in SIgAD Patients
For SIgAD patients with allergic asthma and rhinitis refractory to standard inhaled bronchodilators and corticosteroids, aggressive treatment with all standard allergy modalities is essential, including intranasal corticosteroids, antihistamines, leukotriene modifiers, and consideration of allergen immunotherapy for patients with demonstrable specific IgE antibodies to clinically relevant allergens. 1 The key principle is that allergic inflammation in these patients predisposes them to respiratory tract infections (especially sinusitis and otitis media), making vigorous allergy treatment critical even though the allergic manifestations are IgE-mediated and not directly related to the IgA deficiency itself. 1
The treatment algorithm should proceed as follows: First, optimize intranasal corticosteroids as they remain the most effective single agent for allergic rhinitis and provide modest benefits for asthma symptoms. 2 Second, add continuous (not intermittent) second-generation antihistamines such as levocetirizine or desloratadine, which have been shown to improve both upper and lower respiratory tract symptoms, reduce beta-agonist requirements, and improve quality of life in patients with concomitant rhinitis and asthma. 2, 3 Third, incorporate a leukotriene receptor antagonist (montelukast 10 mg once daily in the evening for adults) as combination therapy with antihistamines and leukotriene modifiers has demonstrated efficacy comparable to corticosteroid use in patients with allergic asthma and seasonal allergic rhinitis. 2, 4 The combination of intranasal corticosteroids with leukotriene modifiers is more effective for controlling both nasal and bronchial symptoms than intranasal corticosteroids combined with antihistamines. 2 Finally, for patients with demonstrable specific IgE antibodies to clinically relevant allergens identified through skin testing (preferred over serum IgE testing), allergen immunotherapy should be strongly considered as it may prevent development of new allergen sensitizations and reduce future asthma risk. 1 Environmental control measures based on allergy testing results must be implemented concurrently. 1