Management of Allergic Asthma and Rhinitis in Patients with Selective IgA Deficiency

Understanding the Association Between SIgAD and Atopy

Selective IgA Deficiency (SIgAD) does not directly cause allergic asthma and rhinitis, but atopic disease occurs frequently in association with SIgAD and requires aggressive treatment because allergic inflammation predisposes these patients to respiratory tract infections, according to the Journal of Allergy and Clinical Immunology 1

The allergic manifestations are IgE-mediated (not related to the IgA deficiency itself), as these patients demonstrate positive allergy tests to inhalant allergens, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 2, 3

Because allergic inflammation predisposes SIgAD patients to respiratory tract infections (especially sinusitis and otitis media), allergy must be diagnosed with standard techniques and treated vigorously with all standard modalities, as recommended by the Journal of Allergy and Clinical Immunology 1
Use standard allergy pharmacotherapy aggressively: intranasal corticosteroids, antihistamines, and leukotriene modifiers as indicated, according to the Journal of Allergy and Clinical Immunology 1, 4
Consider allergen immunotherapy for patients with demonstrable specific IgE antibodies to clinically relevant allergens, as it may prevent development of new allergen sensitizations and reduce future asthma risk, as suggested by the Journal of Allergy and Clinical Immunology 5
Implement environmental control measures for identified allergens based on allergy testing results, as recommended by the Journal of Allergy and Clinical Immunology 1

Perform allergy skin testing or allergen-specific IgE testing to identify specific triggers - skin tests are preferred over serum IgE testing, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 6

The American Academy of Allergy, Asthma, and Immunology recommends optimizing intranasal corticosteroids as the most effective single agent for allergic rhinitis, providing modest benefits for asthma symptoms 7, 8
The European Academy of Allergy and Clinical Immunology suggests adding continuous second-generation antihistamines, such as levocetirizine or desloratadine, to improve upper and lower respiratory tract symptoms, reduce beta-agonist requirements, and improve quality of life in patients with concomitant rhinitis and asthma 7
The American College of Allergy, Asthma, and Immunology recommends incorporating a leukotriene receptor antagonist, such as montelukast, as combination therapy with antihistamines and leukotriene modifiers, demonstrating efficacy comparable to corticosteroid use in patients with allergic asthma and seasonal allergic rhinitis 9
The combination of intranasal corticosteroids with leukotriene modifiers is more effective for controlling both nasal and bronchial symptoms than intranasal corticosteroids combined with antihistamines, according to the European Respiratory Society 9

For a patient with Selective IgA Deficiency (SIgAD) and allergic asthma and rhinitis refractory to standard inhaled bronchodilators and corticosteroids, adding a leukotriene receptor antagonist (such as montelukast) before escalating to systemic corticosteroids is recommended, according to the American College of Chest Physicians (ACCP) guidelines 10, 11
If symptoms remain severe and refractory after adding an LTRA, administering a short course (1-2 weeks) of systemic oral corticosteroids (prednisone 20-60 mg/day) followed by resumption of inhaled corticosteroids is suggested 10, 11

Allergen immunotherapy (subcutaneous or sublingual) should be strongly considered for patients with SIgAD and allergic asthma and rhinitis, 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, according to the ARIA guidelines 12, 13, 14
The ARIA guidelines suggest both subcutaneous and sublingual specific immunotherapy for treatment of asthma in patients with allergic rhinitis and asthma, with consideration of resource limitations and patient preference regarding adverse effects 12, 14

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 14