Determinants of patient compliance with allergen immunotherapy

Evidence of adherence to allergen-specific immunotherapy

PURPOSE OF REVIEW

The main feature of allergen-specific immunotherapy is its capacity to modify the natural history of the disease, reducing the development of asthma and new sensitizations after 3-4 years of treatment. For this reason, adherence to the therapy is mandatory, as happens for all chronic medical treatment.

RECENT FINDINGS

Though subcutaneous immunotherapy is administered directly by physicians, the rate of adherence is surprisingly low, at less than 70%. The explanations for a poor subcutaneous immunotherapy adherence include inconvenience, lack of efficacy, costs and loss of working hours.Local nasal immunotherapy has a very low adherence rate (27%), due to the local nasal side effects.For sublingual immunotherapy, data are available from clinical trials and postmarketing surveys, which are favourable overall (rates of compliance >75%). Cost was the most common reason for discontinuation, followed by inconvenience, feeling of inefficacy and side effects.

SUMMARY

Studies addressing the adherence to allergen-specific immunotherapy in literature are lacking. In real life, costs and patient education are crucial issues in conditioning adherence to this treatment. Reduction of costs and more efforts in education of patients and also specialists may improve the adherence to immunotherapy.

Allergen immunotherapy and health care cost benefits for children with allergic rhinitis: a large-scale, retrospective, matched cohort study

BACKGROUND

Children with allergic rhinitis (AR) often experience significant impairment in quality of life and health, which increases health care utilization.

OBJECTIVE

To determine whether allergen immunotherapy reduces health care utilization and costs in children newly diagnosed as having AR using a retrospective matched cohort design.

METHODS

Among children (age <18 years) with a Florida Medicaid paid claim between 1997 and 2007, immunotherapy-treated patients were selected who had newly diagnosed AR, who had not received immunotherapy before their first (index) AR diagnosis, who had received at least 2 immunotherapy administrations after their index AR diagnosis, and who had at least 18 months of data after their first immunotherapy administration. A control group of patients with newly diagnosed AR who had not received immunotherapy either before or subsequent to their index AR diagnosis also were identified, and up to 5 were matched with each immunotherapy-treated patient by age at first AR diagnosis, sex, race/ethnicity, and diagnosis of asthma, conjunctivitis, or atopic dermatitis.

RESULTS

Immunotherapy-treated patients had significantly lower 18-month median per-patient total health care costs ($3,247 vs $4,872), outpatient costs exclusive of immunotherapy-related care ($1,107 vs $2,626), and pharmacy costs ($1,108 vs $1,316) compared with matched controls (P < .001 for all). The significant difference in total health care costs was evident 3 months after initiating immunotherapy and increased through study end.

CONCLUSIONS

This study demonstrates the potential for early and significant cost savings in children with AR treated with immunotherapy. Greater use of this treatment in children could significantly reduce AR-related morbidity and its economic burden.

Comparison of allergen immunotherapy practice patterns in the United States and Europe

OBJECTIVE

To discuss important differences and similarities in the allergen specific immunotherapy (SIT) treatment practices for aeroallergen sensitivity in the United States and Europe.

DATA SOURCES

Information on regulation and standardization in the United States and Europe was obtained from a Food and Drug Administration Allergenic Products Advisory Committee meeting, published literature, personal communications, and information obtained from the extract manufacturers.

STUDY SELECTION

Information from the published literature included articles known to the authors and acknowledged consultants, textbooks, and PubMed, with search terms dependent on the particular subtopic.

RESULTS

Key differences between Europe and the United States include allergen extract regulation, standardization, formulation, types of allergen extracts, routes of administration, and reimbursement. Most SIT is formulated in US allergists' offices, whereas virtually all SIT is formulated by extract manufacturers in Europe. Sublingual immunotherapy represents a significant percentage of SIT treatment in Europe (approximately 45%), but only a small percentage of US allergists (approximately 5.9%) prescribe sublingual immunotherapy. Similarities between European and US allergist specialists lie in their perception of SIT and approach to providing optimal SIT care, which is detailed in their practice guidelines.

CONCLUSION

Significant differences and similarities exist in SIT practice patterns of US and European allergy specialists. The differences lie primarily in the availability of allergen extracts and how these extracts are formulated. A key similarity is that both recognize the need for ongoing research focused on developing safer and more effective SIT.

Safety of a depigmented, polymerized vaccine for the treatment of allergic rhinoconjunctivitis and allergic asthma

BACKGROUND

Clinical efficacy of specific immunotherapy (SIT) with depigmented, polymerized allergen extracts is well documented in placebo-controlled trials, and safety data are encouraging although further data are required.

METHODS

We enrolled 768 patients (51% men; mean age, 31 years) in this prospective multicenter study on safety and clinical effects of Depigoid (Laboratorios LETI, S.L., Madrid, Spain). Immunotherapy consisted of four injections of increasing doses of Depigoid at weekly intervals followed by monthly maintenance injections. All adverse events were documented. Moreover, nose, eye, and lung symptoms were assessed at baseline after 3 and 6 months. Results were compared with the scores of the preceding season.

RESULTS

Rates for local and systemic reactions that might possibly be related to the study medication were 2.36 and 4.56/1000 injections, respectively. With 5923 injections given, 14 local reactions were reported (5 patients), and 27 systemic reactions were reported, including 20 of grade 1 (6 patients) and 7 of grade 2 (4 patients). The best safety profile was seen for patients vaccinated against house-dust mites. Reductions in nose, eye, and lung symptoms as well as in concomitant medication compared with either the preceding season (pollen-sensitized patients) or the baseline (house-dust mite-sensitized patients) were observed at the end of study.

CONCLUSION

In this large multicenter study on 768 patients with allergic rhinoconjunctivitis and allergic asthma under daily practice conditions SIT with Depigoid was well tolerated with low rates of local and systemic reactions. Furthermore, SIT resulted in considerable reductions in symptoms and concomitant medication.

Development of an allergen extract for sublingual immunotherapy--evaluation of Staloral

BACKGROUND

Specific immunotherapy (IT) is an effective treatment for rhinitis and asthma caused by aeroallergens sensitization. Sublingual IT (SLIT) was introduced to solve the problem of systemic reactions to subcutaneous IT (SCIT) and developed to represent an actual treatment option. It is now generally accepted that allergen doses much higher than those administered by SCIT must be used to achieve clinical efficacy on allergic symptoms.

OBJECTIVE

To evaluate the characteristics of Staloral, an allergen extract produced by Stallergenes (Antony, France) in terms of practical administration, efficacy, safety and mechanism of action.

METHODS

Data were obtained from 20 double-blind, placebo-controlled studies using Staloral in patients sensitized to pollens and house-dust mites, and also from open studies concerning practical administration and the mechanism of action.

RESULTS/CONCLUSION

Efficacy and safety of Staloral, as demonstrated by the revision of the studies, which used doses up to 1125 times those administered with SCIT, are very satisfactory and confer to this allergen extract optimal characteristics for treating patients with seasonal allergies due to pollens or with perennial symptoms induced by dust mites. The main mechanism of action is the interaction with dendritic cells of the oral mucosa and the subsequent tolerance induced in T cells.

A review of allergen-specific immunotherapy in human and veterinary medicine

This article reviews allergen-specific immunotherapy in human and veterinary medicine. Current hypotheses of possible mechanisms of actions are outlined. Indications, success rates, adverse effects and factors influencing outcome of therapy are discussed in humans, dogs, cats and horses.

Systemic tolerability of specific subcutaneous immunotherapy with index-of-reactivity-standardized allergen extracts administered using clustered regimens: a retrospective, observational, multicenter study

BACKGROUND

Subcutaneous immunotherapy is an etiological therapy for certain IgE-mediated diseases. It is usually administered in 2 phases: induction and maintenance. Administration in clustered schedules during the induction phase may be a valid alternative to reach the maintenance dose early if the treatment is well tolerated.

OBJECTIVES

To compare the tolerability of different clustered schedules in subcutaneous immunotherapy with standardized allergen extracts administered and to identify factors associated with increased risk of systemic reactions (SRs).

METHODS

Retrospective, observational, multicenter study in patients with allergic respiratory disease.

RESULTS

Data from 1,147 patients were collected. Thirty-nine patients (3.4%) experienced 42 SRs (0.6% of doses). According to the European Academy of Allergy and Clinical Immunology SR grading system, there were 7 grade 0 reactions (16.7%), 26 grade 1 reactions (61.9%), 8 grade 2 reactions (19.0%), and 1 grade 3 reaction (2.4%). There were no grade 4 SRs (anaphylactic shock). We observed a higher risk of SRs in patients who received an initial dose higher than 0.3 index of reactivity (IR); only 2 reactions occurred after administration of the initial dose of the regimen, both with 0.4 IR. The remainder appeared in subsequent injections, although never with a dose lower than 0.35 IR.

CONCLUSIONS

Clustered regimens with IR-standardized extracts are an alternative to classic immunotherapy thanks to their low incidence of SRs compared with other rapid regimens during the induction phase. The ideal clustered regimen should start at an initial dose no greater than 0.35 IR to minimize the incidence of SRs.

Perception and practice of sublingual immunotherapy among practicing allergists

BACKGROUND

Currently, little information is available regarding who is using sublingual immunotherapy (SLIT) in the United States, what product they may be using, how they are dosing that product, and what perceived effect it may be having on patients.

OBJECTIVE

To gather information regarding the perception and use of SLIT among practicing allergists in the United States.

METHODS

On behalf of the American College of Allergy, Asthma and Immunology (ACAAI) Immunotherapy and Diagnostics Committee, an electronic survey was sent to all practicing allergists of the ACAAI in March 2007.

RESULTS

The survey response rate was 25.7% (828/3,217) in which 92.5% of the respondents (766/828) practiced in the United States. For 61.7% (471/763) the most cited reason for not using SLIT was lack of approval by the Food and Drug Administration (FDA). If SLIT were an FDA-approved form of immunotherapy, 65.7% would use it to treat allergic rhinitis, 45.5% would use SLIT to treat patients younger than 5 years, and 40.9% would use it to treat moderate to severe asthma. A total of 5.9% (45/766) of US allergists reported using SLIT. Most perceived SLIT to be as effective (44.7%) or more effective (10.5%) than subcutaneous immunotherapy (SCIT). Most allergists who used SLIT (65.9%) had it reimbursed by patients paying out of pocket. The most commonly used extract (79.1%) was a commercially available extract used for SCIT. Some practitioners (53.5%) required their patients to administer doses of SLIT in their office, but 81.8% only required that this be done with the first dose. Practitioners gave epinephrine injectors to 41.5% of their patients receiving SLIT.

CONCLUSIONS

Although only 5.9% of US allergists reported using SLIT, most of the 828 surveyed (766 US allergists) viewed SLIT as safe and effective and would consider using SLIT if it were an FDA-approved therapy.

Patient perceptions regarding local reactions from allergen immunotherapy injections

BACKGROUND

Although most allergists agree that local reactions to immunotherapy are not predictive of future systemic reactions, the 2 main reasons for dose adjustments are the concern that local reactions cause discomfort that may lead to patient noncompliance and the concern that local reactions are predictive of future local reactions.

OBJECTIVES

To determine patient perceptions regarding local reactions from immunotherapy.

METHODS

A survey on allergen immunotherapy was provided to patients. Participants were asked about the presence of local reactions, the size of their local reactions, and how bothersome these local reactions were. Patients were also asked if they had considered stopping immunotherapy because of these local reactions.

RESULTS

All 249 patients undergoing immunotherapy completed the survey. Seventy-one percent of the patients reported that they had experienced a local reaction during allergen immunotherapy. Of those patients who reported local reactions, 84.7% reported local reactions smaller than the palm of the hand and 81.9% deemed local reactions not to be bothersome at all or only slightly bothersome. Of those who experienced local reactions, 96.0% stated they would not stop immunotherapy because of these local reactions.

CONCLUSIONS

Although most patients reported local reactions, these local reactions were usually small and not very bothersome. Most patients would not stop allergen immunotherapy because of local reactions.

Sublingual immunotherapy in youngsters: adherence in a randomized clinical trial

BACKGROUND

Adherence is essential for effective treatment. Although several trials on the efficacy of sublingual immunotherapy (SLIT) in youngsters have been published, few contain data on medication intake.

OBJECTIVE

We aimed to quantify adherence both to study protocol and medication intake as well as to identify factors that may influence adherence to SLIT in youngsters with rhinoconjunctivitis.

METHODS

Two hundred and four youngsters (6-18 years) with hayfever participated in a randomized controlled trial and used grass pollen extract or placebo for 2 years. The primary outcome of the trial was the mean daily total rhinoconjunctivitis symptom score in the second grass pollen season. Participants having completed the follow-up were considered adherent to the study protocol. Adherence to medication intake was assessed by weighing the study medication. Participants who completed the follow-up and used > or = 80% of the prescribed medication were considered adherent to medication intake. Patient-, disease- and treatment-related factors were analysed.

RESULTS

One hundred and fifty-four youngsters completed the study. The main reason for discontinuation was the inability to take medication according to schedule. Drop-outs were older, had more difficulty following the medication instructions and their overall evaluation of the treatment effect was lower. The number and reasons for drop-out did not differ between treatment groups. In total, 77% of the participants was adherent to medication intake. Self-reported adherence was 99%. Non-adherent participants experienced more severe symptoms before the trial. Symptom scores did not differ between adherent and non-adherent participants. In adherent as well as non-adherent participants, no difference was found between verum and placebo group with respect to symptom scores.

CONCLUSION

Adherence to both study protocol and medication intake was good. Drop-out was affected by age, evaluation of the treatment effect and medication instructions. Non-adherence to medication intake was influenced by the severity of the disease before the trial. The ineffectiveness of SLIT could not be explained by non-adherence.

Allergy immunotherapy among Medicaid-enrolled children with allergic rhinitis: patterns of care, resource use, and costs

BACKGROUND

Although research demonstrates that allergy immunotherapy (IT) improves allergic rhinitis (AR) outcomes, little is known about IT patterns of care and associated resource use and costs among US children with diagnoses of AR.

OBJECTIVE

We sought to examine characteristics associated with receiving IT, patterns of IT care, and health care use and costs incurred in the 6 months before versus after IT.

METHODS

We performed retrospective Florida Medicaid claims data (1997-2004) analysis of children (<18 years of age) given new diagnoses of AR.

RESULTS

Of 102,390 patients with new diagnoses of AR, 3048 (3.0%) received IT. Male patients, Hispanic patients, and those with concomitant asthma were significantly more likely to receive IT. Approximately 53% completed less than 1 year and 84% completed less than 3 years of IT. Patients who received IT used significantly less pharmacy (12.1 vs 8.9 claims, P < .0001), outpatient (30.7 vs 22.9 visits, P < .0001), and inpatient (1.2 vs 0.4 admissions, P = .02) resources in the 6 months after versus before IT. Pharmacy ($330 vs $60, P < .0001), outpatient ($735 vs $270, P < .0001), and inpatient ($2441 vs $1, P < .0001) costs (including costs for IT care) were significantly reduced after IT.

CONCLUSION

Despite suboptimal treatment persistence (only 16% of patients completed 3 years of IT), resource use and costs after treatment were significantly reduced from pre-IT levels.

Patient's compliance with allergen immunotherapy

BACKGROUND

Allergen immunotherapy (IT) is an effective treatment of respiratory allergy, but requires strict rules of performance. This makes compliance particularly relevant, but thus far only a few studies have investigated this issue.

METHODS

We reviewed all the available articles on compliance and adherence with IT in its different forms of administration, ie, subcutaneous (SCIT), sublingual (SLIT), and local nasal (LNIT).

RESULTS

Early studies, when only SCIT was available, reported a low compliance, ranging from 45% to 60%, but the demanding schedules used, with very frequent injections, accounted for this outcome, as shown by patients' recognition of inconvenience as the major cause of noncompliance. The most recent studies reported a good compliance, estimated in 75% to 90%, to both SCIT and SLIT, inconvenience remaining the major cause of noncompliance, followed by cost of the treatment. The only study addressing LNIT found a very poor compliance (27%), the major cause being the side effects, with repeated nasal reactions to the allergen extract.

CONCLUSIONS

Adequate education of patients and optimization of administration schedules, with fine balancing between dose effectiveness and cost, are the factors most likely to achieve further improvement of compliance with IT.

Sublingual-swallow immunotherapy with standardized 3-grass pollen extract: a double-blind, placebo-controlled study

BACKGROUND

Sublingual immunotherapy (SLIT) is accepted as a safe and effective route for the treatment of grass pollen allergy, but clarification of its clinical and biological efficacy requires more study.

OBJECTIVE

To evaluate the efficacy, safety, and compliance of SLIT with a standardized 3-grass pollen extract in patients with grass pollen seasonal allergic rhinoconjunctivitis, with or without mild asthma.

METHODS

This multicenter, randomized, double-blind study included 127 patients (aged 12-41 years; mean age, 24.9 years) with grass pollen seasonal allergic rhinoconjunctivitis, with or without mild asthma. They received either SLIT with a high-dose, standardized, 3-grass pollen extract or placebo for 10 months before and during the grass pollen season. The efficacy evaluation compared weekly clinical scores (defined as the sum of the symptom score and rescue medication score) to measure rhinoconjunctivitis and asthma for the first 8 weeks of the pollen season. We also evaluated safety and compliance and measured changes in anti-Dactylis specific IgG4 antibody levels.

RESULTS

There was a trend in favor of the study group in the mean adjusted clinical score. The groups were not comparable on inclusion (P = .02): the SLIT group included more subjects with asthma and had a higher mean IgG4 serum level. Additional exploration according to subgroups with and without asthma found that among the patients without asthma, the SLIT group had a significantly better clinical score (P = .045). Anti-Dactylis specific IgG4 levels increased significantly in the SLIT group.

CONCLUSION

SLIT with a standardized, high-dose, 3-grass pollen extract is safe and significantly improves the clinical score in patients with hay fever and without asthma during the pollen season.

Dose adjustment practices among allergists for local reactions to immunotherapy

BACKGROUND

Dose adjustments for local reactions to immunotherapy have been previously proposed. Several studies have shown that systemic reactions from immunotherapy injections are not predicted by previous local reactions. However, no previous reports have evaluated the prevalence and rationale of dose adjustment protocols within allergists' practices.

OBJECTIVE

To examine allergists' response after patients' local reaction to immunotherapy.

METHODS

On behalf of the American College of Allergy, Asthma and Immunology (ACAAI) Immunotherapy and Diagnostics Committee, an electronic survey was sent to all practicing allergists of the ACAAI. Participants were asked whether they make dose adjustments for local reactions to immunotherapy and the rationale behind this decision. Strategies to prevent and minimize local reactions were also queried.

RESULTS

A total of 2,797 electronic letters were successfully sent, and 761 allergists (27.2%) responded to the survey, with 94.7% of the participants having completed a fellowship in allergy and immunology. Common strategies used by allergists to prevent and minimize local reactions included a dose adjustment based on the local reaction from the previous injection (79.1%) and pretreatment with an antihistamine (70.1%). Most allergists (91.9%) dose adjusted for local reactions. Most of these dose adjustments were based on protocols that included criteria for both repeating and decreasing the dose of immunotherapy based on the size of the local reaction. Rationales used by allergists for local reaction dose adjustment protocols included beliefs that local reactions cause discomfort that leads to patient noncompliance (88.9%), local reactions are predictive of future local reactions (45.7%), and local reactions are predictive of future systemic reactions (29.2%).

CONCLUSIONS

Our survey results indicate that most allergists dose adjust for local reactions to allergen immunotherapy. Although most allergists agree that local reactions are not predictive of future systemic reactions, the 2 main reasons for dose adjustments include the concern that local reactions cause discomfort that may lead to patient noncompliance with immunotherapy and the concern that local reactions are predictive of future local reactions.

Duration of allergen immunotherapy in respiratory allergy: when is enough, enough?

OBJECTIVES

To investigate the duration of effective inhalant subcutaneous immunotherapy (SCIT) reported in the published literature and to determine if any specific biomarkers or clinical predictors exist that may identify patients who will remain in long-term remission after discontinuing treatment.

DATA SOURCES

Articles were selected from a search of the PubMed database from 1976 to 2006 using the search terms immunotherapy and allergen immunotherapy in combination with venom, allergic rhinitis, asthma, mechanism, efficacy, and duration, as well as articles known to the authors and referenced in review articles.

STUDY SELECTION

Articles were selected if evaluation of efficacy of the primary allergic disease treated after discontinuation of SCIT was stated as one of the objectives of the study.

RESULTS

The rate of relapse after discontinuing SCIT ranges from 0% to 55% of patients in the studies reviewed in this article. The length of the specific allergen immunotherapy and allergen type (ie, perennial vs seasonal) may be variables that affect the duration of clinical remission after cessation of SCIT. One study found the duration of SCIT efficacy after discontinuation depended on duration of treatment and correlated with decrease in skin test reactivity.

CONCLUSION

Until specific tests or clinical markers are identified that will clearly distinguish between patients who will relapse from those who will remain in long-term clinical remission after discontinuing effective allergen immunotherapy, the decision to continue or stop immunotherapy must be individualized.

Accelerated immunotherapy schedules: review of efficacy and safety

OBJECTIVE

To provide a comprehensive evaluation of accelerated immunotherapy build-up schedules in terms of adverse reactions and clinical efficacy.

DATA SOURCES

Peer-reviewed studies and review articles were selected from the PubMed database for articles published in the years 1976 to 2006 using the following keywords: rush, cluster immunotherapy in combination with allergic rhinitis, asthma, Hymenoptera, and imported fire ant.

STUDY SELECTION

Studies were selected if they provided safety and efficacy information on accelerated allergen immunotherapy schedules. Most of the studies reviewed were double-blind, placebo controlled, but some open-observational studies were included if they provided immunotherapy safety or other information the author thought was relevant.

RESULTS

A wide range of systemic reactions were reported in the literature with inhalant allergens: ranging from 27% to 100% of the patients in rush immunotherapy studies and 0% to 79% of patients in the cluster studies. Predictors of systemic reactions with rush immunotherapy were forced expiratory volume in 1 second less than 80% of predicted and a high degree of skin test reactivity. Premedication clearly reduces the risk of systemic reactions with rush immunotherapy, but the effect on cluster schedules was not as clear.

CONCLUSION

Accelerated immunotherapy build-up schedules in selected patients may provide a rapid alternative to conventional build-up schedules without a significant increase in risk.

Safety of an ultra-rush immunotherapy build-up schedule with therapeutic vaccines containing depigmented and polymerized allergen extracts

BACKGROUND

Four administration schedules of immunotherapy have been reported: conventional, cluster, rush and ultra-rush.

OBJECTIVES

To evaluate the safety and the clinical advantage of using standardized modified allergen extracts in an ultra-rush protocol without premedication and/or hospitalization.

MATERIAL AND METHODS

One thousand and sixty-eight patients with rhinoconjunctivitis and/or asthma sensitized to mites and/or pollen were included in a prospective observational study. Patients received a therapeutic vaccine containing depigmented and glutaraldehyde-modified extracts (mites and/or pollens) adsorbed onto alum prescribed by a specialist. The schedule of administration consisted of injecting 0.2 and 0.3 ml of the vial of maximum concentration during the first day of immunotherapy, separated by a time interval of 30 min. All patients reached the maximum dose (0.5 ml) after 2 injections. Tolerance was assessed by recording all side reactions related to immunotherapy, classified according to the criteria of the EAACI.

RESULTS

The total number of injections was 2,136. All patients reached the maximum established dose on the 1st day. No premedication was used. Seven clinically relevant local reactions were recorded. The systemic reactions were 5 grade-1 (2 immediate and 3 delayed) and 3 delayed grade-2 reactions.

CONCLUSIONS

The therapeutic vaccines containing chemically modified extracts can be administered using an alternative ultra-rush schedule in an immunotherapy unit, reaching the maximum dose on the 1st day with 2 injections, without the need of premedication and/or hospitalization.

Sublingual and oral immunotherapy

Sublingual immunotherapy (SLIT) is a viable alternative to the subcutaneous route for the treatment of respiratory allergy, whereas the pure oral route has been abandoned because of its lack of efficacy. The main distinctive feature of SLIT is its optimal safety profile, which has been demonstrated in adults and children. The indications for SLIT are similar to those for the subcutaneous route. A long-lasting effect has been demonstrated for the sublingual route, but data are needed to determine the optimal dose and the preventive effect in asthma.

Sublingual immunotherapy: an update

PURPOSE OF REVIEW

Sublingual immunotherapy is now officially accepted as a viable alternative to the traditional subcutaneous route, and it is widely used especially in European countries. Despite the large amount of experimental evidence on the safety and efficacy of the method, some concerns still exist, and several aspects need to be clarified: magnitude of the efficacy, adherence, long-lasting effect and others. Recently published studies have provided answers to some of these points.

RECENT FINDINGS

The most recent studies have shown that sublingual immunotherapy exerts a long-lasting effect up to 5 years after discontinuation and that it is able to prevent the onset of new sensitizations. Moreover, when systematically assessed, the adherence to treatment is quite satisfactory, despite the treatment being self-administered. In addition, evidence has been provided that sublingual immunotherapy is effective in treating allergic conjunctivitis, and a metaanalysis has confirmed its efficacy in rhinitis. Moreover, some studies have addressed the possibility of simplifying the schedule of administration by shortening the build-up phase.

SUMMARY

More and more new data on sublingual immunotherapy are rapidly appearing in the international literature. These data confirm the clinical value of this treatment and show that it is comparable to subcutaneous immunotherapy from several points of view.

Efficacy and safety of sublingual immunotherapy

OBJECTIVE

To review the available published data concerning the use of sublingual immunotherapy (SLIT) in respiratory allergy to primarily evaluate the clinical efficacy and safety of the treatment and to secondarily consider the mechanisms of action and any unresolved questions.

DATA SOURCES

Articles in the medical literature (starting from 1986 up to November 2003) derived from searching the MEDLINE database with the keywords sublingual immunotherapy, respiratory allergy, asthma, and rhinitis. Sources included review articles, randomized controlled clinical trials, postmarketing surveillance studies, and relevant reports from meeting proceedings.

STUDY SELECTION

Articles concerning safety, efficacy, and mechanisms of SLIT published in English-language, peer-reviewed journals.

RESULTS

SLIT proved effective and safe in adults and children. As with traditional subcutaneous immunotherapy, SLIT has long-lasting efficacy and a preventive effect on new sensitizations.

CONCLUSION

SLIT is a viable alternative to subcutaneous immunotherapy. Its use in pediatric patients seems to be particularly promising.

Knowledge and expectations of patients receiving aeroallergen immunotherapy

BACKGROUND

Patients receiving aeroallergen immunotherapy frequently have poor knowledge and unfounded expectations of various important aspects of their treatment.

OBJECTIVE

To evaluate patients' knowledge about the content, benefit, and risk related to the aeroallergen immunotherapy that they were receiving.

METHODS

A self-administered questionnaire was distributed to all patients older than 16 years who had undergone aeroallergen immunotherapy for allergic rhinitis at 3 university-affiliated allergy clinics.

RESULTS

A total of 132 patients (77 males and 57 females; mean +/- SD age, 30 +/- 13 years) participated in the study. The mean +/- SD duration of treatment was 30 +/- 60 months. Complete recovery of their allergies was expected by 39% of the patients. One fifth of the study group did not know when improvement should be expected, and 18% anticipated improvement to occur within days or weeks from the initiation of treatment. Only 32% were aware that immunotherapy might have some potential risk or adverse effects, and 24.2% failed to identify at least one of the allergens they were receiving. Patients who were interviewed during their first 6 months of aeroallergen immunotherapy had more knowledge about it than those who had been undergoing long-term treatment.

CONCLUSIONS

There is a grave lack of knowledge and numerous misconceptions among substantial numbers of patients receiving aeroallergen immunotherapy. More educational effort is needed to increase patients' knowledge about immunotherapy before and during aeroallergen immunotherapy to improve their compliance and the success and safety of this therapeutic modality.

Noninjection routes for immunotherapy

Allergen specific immunotherapy, together with drugs and allergen avoidance, is a cornerstone in the management of respiratory allergy. The traditional subcutaneous route is burdened with the risk of severe adverse events; therefore, safer routes of administration (noninjection or local routes) have been investigated and developed. Controlled trials failed to demonstrate the clinical efficacy and the safety of oral and bronchial administration, and these routes have been abandoned. Local nasal immunotherapy proved effective and safe in 17 of 18 controlled trials; thus it is considered a viable route of immunotherapy. Nevertheless, nasal immunotherapy is effective in rhinitis only and requires a particular administration technique; therefore its use is slowly declining. The sublingual route is supported by numerous controlled trials showing its efficacy in asthma and rhinitis in adults and children. The safety profile, assessed in clinical trials and postmarketing surveillance studies, is satisfactory; the most frequent side effects are gastrointestinal complaints, which can be easily managed by proper dose adjusting. Sublingual immunotherapy is now accepted by the World Health Organization as a valid alternative to the subcutaneous route also in children. Although the long-lasting efficacy has been recently documented for the sublingual route, several points still need to be elucidated, including mechanisms of action, optimal dosage, cost-effectiveness, and adherence.

Factors affecting compliance with allergen immunotherapy at a military medical center

BACKGROUND

Allergen immunotherapy (AIT) is a safe and effective treatment for certain allergic disorders; however, noncompliance with therapy is common. We evaluated the compliance rates among groups receiving AIT at a military medical center and identified factors affecting compliance.

METHODS

The charts of the 381 actively enrolled patients in our AIT program were evaluated for patient compliance. Noncompliant patients were contacted to determine the reason for stopping therapy. Patients were then grouped by diagnosis, age, sex, military status, and schedule of AIT and evaluated for differences.

RESULTS

The overall compliance rate was 77.4%. The most common reasons for noncompliance included inconvenience, precluding medical condition, and adverse systemic reaction. There were no differences in compliance rates by diagnosis or sex. Noncompliant patients were younger than compliant patients, 35.4 years versus 42.4 years (P = 0.001); however, when patients were divided into three age categories (<18, 18 to 45, and >45 years), the youngest and oldest groups were more compliant (P < 0.001). Active-duty members were less compliant than retirees and family members, 65.7% versus 83.1% and 81.4%, respectively (P = 0.004). Patients receiving a conventional schedule of AIT were more compliant than those on a rush schedule, 80.0% versus 48.4% (P < 0.001).

CONCLUSIONS

Factors found to affect patient compliance with an AIT regimen at our military medical center include age, military status, and schedule of AIT. The most common reasons for noncompliance included inconvenience, precluding medical conditions, and adverse systemic reactions. Clinicians need to be aware of the factors limiting patient compliance with AIT in an attempt to maximize treatment effectiveness.

Allergen-specific sublingual immunotherapy for respiratory allergy

Present knowledge regarding the clinical efficacy and safety of sublingual immunotherapy (SLIT) for the treatment of respiratory allergy is reviewed. Allergen-specific immunotherapy is presently considered a 'biological response modifier' for the treatment of respiratory allergy, to be used in association with drug therapy and allergen avoidance. Its value in the treatment of these conditions has been established in position papers from the World Health Organization and the European Academy of Allergology and Clinical Immunology. Immunotherapy is usually administered subcutaneously (SCIT), and with this route several severe adverse events and fatalities have been described. Therefore, in the last 15 years, novel and safer routes of administration (local routes) have been developed. SLIT, in particular, has been investigated in 18 randomised controlled clinical trials. SLIT's clinical efficacy (improvement in symptoms and reduction in drug intake) in both asthma and rhinitis has been clearly assessed in 16 of these studies and for the most common allergens. SLIT's safety profile, derived from the clinical trials and from post-marketing surveillance studies, was shown to be satisfactory in both adults and children. The most frequently reported adverse events are gastrointestinal complaints, which can be avoided through appropriate dosage adjustment. For these reasons, SLIT has been accepted as a viable alternative to SCIT in recent position papers. The main advantages of SLIT are its safety (no severe systemic adverse event has ever been described) and good patient acceptance, especially in children; in addition, SLIT is a self-administered treatment that can be carried out at home by the patient. In contrast to injection immunotherapy, knowledge of the mechanisms of action of SLIT is still developing, albeit rapidly, although interesting data about its pharmacokinetics in humans are available. Data are also required concerning the possible preventive and long-lasting effects. SLIT is a viable alternative to SCIT, with the same rationale and indications. It is intended to be used in association with proper pharmacological treatment, at the earliest stages of the disease, for optimal management of respiratory allergy.

Pollen-specific rush immunotherapy: clinical efficacy and effects on antibody concentrations

BACKGROUND

Studies of rush immunotherapy (RIT) with standardized extracts for the treatment of seasonal pollen allergy are few, especially for birch-pollen RIT.

OBJECTIVE

The study was performed to investigate the efficacy of RIT with standardized birch- or timothy-pollen extracts. Further, the serum antibody levels were evaluated for correlation with clinical efficacy.

METHODS

This open, longitudinal study included 30 allergic patients treated with RIT and 16 allergic patients serving as a control group. The therapy was continued for 3 years and blood samples were collected at regular intervals for antibody measurements using the Pharmacia CAP System.

RESULTS

The RIT was generally well tolerated. An increase in the total and specific IgE concentrations during the early months of RIT was observed, followed by decreased levels. Specific IgG and IgG4 increased continuously for 2 years. The symptom and medication scores were significantly decreased, compared with preRIT, at both the first and third pollen seasons after the start of RIT treatment (P < .0001 and P < .001, respectively). The clinical improvement during RIT was significantly greater compared with the control group (P < .05). The decreased medication and the symptom improvement during the third year of RIT correlated with the relative decrease in specific IgE (rs = .52, P < .05) and with the specific IgG4 level before the start of RIT (rs= -.68, P < .01), respectively.

CONCLUSIONS

Our study indicates that RIT with standardized birch- or timothypollen extracts is clinically effective and safe. Measurements of specific antibody levels during treatment may be helpful in monitoring RIT.

Patient dropouts before completion of optimal dose, multiple allergen immunotherapy

BACKGROUND

Many patients don't complete the recommended 3 to 5-year course of immunotherapy. Why?

OBJECTIVE

Determine the percentage of our patients receiving optimal dose, multiple-allergen immunotherapy from 1982 to 1996 who discontinued their immunotherapy prior to completion of the recommended 3 to 5-year immunotherapy protocol. Second, assess the reasons for these premature dropouts. Third, determine any differences related to the clinic location where injections are given.

DESIGN AND METHODS

The medical records of patients who dropped out of our immunotherapy program before 3 years were analyzed by the author.

SUMMARY OF RESULTS

Our dropout rate before 3 years was 12%. The five commonest reasons for early dropout were concurrent medical problems, noncompliance, change of residence, inconvenience, and allergic reactions. The systemic reaction rate for the 3-year dropout group was 1.00% compared with 0.9% for our overall study group. Eighty-eight percent of the systemic reactions were mild. About 1% of our immunotherapy patients quit early due to allergic reactions secondary to immunotherapy.

CONCLUSIONS

The dropout rate for our optimal-dose patients is similar to/that reported previously by Tinkelman who apparently used a lower than optimal maintenance dose. (2) Many of our dropouts were predictable and avoidable. Few patients quit early due to allergic reactions secondary to our immunotherapy program.

Executive summary

Allergic rhinitis is now recognized as a major cause of morbidity that significantly impairs function and quality of life. Moreover, it is now widely held that the pathophysiologic mechanisms causing nasal allergy contribute, or predispose many individuals, to the development of other airway diseases, including asthma. Allergic rhinitis may well be a factor in 24% of children with otitis media with effusion (OME), and perhaps 28% of cases of chronic sinusitis. As many as 78% of persons with asthma aged 15 to 30 years have elevated serum IgE antibodies to five common aeroallergens. In many instances, nasal allergy signals the presence of more severe disease.

Considerable evidence now suggests that early and appropriate intervention can improve the quality of life and productivity of patients with allergic rhinitis, enhance the academic performance of children, and reduce the prevalence of airway complications. The goal of treatment has shifted from mere symptom alleviation to blocking the pathophysiologic mechanisms that cause chronic allergic inflammation and leave patients vulnerable to airway infections. The earlier in a patient's life that this can be accomplished, the better the anticipated consequences.

A panel of experts was convened in Amsterdam, The Netherlands, on 2 September 1996, to explore these issues and their impact on allergy prevention and treatment in primary care. Their undertaking was supported by an unrestricted educational grant from Schering‐Plough Pharmaceuticals.

Reactance theory and patient noncompliance

With surprising frequency, and to the considerable dismay of health care professionals, patients both subtly and overtly refuse to cooperate with medical treatment. Despite considerable empirical and theoretical attention, and an abundance of interventions designed to combat it, noncompliance continues. Its persistence is accompanied by considerable costs borne by patients and society alike. The theory of psychological reactance sheds new light on the phenomenon. Reactance theory proposes that a perceived threat to an individual' freedom generates a motivational state aimed at recapturing the affected freedom and preventing the loss of others. In a medical context, patients' perceptions of threats to their freedom or control may induce noncompliance. This theory permits integration of many of the seemingly disparate and/or contradictory findings, and may afford professionals new opportunities for improving patient compliance.

How many teenagers think they have allergic rhinoconjunctivitis and what they do about it

OBJECTIVE

A study was made to assess the proportion of 17-year-old students who consider themselves to have allergic rhinoconjunctivitis and to find out how they treat themselves.

METHOD

The study was performed outside the pollen season in 1993 and 1994 and 5,938 first-year secondary school students in eight different cities were asked to answer a questionnaire during class.

RESULTS

A total of 1,458 students (24%) claimed that they suffered from allergic rhinoconjunctivitis after being given a description of the disease. Sixty-five percent had had symptoms for 3 or more years and most of the sufferers, 71%, had had symptoms during the spring and/or summer. In 32% of the sufferers the causative agent was unknown. Seventy-six percent (n = 1,103) of the sufferers treated themselves with drugs. The most commonly used drugs for a systemic effect were nonsedating antihistamines and for a local effect, sodium cromoglycate. Of those who used nasal drugs (sodium cromoglycate and/or steroids, n = 545), only 14% used them daily, 51% always when having symptoms, and 35% occasionally when having symptoms. The reasons for not using nasal sprays daily were inconvenience and embarrassment. Twenty-five percent had bought the drug over the counter in 1992, the first year when allergy drugs could be purchased without a prescription. The use of over-the-counter treatment increased in the following year to 33% (P < .05).

CONCLUSION

We conclude that many young people perceive themselves as having allergic rhinoconjunctivitis and that the treatment can be much improved for the group as a whole.

Rush immunotherapy: experience with a one-day schedule

INTRODUCTION

Rush immunotherapy is a method for rapidly desensitizing patients to inhalant allergens. The frequency of systemic reactions during rush immunotherapy is similar to conventional immunotherapy when premedication is used. The most rapid protocol for rush immunotherapy reported to date requires one and one-half days which is inconvenient to patients and clinic schedules. To improve this situation and decrease the cost of giving rush immunotherapy, we have developed a 1-day protocol.

METHODS

for this ongoing study, 22 allergic patients received rush immunotherapy consisting of eight injections over six hours followed by two hours of observation in an outpatient clinic. Five had rhinitis and the rest has asthma, seven of whom were steroid-dependent. All were premedicated with astemizole, ranitidine, and prednisone for three days including the day of rush immunotherapy, and peak expiratory low rates were monitored.

RESULTS

Systemic reactions were seen in five of 22 (23%). They occurred following the sixth injection (1), seventh injection (2), or the final one (2) and consisted primarily of rhinitis or pulmonary symptoms with one episode of mild anaphylaxis. A systemic reaction was seen in only one steroid-dependent asthmatic patient. A local reaction preceded a systemic reaction in only one patient. All but three reached a maintenance dose in one day. All systemic reactions responded to epinephrine and all patients could go home after rush immunotherapy. Only one patient had a systemic reaction during the three months after rush immunotherapy.

CONCLUSION

One day rush immunotherapy is tolerated by most patients with a systemic reaction rate comparable to conventional immunotherapy. All patients were able to reach a maintenance dose months sooner than weekly schedules. With refinement of this procedure, rush immunotherapy may become a widely used method for desensitizing patients with inhalant allergens, and could make immunotherapy less expensive and more convenient.