Treatment of Refractory Allergic Asthma and Rhinitis in SIgAD
For a patient with Selective IgA Deficiency (SIgAD) and allergic asthma and rhinitis refractory to standard inhaled bronchodilators and corticosteroids, add a leukotriene receptor antagonist (such as montelukast) before escalating to systemic corticosteroids, and strongly consider allergen immunotherapy given the demonstrable IgE-mediated allergic component. 1, 2
The allergic manifestations in SIgAD patients are IgE-mediated (not caused by the IgA deficiency itself), and aggressive treatment is critical because allergic inflammation predisposes these patients to respiratory tract infections, particularly sinusitis and otitis media. 2 For refractory asthmatic symptoms despite standard inhaled therapy, the ACCP guidelines recommend adding a leukotriene receptor antagonist before escalating to systemic corticosteroids, as LTRAs have demonstrated efficacy in suppressing cough and asthma symptoms that were previously resistant to bronchodilators and inhaled steroids. 1 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
If symptoms remain severe and refractory after adding an LTRA, administer a short course (1-2 weeks) of systemic oral corticosteroids (prednisone 20-60 mg/day) followed by resumption of inhaled corticosteroids. 1 Allergen immunotherapy (subcutaneous or sublingual) should be strongly considered for these patients, as they have demonstrable specific IgE antibodies to clinically relevant allergens, and immunotherapy may prevent development of new allergen sensitizations and reduce future asthma risk. 1, 2 The ARIA guidelines suggest both subcutaneous and sublingual specific immunotherapy for treatment of asthma in patients with allergic rhinitis and asthma, with the caveat that resource limitations and patient preference regarding adverse effects should be considered. 1 For patients with severe persistent allergic asthma with a clear IgE-dependent allergic component who remain uncontrolled despite optimal pharmacologic treatment, omalizumab (anti-IgE monoclonal antibody) may be considered, though this represents a more advanced therapeutic option. 1, 3