This document discusses updates to guidelines from GOLD and GINA. Some key points discussed include:
1. The GOLD guidelines now recommend LAMA/LABA combination therapy as first-line treatment for COPD based on studies showing greater improvement in quality of life compared to individual bronchodilators or placebo.
2. Studies showed the benefits of a single-inhaler triple therapy compared to ICS/LABA therapy for advanced COPD, with reductions in exacerbations.
3. The GINA guidelines now recommend considering ICS for mild asthma to reduce exacerbations based on new evidence. Anti-IL5 monoclonal antibodies like mepolizumab and benralizumab were added as add-
The latest guidelines on the management of a COPD patient ( Stable COPD, patient with an exacerbation of COPD), latest modalities of treatment of a COPD patient
The latest guidelines on the management of a COPD patient ( Stable COPD, patient with an exacerbation of COPD), latest modalities of treatment of a COPD patient
Biphasic Cuirass Ventilation for Respiratory Failure and ARDSGary Mefford RRT
There is a great deal of information that points to the potential efficacy of BCV for acute and chronic respiratory failure as well as ARDS. Some is gathered here with a discussion of the open lung concept with BCV.
Chronic obstructive pulmonary disease (COPD), a complex progressive disease, is currently the third leading cause of death worldwide. One recommended treatment option is fixed-dose combination therapy of an inhaled corticosteroid (ICS)/long-acting β-agonist. Clinical trials suggest pressurized metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs) show similar efficacy and safety profiles in COPD. Real-world observational studies have shown that combination therapy has significantly greater odds of achieving asthma control when delivered via pMDIs. Our aim was to compare effectiveness, in terms of moderate/severe COPD exacerbations and long-acting muscarinic antagonist (LAMA) prescriptions, for COPD patients initiating fluticasone propionate (FP)/salmeterol xinafoate (SAL) via pMDI versus DPI at two doses of FP (500 and 1,000 μg/d) using a real-life, historical matched cohort study. COPD patients with $2 years continuous practice data, $2 prescriptions for FP/SAL via pMDI/DPI, and no prescription for ICS were selected from the Optimum Patient Care Research Database. Patients were matched 1:1. Rate of moderate/severe COPD exacerbations and odds of LAMA prescription were analyzed using conditional Poisson and logistic regression, respectively. Of 472 patients on 500 µg/d, we observed fewer moderate/severe exacerbations in patients using pMDI (99 [42%]) versus DPI (115 [49%]) (adjusted rate ratio: 0.71; 95% confidence interval: 0.54, 0.93), an important result since the pMDI is not licensed for COPD in the UK, USA, or China. At 1,000 µg/d, we observed lower LAMA prescription for pMDI (adjusted odds ratio: 0.71; 95% confidence interval: 0.55, 0.91), but no difference in exacerbation rates, potentially due to higher dose of ICS overcoming low lung delivery from the DPI.
Read the full paper: https://doi.org/10.2147/COPD.S141409
Biphasic Cuirass Ventilation for Respiratory Failure and ARDSGary Mefford RRT
There is a great deal of information that points to the potential efficacy of BCV for acute and chronic respiratory failure as well as ARDS. Some is gathered here with a discussion of the open lung concept with BCV.
Chronic obstructive pulmonary disease (COPD), a complex progressive disease, is currently the third leading cause of death worldwide. One recommended treatment option is fixed-dose combination therapy of an inhaled corticosteroid (ICS)/long-acting β-agonist. Clinical trials suggest pressurized metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs) show similar efficacy and safety profiles in COPD. Real-world observational studies have shown that combination therapy has significantly greater odds of achieving asthma control when delivered via pMDIs. Our aim was to compare effectiveness, in terms of moderate/severe COPD exacerbations and long-acting muscarinic antagonist (LAMA) prescriptions, for COPD patients initiating fluticasone propionate (FP)/salmeterol xinafoate (SAL) via pMDI versus DPI at two doses of FP (500 and 1,000 μg/d) using a real-life, historical matched cohort study. COPD patients with $2 years continuous practice data, $2 prescriptions for FP/SAL via pMDI/DPI, and no prescription for ICS were selected from the Optimum Patient Care Research Database. Patients were matched 1:1. Rate of moderate/severe COPD exacerbations and odds of LAMA prescription were analyzed using conditional Poisson and logistic regression, respectively. Of 472 patients on 500 µg/d, we observed fewer moderate/severe exacerbations in patients using pMDI (99 [42%]) versus DPI (115 [49%]) (adjusted rate ratio: 0.71; 95% confidence interval: 0.54, 0.93), an important result since the pMDI is not licensed for COPD in the UK, USA, or China. At 1,000 µg/d, we observed lower LAMA prescription for pMDI (adjusted odds ratio: 0.71; 95% confidence interval: 0.55, 0.91), but no difference in exacerbation rates, potentially due to higher dose of ICS overcoming low lung delivery from the DPI.
Read the full paper: https://doi.org/10.2147/COPD.S141409
History, Pharmacokinetics and Drug Deposition, Types, Techniques, Differences between different inhalers, Pitfalls and Errors of use, and Drugs used by inhalation
Early Enteral Nutrition in Critically Ill Patients is the best for helping early recovery, decreasing hospital stay and decreasing malnutrition in ICU
How? When? Formulas used? Access forms?
How is COPD and Nutrition Overlapped and Affecting Each Other
How to Solve the Problem as a Part of Pulmonary Rehabilitation
The Presentation is Discussing these items in the form of Problem Solving
What are the main sleeping disorders and what are the sleeping disorders related to respiratory system ? how to deal with it and how to diagnose and treat?
What are the pulmonary function tests used?
What are the indications?
What are the contraindications?
How to perform each and prepare patients?
How to interpret and reach a diagnosis?
How to clean and calibrate devices?
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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1. COPD vs BA
GOLD & GINA
Updates in Guidelines
By: Dr Riham Hazem Raafat
Ass. Prof. of Chest Diseases
Ainshams University
1
2. 70 years old male with a history of dyspnea for 10 years
Presenting with dyspnea with white productive
sputum, no fever or URI symptoms
Skin test +ve for house dust mites, pollens, and cockroaches
Non-smoker
Is it COPD or Asthma ?
3. Obstructive Lung Diseases
Integrity and elasticity of lung : DESTROYED
Poor elastic recoil: Air trapping (Hyperinflation)
Problem is with expiration.
Patient has to force the air out using abdominal & intercostal muscles: EXERTION
In Spirometry: FEV1/FVC is decreased.
2
7. 10 %
COPD
have more
reversibility
5% severe
Asthma
usually episodic in
nature, does not
progress, usually
begins in early
childhood, and shows
a good response to
bronchodilators and
corticosteroids
very slowly
progressive onset
and most patients
are diagnosed in
their 60s, there is
little variability in
symptoms, and
patients show a
poor response to
bronchodilators and
corticosteroids
Airflow Limitation
8.
9.
10. CXR Usually Normal unless?
Abnormal
Usually in > 20 pack years
(Triggers)
11. Features suggestive of BA or COPD must fulfill at least 3 or more
of the following to settle diagnosis of one of them:
• Age of onset
• Pattern of symptoms
• Lung Function
• Lung Function between attacks
• PH/FH
• Time course
• CXR
12.
13.
14. GOLD
• Launched in 1997 in collaboration with the NHLBI, NIH and WHO.
• Non-biased review of the current evidence for assessment, diagnosis
and treatment of patients with COPD that can aid the clinician.
Objectives
Recommend effective management and prevention strategies.
Increase awareness among medical community, health officials and the
general public
Decrease morbidity and mortality through implementation of effective
programs
6
15. Descriptive levels of Evidence
7
Evidence
category
Sources of Evidence
A • RCT with a rich body of data
B • RCT with a limited body of data
• Meta-analysis of RCTs
C • Non-randomized trials
• Observational studies
D • Panel Consensus Judgment
24. Co-suspension technique
• New formulation:
• Drug crystals are suspended in HFAbased propellant
by engineered low-density phospholipid particles.
Ferguson GT, Hickey AJ, Dwivedi S. Co-suspension delivery technology in pressurized metered-dose
inhalers for multi-drug dosing in the treatment of respiratory diseases. Respir Med. 2018 Jan
10
ADVANTAGES
1. Porous particle + drug crystal mixtures remain afloat instead of
sedimenting
2. Prevents flocculation/aggregation of drug particles
3. Decreased DDI/DCI
4. Size: 2-3 um: optimum
5. Low spray velocity HFApropellant: decreased dysphonia
25. 1. LABA+LAMA has greater improvement in quality of life
compared to placebo or its individual bronchodilator
components
Martinez FJ et al., Efficacy and Safety of Glycopyrrolate/Formoterol Metered Dose Inhaler Formulated
Using Co-Suspension Delivery Technology in Patients With COPD. Chest. 2017 Feb 11
26. LABA+LAMA combination
Martinez FJ et al., Efficacy and Safety of Glycopyrrolate/Formoterol Metered Dose Inhaler Formulated
Using Co-Suspension Delivery Technology in Patients With COPD. Chest. 2017 Feb 12
• Efficacy and safety data from 9 DB-RCTs evaluated GP MDI at doses 0.6 to 144ug and
FF MDI at doses 2.4 to 19.2 ug supported selection on GFF (18/9.6 ug) MDI for Phase III
evaluation
• Time period: 24 weeks
• Patients:
Age group: 40-80 years
Moderate to severe COPD
Can continue OCS, ICS or PDE-4 inhibitors
PINNACLE-1
(2103 pts.)
PINNACLE-2
(1615 pts.)
GFF MDI 526 510
GP MDI 451 439
FF MDI 449 437
Placebo 219 223
Tiotropium* 451 N/A
*Open- label (EMA: Active comparator)
Adm. via DPI
27. Results: Lung Functions
Martinez FJ et al., Efficacy and Safety of Glycopyrrolate/Formoterol Metered Dose Inhaler Formulated
Using Co-Suspension Delivery Technology in Patients With COPD. Chest. 2017 Feb 13
GFF MDI 126 ml GP MDI 66 ml FF MDI 62 ml
PL MDI -24 ml
TIO 105 ml
GFF MDI 116 ml GP MDI 63 ml FF MDI 61 ml
PL MDI 13 ml
150
91
86
-7
122
137
80
8
82
1º 1º
28. Results: Treatment difference (1º)
14
Resp. Q’naire (on a scale of 0 to100, with lower scores: better functioning)
Other parameters measured:
1. Average use of Rescue Albuterol (Daily andNighttime)
2. No. of exacerbations
CONCLUSION: IMPROVED EFFICACY, SIMILAR SAFETY PROFILE
Martinez FJ et al., Efficacy and Safety of Glycopyrrolate/Formoterol Metered Dose Inhaler Formulated
Using Co-Suspension Delivery Technology in Patients With COPD. Chest. 2017 Feb
PINNACLE-1 PINNACLE-2
GFF MDI GP MDI FF MDI PL MDI TIO GFF MDI GP MDI FF MDI PL MDI
Change
(Baseline Vs. Wk 24)
- 3.3 -1.0 -2.7 -0.8 -2.6 -3.0 -2.2 -2.3 -1.2
Rx difference
(GFF MDI Vs. Others)
N/A -2.33** -0.64 -2-52* -0.73 N/A -0.78 -0.66 -1.72
29. 2. Double blind RCT reported benefits of single-inhaler triple therapy
compared with ICS/LABA therapy in patients with advanced COPD
Lipson DA et al., FULFIL Trial: Once-Daily Triple Therapy for Patients with Chronic
Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2017 Aug 15
FULFIL: Lung Function and Quality of Life Assessment in COPD with Closed TripleTherapy
30. Results
16
24 weeks (ITT) 54 weeks (EXT)
OD triple
therapy#
BD ICS/LABA## Vs. OD triple
therapy#
BD ICS/LABA## Vs.
n 911 899 210 220
Change from
baseline FEV1
142 ml -29 ml p<0.001 126 ml -53 ml p<0.001
Mean change
from baseline
SGRQ score
-6.6 -4.3 p<0.001 -4.6 -1.9 p = 0.065
(Maybe due to small
sample size)
Reduction in
exacerbation rate
N/A
Lipson DA et al., FULFIL Trial: Once-Daily Triple Therapy for Patients with Ch
35% reduction; 95%CI, 14–51; (p=0.002) versus dual
ICS/LABA therapy
ronic Obstructive Pulmonary Disease. Am J
Respir Crit Care Med. 2017Aug
# fluticasone furoate 100/umeclidinium 62.5/vilanterol 25 ug
## budesonide 400/formetrol 12 ug
31. September 2017: USFDAapproval
Grade D-COPD
Once a day oral inhalation
Enhances patient’s adherence to therapy
and reduces device errors that occur when
patients are using multiple inhalers.
C/I during exacerbation episode
Systemic S/E of steroids +
https://www.fiercepharma.com/pharma/glaxo-wins-fda-nod-for-closed-triple-therapy-
trelegy-ellipta-pegged-as-a-blockbuster
17
FDA approval for first “closed” triple therapy
33. Exacerbation phenotype
Wedzicha JA, Roflumilast: a review of its use in the treatment of
COPD. International Journal of Chronic Obstructive Pulmonary Disease. 2016 18
34. 4. Beneficial effects of roflumilast have been reported in greater
patients with a prior history of hospitalization for an acute
exacerbation
Martinez FJ, Calverley PM, Goehring UM, Brose M, Fabbri LM, Rabe KF.Effect of roflumilast on exacerbations in
patients with severe chronic obstructive pulmonary disease uncontrolled by combination therapy (REACT): a
multicentre randomised controlled trial. Lancet.2015
19
When Blood Eosinophils < 100 cells/ul
35. Post-hoc analysis
Rabe KF et al., Effect of roflumilast in patients with severe COPD and a history of hospitalisation. Eur Respir J. 2017 Jul
20
• Chronic Bronchitis patients
• Patients who had previously suffered at least one serious exacerbation
Decreases
Neutrophil chemotactic factor
NF-KB translocation
Increases
IL-10
HDAC 2 expression
Non-selective PDE-4 inhibitors
PDE-4B: anti-inflammatory effects
PDE-4D: vomiting
Rate of severe exacerbations per patient per
year by history of prior hospitalisation in the
previous year.
37. 5. Oral Macrolide for one year in patients prone to exacerbations
reduced the risk of exacerbations compared to usual care in
non current smokers.
Albert RK, Connett J, Bailey WC, et al. Azithromycin for Prevention of Exacerbations of COPD. The New
England journal of medicine. 2011;365(8):689-698. doi:10.1056/NEJMoa1104623.
22
38. Azithromycin 250 mg/day for one year
Albert RK, Connett J, Bailey WC, et al. Azithromycin for Prevention of Exacerbations of COPD. The New
England journal of medicine. 2011;365(8):689-698. doi:10.1056/NEJMoa1104623.
23
Endpoint Azithromycin Placebo
Median time to first exacerbation (days) 266 days 174 days
SGRQ -2.8 ± 12.1 -0.6 ± 11.4
Group Participants Exacerbations
Azithromycin 558 317 (57%)
Placebo 559 380 (68%)
41. GINA
GINA guidelines 2018 27
• Launched in 1993 in collaboration with the NHLBI, NIH and WHO.
Objectives
Increase awareness of asthma
Improve management of asthma
Improve availability and accessibility of effective asthma therapy
Difference from GOLD guidelines
Meta analysis: EvidenceA
45. 29
KEY CHANGES
ICS should be considered for
patients with mild asthma
(rather than SABAalone)
• Reduces R/O
serious exacerbations.
{Reddel et al., Lancet 2017}
SC Mepolizumab
(anti-IL5 mAB) add-on Rx
for patients with severe
eosinophilic asthma
46. Anti IL-5
Nair P,Wenzel Set al.; ZONDA Trial Investigators. Oral Glucocorticoid-Sparing Effect of Benralizumab inSevere
Asthma. N Engl J Med. 2017
31
*EosinophilicAsthma
*
47. Nair P,Wenzel Set al.; ZONDA Trial Investigators. Oral Glucocorticoid-Sparing Effect of
Benralizumab in Severe Asthma. N Engl J Med. 2017 33
Results
48.
49. Other key updates: GINA 2018
1. New Section added: Perimenstrual (catamenial) asthma
• Asthma worse perimenstrually in ~20% women
• More common in women with high BMI; often have dysmenorrhea and shorter cycles.
• Add-on treatment: OCP and/or LTRA may be helpful
2. New therapy added: HDM-SLIT (house dust mite – sublingual IT) Therapy
• When medication is discontinued, symptoms may recur. This is where allergen immunotherapy
(AIT) comes into play
• Repeated doses of a specific relevant allergen for the treatment of IgE-mediated allergicdisease
3. Evidence A: recommendation against stopping ICS during pregnancy
• Stopping ICS increases the risk of exacerbations in pregnancy
34