Background Allergic rhinitis (AR) affects approximately 10% of Indian adults, but its clinical and biological heterogeneity remains poorly defined. Objective We sought to characterize AR phenotypes in South Indian adults using clinical features, spirometry, fractional exhaled nitric oxide (Feno), skin prick tests, blood biomarkers, and cluster analysis. Methods This was a prospective observational study of 122 patients (≥18 years old) with AR with or without asthma attending a South Indian tertiary allergy clinic and 50 asymptomatic nonatopic control subjects. Participants underwent standardized symptom/exposure assessments, spirometry, Feno, blood counts, serum IgE, and skin prick tests to 10 aeroallergens. Principal component analysis, correlation networks, and unsupervised k-means clustering were applied to define phenotypes. Results Patients with AR were younger than control subjects, predominantly female, and frequently exposed to incense and mosquito repellents. Sensitization to house dust mite (>70%) and polysensitization were common. Compared with control subjects, patients with AR had elevated Feno (43 vs18 ppb; P < .01) but no significant differences in serum IgE or eosinophils. Spirometry revealed modestly lower FEV1/forced vital capacity in patients with AR (P < .01), though values remained within normal limits. Cluster analysis identified 3 subgroups: high Feno, low eosinophils, moderate-to-severe AR with less asthma; low Feno, high eosinophils, with more asthma; and impaired lung function with moderate eosinophilia and the highest asthma burden. Network analysis demonstrated strong cosensitization between house dust mite, Parthenium hysterophorus (weed pollen), Cynodon dactylon (Bermuda pollen), and cockroach. Conclusions This study showed 3 distinct AR clusters with high dust mite sensitization alongside cosensitization with cockroach, weed, and Bermuda pollens. Multicenter studies are warranted to further refine AR clusters, including tissue-level biomarker profiling and relevance to pharmacotherapy and immunomodulatory therapies.

Allergic rhinitis (AR), the most prevalent immunological disease, affects approximately 400 million individuals globally and can significantly impact quality of life (QoL). Despite nearly 25 years of guidelines, AR remains largely under- diagnosed, suboptimally treated and poorly controlled. In the light of new knowledge and treatment options, there is a necessity to update or revise fundamental AR definitions to facilitate communication across diverse specialties engaged in its treatment and to improve patient care. The European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) convened a meeting of experts and patient representatives to deliberate the optimal methodology for measuring AR treatment responses and establishing novel treatment goals. This paper presents a consensus on revised AR definitions, including control, severe allergic rhinoconjunctivitis (SARC), refractory severe allergic rhinoconjunctivitis (R-SARC), remission, resolution, improvement, exacerbation, treatable traits (TTs), treat to target, relapse, progression, disease modification, and prevention.

In April 2024, the European Summit “Raising the bar in respiratory care” was organized by the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) in the European Parliament and hosted by Members of the European Parliament Dorien Rookmaker and Mislav Kolakušić. The aim of the Summit was to respond to the need of European patients suffering from chronic respiratory diseases (CRDs) by joining forces with European and global organisations in the management of the epidemics of CRD, recognising the weaknesses of current care models and focussing on collaboration to improve care and prevention. Participants belonging to International and National Societies and Committees from the European Rhinologic Society (ERS), International Rhinologic Society (IRS), Belgian Respiratory Society (BeRS), Global Initiative for Asthma (GINA), Global Initiative for Chronic Obstructive Lung Disease (GOLD), Global Alliance against Chronic Respiratory Diseases (GARD), and from the European Federation of Allergy and Airways Diseases Patients Associations (EFA) and the EUFOREA's Patient Advisory Board (PAB) described their vision and action plan to work in partnership to raise the bar in respiratory care. This report summarizes the contributions of the representatives of different European stakeholders in the field of CRDs.

Asthma is a common, multifaceted respiratory disease with a major impact on quality of life. Despite increased insights into mechanisms underlying various asthma phenotypes and endotypes and the availability of targeted biologic treatment options, the disease remains uncontrolled in a substantial proportion of patients with risk of exacerbations, requiring systemic corticosteroids, and with progressive disease. Current international guidelines advocate for a personalized management approach to patients with uncontrolled severe asthma. The European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) asthma expert panel was convened to discuss strategies to optimize asthma care and to prevent systemic corticosteroid overuse and disease progression. In this meeting report, we summarize current concepts and recommendations and provide a rationale to implement personalized asthma management at earlier stages of the disease. The ultimate goal is to move away from the current one-size-fits-most concept, which focuses on a symptom-driven treatment strategy, and shift toward a phenotype- and endotype-targeted approach aimed at curbing the disease course by improving clinical outcomes and preserving health-related quality of life. Herein, we provide a consensus view on asthma care that advocates a holistic approach and highlight some unmet needs to be addressed in future clinical trials and population studies.

Severe chronic rhinosinusitis with nasal polyps (CRSwNP), a form of diffuse bilateral (usually type 2) CRS, is a debilitating disease with a significant impact on quality of life (QoL). With novel knowledge and treatment options becoming available, there is a growing need to update or revise key definitions to enable communication across different specialties dealing with CRS, and to agree on novel goals of care in CRSwNP. The European Forum for Research and Education in Allergy and Airway diseases (EUFOREA) and EPOS expert members discussed how to measure treatment responses and set new treatment goals for CRSwNP. In this paper a consensus on a list of definitions related to CRSwNP is provided: control, remission, cure, recurrence/exacerbation, treatable traits, remodeling, progression, and disease modification. By providing these definitions, the involved experts hope to improve communication between all stakeholders involved in CRSwNP treatment for use in routine care, basic and clinical research and international guidelines aimed to harmonize and optimize standard of care of patients with CRSwNP in the future.

The concept of pre-diabetes has led to provision of measures to reduce disease progression through identification of subjects at risk of diabetes. We previously considered the idea of pre-asthma in relation to allergic asthma and considered that, in addition to the need to improve population health via multiple measures, including reduction of exposure to allergens and pollutants and avoidance of obesity, there are several possible specific means to reduce asthma development in those most at risk (pre- asthma). The most obvious is allergen immunotherapy (AIT), which when given for allergic rhinitis (AR) has reasonable evidence to support asthma prevention in children (2) but also needs further study as primary prevention. In this second paper we explore the possibilities for similar actions in late onset eosinophilic asthma.

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) is a chronic inflammatory disease of the nose and paranasal sinus cavities that significantly affects well-being and social function, particularly in young adults and middle-aged populations. CRSwNP is a common health condition in the Western world, with an estimated prevalence of 3%. Despite worldwide evidence-based treatment guidelines such as the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 and the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) chronic rhinosinusitis (CRS) pocket guide, a significant number of patients remain undiagnosed and/or uncontrolled with repeated oral corticosteroids (OCS) treatments and/or (multiple) endoscopic sinus surgeries (ESS).

Background: Intranasal administration of lysine aspirin (LAS) is a safe and effective method for aspirin treatment after desensitisation (ATAD). Changes in quality of life (QoL) in patients on intranasal LAS have not been documented and we aimed to investigate QoL in N-ERD patients on or off nasal ATAD. Moreover, an estimate of the cost burden of intranasal LAS is given. Methods: A cross-sectional review was conducted for all challenge-confirmed N-ERD patients who were in follow-up in our rhinology clinic. They were asked to complete a SNOT-22 questionnaire, a visual analogue scale for sense of smell (sVAS). Information on prices of LAS and other consumables used for intranasal ATAD was obtained from our hospital pharmacy to obtain an estimate of the cost burden. Results: Thirty-four patients replied to the email (79.1% response rate). Of these, 21 (61.8%) were on intranasal LAS. A statistically significant lower score in the total SNOT-22 was found amongst patients on intranasal LAS (p = 0.02). The subanalysis of SNOT-22 domains showed that patients on LAS had statistically significant lower scores in the domains “rhinologic symptoms” (p = 0.05), “function” (p = 0.02), and “emotion” (p = 0.01). No significant differences were observed when looking at sVAS. The cost of 1-year treatment of LAS per person was ≈GBP 180.7 with a daily cost of ≈GBP 0.50. Conclusions: This study supports the efficacy of nasal ATAD in the management of N-ERD and suggests that long-term use can lead to QoL improvement with cost benefits.

The European Forum for Research and Education in Allergy and Airways diseases (EUFOREA) organized the first European Biologic Training Course (EBTC) in Brussels on 1st March 2024. The aim of this hybrid EBTC including both face-to-face and web-based participation was to address the educational needs of physicians dealing with asthma and Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) on the clinically relevant aspects of diagnosing and treatment with biologics. EUFOREA is an international non-for-profit organization forming an alliance of all stakeholders dedicated to reducing the prevalence and burden of chronic respiratory diseases through the implementation of optimal patient care via educational, research, and advocacy activities. The inclusive and multidisciplinary approach of EUFOREA was reflected in faculty coming from the paediatric, allergology, pulmonology, and Ear, Nose and Throat (ENT) speciality and from different continents, with more than 250 participants from over 30 countries in the first EBTC. The current report provides a comprehensive overview of key statements made by the faculty of the EBTC 2024, especially focusing on patient selection for a biologic drug, the communication with patients, the onset of biological treatment and the follow-up in routine clinical practice.

ObjectiveFexofenadine is a second-generation inverse agonist of H1-receptor of histamine which is highly selective with proven efficacy in relieving symptoms associated with allergic conditions. It has an additional benefit of not penetrating the blood-brain barrier and therefore do not induce sedation and not impair the cognitive function/psychomotor performance. This review aimed at providing evidence based on available controlled studies to reinforce the non-sedative property of fexofenadine for treating patients with allergic rhinitis and urticaria.MethodsWe performed an electronic literature search using keywords such as fexofenadine, drowsiness, somnolence, sedation, fatigue, cognitive, impairment, psychomotor, driving performances, sleep, rapid eye movement, alertness, clinical study, in vitro study, in vivo study, and pharmacodynamics in the Embase search engine. The review included randomized controlled trials, review articles, systematic reviews, and meta-analyses, together with post-marketing analysis conducted in healthy subjects and patients with allergy and were focused on comparing the antihistaminic potential or safety of fexofenadine with other antihistamines or placebo.ResultsPositron emission tomography (PET) and proportional impairment ratio (PIR) data along with other objective tests from various studies confirmed the non-sedative property of fexofenadine. Results of brain H1-receptor occupancy (H1RO) obtained from PET showed no H1RO by fexofenadine, the receptor which is known to cause sedation of H1 antihistamines. Most studies calculating PIR value as 0 showed fexofenadine to be a non-impairing oral antihistamine regardless of dose. Clinical trials in adults and children showed fexofenadine to be well tolerated without sedative effect or impairment of cognitive/psychomotor function even at higher than recommended doses.ConclusionPublished literature based on various parameters and clinical trials conducted for evaluating the effect of fexofenadine on sedation and central nervous system shows fexofenadine is both clinically effective and non-sedating.

This narrative review aims to provide an up-to-date definition of local allergic rhinitis (LAR), its classification, mechanisms, comorbidities, recommendations for diagnosis and treatment, and define needs in this area. Both 'PubMed' and 'Science Direct' literature was reviewed systematically, and a manual search for studies not previously encountered in the databases was also carried out. Published studies were identified in PubMed covering the period from 1947 to 2022. The following keyword search strategy was used: (local allergic rhinitis* OR entopy* OR local Immunoglobulin E * OR nasal specific Immunoglobulin E). LAR involves Type 2 nasal inflammation with local IgE and cannot be diagnosed by systemic methods, such as skin prick or blood IgE tests. A nasal allergen challenge is necessary for diagnosis. LAR can respond to usual AR treatments, including allergen specific immunotherapy (AIT). LAR is a novel entity that requires additional investigation in terms of prevalence, proper diagnosis, treatment, and prognosis. The target outcomes and possible benefits of this review are to achieve a consensus for the study and diagnosis of LAR and increase interest in this area.

The European Forum for Research and Education in Allergy and Airways diseases (EUFOREA) organized its bi‐annual forum EUFOREUM in Berlin in November 2023. The aim of EUFOREUM 2023 was to highlight pediatric action plans for prevention and optimizing care for type 2 inflammatory conditions starting in childhood, with a focus on early‐stage diagnosis, ensuring neither under‐ nor overdiagnosis, optimal care, and suggestions for improvement of care. EUFOREA is an international not‐for‐profit organization forming an alliance of all stakeholders dedicated to reducing the prevalence and burden of chronic respiratory diseases through the implementation of optimal patient care via educational, research, and advocacy activities. The inclusive and multidisciplinary approach of EUFOREA was reflected in the keynote lectures and faculty of the virtual EUFOREUM 2023 (www.euforea.eu/euforeum) coming from the pediatric, allergology, pulmonology, ENT, dermatology, primary health care fields and patients around the central theme of type 2 inflammation. As most type 2 inflammatory conditions may start in childhood or adolescence, and most children have type 2 inflammation when suffering from a respiratory or skin disease, the moment has come to raise the bar of ambitions of care, including prevention, remission and disease modification at an early stage. The current report provides a comprehensive overview of key statements by the faculty of the EUFOREUM 2023 and the ambitions of EUFOREA allowing all stakeholders in the respiratory field to be updated and ready to join forces in Europe and beyond. image

Asthma, which affects some 300 million people worldwide and caused 455,000 deaths in 2019, is a significant burden to suffers and to society. It is the most common chronic disease in children and represents one of the major causes for years lived with disability. Significant efforts are made by organizations such as WHO in improving the diagnosis, treatment and monitoring of asthma. However asthma prevention has been less studied. Currently there is a concept of pre- diabetes which allows a reduction in full blown diabetes if diet and exercise are undertaken. Similar predictive states are found in Alzheimer's and Parkinson's diseases. In this paper we explore the possibilities for asthma prevention, both at population level and also investigate the possibility of defining a state of pre-asthma, in which intensive treatment could reduce progression to asthma. Since asthma is a heterogeneous condition, this paper is concerned with allergic asthma. A subsequent one will deal with late onset eosinophilic asthma.

Nasal endoscopy is not only used for the diagnosis of chronic rhinosinusitis with nasal polyps (CRSwNP), but also for monitoring the response to therapy playing an important role in both daily practice and research. In contrast to patient-reported outcomes, endoscopic nasal polyp scoring by independent blinded readers is an objective measurement, not influenced by the placebo effect. It is safer and cheaper compared with computed tomography imaging and therefore, better suited for regular assessments of the extent of the disease. Since the early 90s, a variety of endoscopic staging methods have been proposed and used in clinical research, making it hard to compare results from different studies. This paper resulted from a task force with experts in the field of CRSwNP, originated by the Ear, Nose and Throat section of the European Academy of Allergy and Clinical Immunology and aims to provide a unified endoscopic NP scoring system that can serve as a reference standard for researchers, but also as a useful tool for practitioners involved in the management of CRSwNP.