Noninjection routes for immunotherapy

Emerging treatment of atopic dermatitis

Atopic dermatitis is a chronically relapsing eczematous disease of the skin. A wide range of therapeutic regimens has been used for atopic dermatitis. A better understanding of its pathogenesis will also lead to the development of novel approaches to treating this disease. This article reviews the recent advances in allergen-specific sublingual immunotherapy and therapy with antileukotriene drugs, probiotics, mycophenolate mofetil, leflunomide, and intermittent fluticasone propionate ointment, which the authors expect will be clinically useful therapies in the near future.

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 immunotherapy: a novel, albeit not so new, immunotherapy treatment modality

BACKGROUND

Specific allergy immunotherapy traditionally has been thought of as subcutaneous injection immunotherapy (SCIT). There also are noninjection routes for the administration of immunotherapy. The best-known and studied of these noninjection routes is the sublingual route, usually known as sublingual immunotherapy (SLIT). SLIT has been in use for many decades; however, to this date, it is not well known to the majority of allergy practitioners in this country. The purpose of this study is to help change this perception so that SLIT eventually can be considered one more tool in the allergist's armamentarium.

METHODS

A literature review was performed. It included articles from the early American clinicians and present publications that are mostly of European origin.

RESULTS

It will become clear to the reader that the key features of SLIT are its efficacy, great safety, and simplicity of administration.

CONCLUSION

SLIT is a safe treatment modality that should be considered as a useful additional tool in the therapeutic armamentarium.

BSACI guidelines for the management of allergic and non-allergic rhinitis

This guidance for the management of patients with allergic and non-allergic rhinitis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is for use by both adult physicians and paediatricians practicing in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a web-based system. Their comments and suggestions were carefully considered by the SOCC. Where evidence was lacking, consensus was reached by the experts on the committee. Included in this guideline are clinical classification of rhinitis, aetiology, diagnosis, investigations and management including subcutaneous and sublingual immunotherapy. There are also special sections for children, co-morbid associations and pregnancy. Finally, we have made recommendations for potential areas of future research.

Effect of sublingual administration with a native or denatured protein allergen and adjuvant CpG oligodeoxynucleotides or cholera toxin on systemic T(H)2 immune responses and mucosal immunity in mice

BACKGROUND

Sublingual immunotherapy has been recently used for allergic diseases, but its mechanisms are still unclear.

OBJECTIVE

To examine the effect of sublingual administration of a native or denatured allergen alone or plus adjuvant on systemic T(H)2 responses and mucosal immunity in mice.

METHODS

Naive or sensitized BALB/c mice were sublingually vaccinated biweekly for 3 weeks with ovalbumin (OVA) or urea-denatured OVA (CM-OVA) only or plus adjuvant CpG oligodeoxynucleotides (CpG) or cholera toxin (CT). Two weeks later, their specific serum IgG, IgG1, IgG2a, IgE, and saliva secretory IgA (SIgA) antibody responses and the cytokine profiles of spleen and cervical lymph node cells were investigated.

RESULTS

Specific SIgA antibody responses were induced by vaccination with CM-OVA plus CpG or CT. Whereas vaccination with CM-OVA and CpG enhanced T(H)1 responses but inhibited IgE production, vaccination with CT and CM-OVA or OVA increased cervical lymph node cell production of interleukin (IL) 4, IL-5, and IL-6 and serum IgG1 antibody responses. In previously sensitized mice, sublingual vaccination with OVA or CM-OVA plus CT or CpG stimulated mucosal SIgA antibody responses, but did not enhance ongoing IgE antibody responses.

CONCLUSIONS

Sublingual vaccination with OVA or CM-OVA plus adjuvant CT or CpG all can induce systemic and mucosal immunity, but CM-OVA plus CpG had the best prophylactic and therapeutic effects on IgE antibody production. It is likely that sublingual vaccines may have a role for the prophylaxis and immunotherapy of allergic reactions.

Efficacy of long-term sublingual immunotherapy as an adjunct to pharmacotherapy in house dust mite-allergic children with asthma

Although sublingual immunotherapy (SLIT) is accepted to be a viable alternative of specific-allergen immunotherapy, the efficacy of long-term SLIT in asthmatic children is not well established. The efficacy of 3 yr of SLIT in addition to pharmacotherapy was compared with pharmacotherapy alone in a prospective, open, parallel-group, controlled study. Children with asthma aged 4-16 yr, sensitive to house dust mite (HDM) were followed up for a run-in period of 1 yr and then grouped as those who would receive SLIT + pharmacotherapy (n = 62) or pharmacotherapy alone (n = 28). All patients were evaluated based on symptom-medication scores and lung function tests every 3 months, as well as skin-prick test and serum total immunoglobulin E (IgE) levels annually for 3 yr. Children in the SLIT + pharmacotherapy group demonstrated significantly lower mean daily dose and annual duration of inhaled corticosteroid (ICS) usage when compared with controls. At the end of the 3 yr, within-group comparisons revealed statistically significant decreases in the dose and duration of ICS only in the SLIT group. Furthermore, 52.4% of subjects in the SLIT + pharmacotherapy group were able to discontinue ICS treatment for at least 6 months, which was only 9.1% for the pharmacotherapy group. Three years of SLIT as an adjunct to pharmacotherapy resulted in reduction of both the duration and dose of ICSs and successful discontinuation of ICSs along with improvement in lung functions in HDM-allergic children with asthma.

Prolonged preseasonal treatment phase with Grazax sublingual immunotherapy increases clinical efficacy

BACKGROUND

Sublingual immunotherapy treatment with grass allergen tablets (Grazax) is initiated preseasonally without up-dosing and treatment is continued throughout the entire grass pollen season.

AIMS OF THE STUDY

The influence of the duration of preseasonal treatment on clinical efficacy obtained within the grass pollen season was investigated.

METHODS

Data from three randomized, double-blind, placebo-controlled, multi-centre trials with varying preseasonal treatment periods were analysed. In the grass pollen season, symptom and medication score reductions relative to placebo were calculated and correlated with the duration of the preseasonal treatment period.

RESULTS

The analysis was based on data from 934 patients. A significant reduction in seasonal daily rhinoconjunctivitis symptom and medication scores (17%, CI: 1-33% and 23%, CI: 1-47%, P < 0.05) was observed for patients treated with Grazax compared with placebo after approximately 8 weeks of pretreatment. The magnitude of the reductions in rhinoconjunctivitis symptom and medication scores increased with longer duration of preseasonal treatment (P < 0.0001).

CONCLUSIONS

Sublingual immunotherapy with Grazax) must be initiated at least 8 weeks prior to the grass pollen season to provide a significant clinical efficacy. A longer preseasonal treatment period (>8 weeks) improves the clinical efficacy (relative to placebo) during the grass pollen season.

Efficacy Comparison of Multiple-Antigen Subcutaneous Injection Immunotherapy and Multiple-Antigen Sublingual Immunotherapy

We performed an observational study to determine whether allergen-specific sublingual immunotherapy (SLIT) is as effective as allergen-specific subcutaneous injection immunotherapy (SCIT). Our study population was comprised of 66 patients who had been taking SLIT. Of this group, 36 patients had switched to SLIT after having been treated with SCIT (group I), while the remaining 30 patients had received SLIT only (group II). A questionnaire was used to evaluate the results of treatment. In group I, 33 patients (92%) gave SLIT a favorable rating; 27 of these patients (75%) said it was just as effective as SCIT, and 6 (17%) said it was actually superior (the remaining 3 patients [8%] said that SCIT was better). In group II, 27 of 30 patients (90%) said they had attained symptom relief with SLIT; 21 (70%) said that the relief had been very significant. Overall, 60 of the 66 patients (91 %) expressed various degrees of satisfaction with SLIT. We believe that our SLIT protocol, which is based on established guidelines for SCIT administration, is an effective, safe, well-tolerated, and easy-to-use regimen. Future prospective studies of larger groups are clearly indicated.

Keys to successful management of patients with allergic rhinitis: focus on patient confidence, compliance, and satisfaction

OBJECTIVE

The American Academy of Otolaryngic Allergy (AAOA) convened an expert, multidisciplinary Working Group on Allergic Rhinitis to discuss patients' self-treatment behaviors and how health care providers approach and treat the condition. PROCEDURES AND DATA SOURCES: Co-moderators, who were chosen by the AAOA Board of Directors, were responsible for initial agenda development and selection of presenters and participants, based on their expertise in diagnosis and treatment of allergic rhinitis. Each presenter performed a literature search from which a presentation was developed, portions of which were utilized in developing this review article.

SUMMARY OF FINDINGS

Allergic rhinitis is a common chronic condition that has a significant negative impact on general health, co-morbid illnesses, productivity, and quality of life. Treatment of allergic rhinitis includes avoidance of allergens, immunotherapy, and/or pharmacotherapy (ie, antihistamines, decongestants, corticosteroids, mast cell stabilizers, anti-leukotriene agents, anticholinergics). Despite abundant treatment options, 60% of all allergic rhinitis patients in an Asthma and Allergy Foundation of America survey responded that they are "very interested" in finding a new medication and 25% are "constantly" trying different medications to find one that "works." Those who were dissatisfied also said their health care provider does not understand their allergy treatment needs and does not take their allergy symptoms seriously. Dissatisfaction leads to decreased compliance and an increased reliance on multiple agents and over-the-counter products. Furthermore, a lack of effective communication between health care provider and patient leads to poor disease control, noncompliance, and unhappiness in a significant portion of patients.

CONCLUSIONS

Health care providers must gain a greater understanding of patient expectations to increase medication compliance and patient satisfaction and confidence.

Cost-effectiveness of GRAZAX for prevention of grass pollen induced rhinoconjunctivitis in Southern Europe

BACKGROUND

Allergic rhinoconjunctivitis is a global health problem. Around 14 million people in Spain, France, Italy, and Austria suffer from grass pollen induced allergic rhinitis. Standard care only provides symptoms relief, while allergen specific immunotherapy (SIT) treats the underlying cause of the disease. Grazax from ALK-Abelló is a new, tablet-based, effective route of SIT for home treatment. The objective was to assess the cost-effectiveness of Grazax in four Southern European countries.

METHODS

A prospective pharmacoeconomic analyses was carried out alongside a multinational, clinical trial measuring the efficacy of Grazax. Pooled data on resource use and health outcomes were collected. A societal perspective was adopted, and the analysis had a nine-year time horizon. The primary outcome measure was quality adjusted life years (QALYs).

RESULTS

Grazax was superior to standard care for all efficacy endpoints, including QALYs gained, and resulted in significantly less use of rescue medication and fewer hours missed from work. Grazax was cost-effective for all countries for an annual price in the range of 1500 euros - 1900 euros. The result was improved by inclusion of future costs of asthma and exclusion of Spanish trial centers which experienced an exceptionally low pollen season.

CONCLUSION

The analysis illustrates that allergen SIT with Grazax for grass pollen induced rhinoconjunctivitis is a cost-effective intervention in Southern Europe.

Gantrez® AN nanoparticles as an adjuvant for oral immunotherapy with allergens

The aim of this study was to investigate the adjuvant properties of oral-administered Gantrez AN nanoparticles with ovalbumin (as allergen model) and, in some cases, lipopolysaccharide of Brucella ovis as immunomodulator. For this purpose, BALB/c mice were administered by oral gavage with OVA nanoparticles and both Th1 and Th2 markers (IgG2a and IgG1, respectively) were enhanced. On the other hand, these carriers administered by oral route were able to protect a model of sensitized mice to ovalbumin from anaphylactic shock. These results are highly suggestive for the valuable use of Gantrez nanoparticles in oral immunotherapy with allergens.

Sublingual immunotherapy: update 2006

PURPOSE OF REVIEW

Sublingual immunotherapy is currently accepted as a viable therapeutic option, and is widely used in many European countries. In the past 2 years, new data concerning clinical, immunological and practical aspects of sublingual immunotherapy have been published, and many critical points have been addressed.

RECENT FINDINGS

In addition to the new data on clinical efficacy, the most recent studies have shown that, similar to the injection route, sublingual immunotherapy can also prevent the onset of new sensitizations and the onset of asthma. Moreover, several postmarketing surveys have confirmed the satisfactory safety profile, even in very young children, and compliance has been measured. The good safety profile has also suggested the possibility of using sublingual immunotherapy without the updosing phase. Finally, the mechanisms of action have been systematically investigated and the biodistribution of sublingual allergens has been further clarified.

SUMMARY

More new data on sublingual immunotherapy are rapidly appearing in the international literature. These data consistently confirm the value of this treatment and show that sublingual immunotherapy is a viable and useful form of immunotherapy.

Allergen immunotherapy: where is it now?

The scientific basis and the proof of clinical effectiveness of allergen immunotherapy administered by subcutaneous injection (SCIT) are well established. It is effective treatment for sensitivity to Hymenoptera venom and for allergic rhinitis and allergic asthma. SCIT administered in the proper setting reduces the development of new sensitivities and progression from rhinitis to asthma. Further, the beneficial effects persist long after completion of a course of treatment. Although many people enjoy the benefits of SCIT, extension of its use to the many others who might be candidates for this treatment is limited by its drawbacks of safety concerns and the inconvenience of repeated clinic visits over several years to receive the injections. There are many attempts underway to improve on the safety and convenience while still retaining the benefits of SCIT. These include approaches using current allergen extracts, especially by administering them sublingually. Alternatively, through recombinant technology, extracts are being modified to reduce their allergenicity without reducing their immunogenicity. They are being linked to immunostimulatory DNA sequences that will modify their in vivo processing resulting in an enhanced nonallergic response or they are being incorporated into fusion proteins with inhibitory properties for mast cells and basophils.

Recommendations for standardization of clinical trials with Allergen Specific Immunotherapy for respiratory allergy. A statement of a World Allergy Organization (WAO) taskforce

Specific Immunotherapy for respiratory allergy is used since about one century and there is now solid documentation of its efficacy. Nevertheless, the methods and experimental designs used in clinical trials are quite heterogeneous and there is no unanimously accepted methodological standard. Many studies are planned with study designs that may not confirm the clinical value of SIT as an effective treatment to reduce disease severity. To ensure that patients are treated based on sound scientific evidence and to minimize the risk of misusing limited financial resources for scientific studies, the World Allergy Organization (WAO) convened a group of experts to provide guidelines for the methodology of future immunotherapy studies. This document summarizes the recommendations for study design, patients' selection, appropriate outcomes and statistical treatment to be used in planning and performing clinical trials with specific immunotherapy.

Sublingual immunotherapy: the optimism and the issues

The acceptability of sublingual immunotherapy (SLIT) in guidelines or statements has recently increased. SLIT is currently used in Europe, Asia, and Australia for the treatment of allergic respiratory diseases. Four meta-analyses have shown that SLIT is an effective tool for the treatment of patients with asthma and/or rhinitis, and only conflicting results were reported for children with allergic rhinitis. Moreover, it offers logistic advantages and is safe. However, some unmet needs are to be faced, such as the difficulty of manufacturers to achieve the homogeneity of standardized vaccines, the magnitude of their clinical efficacy, and the pivotal question of an early intervention with SLIT in young children with IgE-mediated disorders. Altogether, SLIT has already given convincing results in respiratory diseases both in adults and children. In the future, this route of administration of allergic vaccines may improve even the treatment of patients with IgE-mediated food allergy. These patients indeed deserve better than allergen avoidance. The immunomodulatory treatment of allergic diseases probably has found a new tool; however, a more balanced understanding of this form of allergen immunotherapy is needed. This aim could be achieved through: (1) the improvement of products standardization quality; (2) an attempt to modify in children the natural course of allergic diseases; and (3) new research on mechanisms of action.

Assessment of sublingual immunotherapy efficacy in children with house dust mite-induced allergic asthma optimally controlled by pharmacologic treatment and mite-avoidance measures

Although several studies have demonstrated the efficacy of subcutaneous immunotherapy in allergic asthma, few have shown the same benefit using sublingual immunotherapy (SLIT) in asthmatic patients. This study was conducted to assess the efficacy of house dust mite (HDM) SLIT in addition to allergen avoidance and standard pharmacologic treatment. A double-blind, placebo-controlled trial was performed in 111 children (aged 5-15 yr) with HDM-induced mild-to-moderate asthma. After a 4-week baseline phase, patients were randomly assigned to receive SLIT with tablets of HDM extract (n = 55) or placebo (n = 56) for 18 months. Pharmacologic treatment was adjusted every 3 months following a step-down approach. Asthma symptom scores, reduction in use of inhaled corticosteroids and inhaled beta(2)-agonists, rhinitis symptoms, lung function tests, skin sensitivity to HDM, dust mite-specific immunoglobulin (Ig) E and IgG(4), and quality of life (QoL) were assessed during the study. After 18 months of treatment, diurnal and nocturnal asthma symptoms scores did not show significant differences between SLIT and placebo groups. Inhaled corticosteroids and inhaled beta(2)-agonists use was reduced in both groups without significant differences between groups. There were no significant differences in lung function (forced expiratory volume in 1 s and peak flow rate variations) between groups. Rhinitis symptom score decreased in both groups, with no difference between the two groups. The severity dimension of QoL was significantly improved in the SLIT group (age 6-12 yr). SLIT induced a significant reduction of skin sensitivity to HDM (p < 0.01) and a significant increase in HDM-specific IgE and IgG(4) antibodies (p < 0.001) in the SLIT group compared with the placebo group. SLIT was well tolerated with mild/moderate local adverse events. No severe systemic reactions were reported. This study indicates that, when mild-moderate asthmatic children are optimally controlled by pharmacologic treatment and HDM avoidance, SLIT does not provide additional benefit, despite a significant reduction in allergic response to HDM. Under such conditions, only a complete, but ethically unfeasible, discontinuation of inhaled corticosteroid would have demonstrated a possible benefit of SLIT.

Economic evaluation of sublingual immunotherapy vs symptomatic treatment in adults with pollen-induced respiratory allergy: the Sublingual Immunotherapy Pollen Allergy Italy (SPAI) study

BACKGROUND

Few data are available on the pharmacoeconomic aspects of immunotherapy.

OBJECTIVE

To evaluate, from the health care system and societal perspectives, the costs and consequences of sublingual immunotherapy (SLIT) added to pharmacotherapy compared with drugs alone for respiratory allergy.

METHODS

This study compared costs, clinical outcomes, and cost-effectiveness ratios of 2 strategies in the management of allergic rhinitis and asthma, namely, SLIT associated with pharmacotherapy and pharmacotherapy alone (no SLIT). A decision tree was developed and populated with epidemiologic and resource utilization data concerning approximately 2,200 patients. Direct costs included visits, tests, pharmacotherapy, immunotherapy, and hospitalizations. Indirect costs and out-of-pocket drugs were also included. Outcome was calculated as the number of improved patients and asthma cases avoided at 6 years. Sensitivity analysis was performed by varying costs and epidemiologic data.

RESULTS

SLIT improved the symptoms of 399 of 1,000 patients and prevented asthma in 229 of 1,000 patients compared with drugs alone. For SLIT added to pharmacotherapy and pharmacotherapy alone, the direct cost per patient at more than 6 years was Euro2,400 and Euro3,026, whereas the indirect cost was Euro1,913 and Euro3,400.

CONCLUSION

From both perspectives and for both effectiveness end points, SLIT is less expensive and more effective than pharmacotherapy alone.

Evaluation of serum IgG4 antibodies specific to grass pollen allergen components in the follow up of allergic patients undergoing subcutaneous and sublingual immunotherapy

BACKGROUND

A number of reports suggest that induction of IgG 'blocking antibodies' may be important for successful allergen immunotherapy. Nevertheless, a significant increase in specific IgG and IgG4 antibodies has not been consistently demonstrated for sublingual immunotherapy (SLIT).

METHODS

The present observation included three groups of grass pollen allergic patients all submitted to three different allergen immunotherapeutic regimens in an open, non-placebo controlled clinical study: (i) 16 patients underwent a modified 'cluster' regimen of weekly injections of a standardized aluminium-absorbed Phleum pratense extract for 5 weeks, followed by 3 weeks of maintenance injections. (ii) Fifteen patients were treated with standardized timothy grass pollen-allergen oral vaccine. In the first session of a SLIT protocol without up-dosing, each patient received 2.4 ml of sublingual vaccine containing about 57 microg of Phl p 5 and received a maintenance dose of 24 microg of Phl p 5 once a day for 120 days. (iii) Fourteen subjects were treated with a standardized allergen extract containing 5-grass pollen mixture; a SLIT protocol was performed without up-dosing, administering a dose corresponding to about 10.0 microg/ml grass-pollen Group 5 and a maintenance dose of 4 microg of grass-pollen Group 5 once a day for 135 days. Patients' sera were characterized in detail by determining IgG4 antibodies to rPhl p 1, 2, 5, 6, 7, 11, 12 and nPhl p 4 and eosinophil cationic protein before the start of immunotherapy and during the peak of pollen season.

RESULTS

No relevant systemic side effects were registered in patients treated with the modified cluster subcutaneous immunotherapy (SCIT) protocol and the two SLIT protocols without build-up phase. After SCIT all patients had high titres of serum allergen-specific IgG4 antibodies. High-dose SLIT led to an IgG4 increase comprising 25% of the SCIT level, while low-dose SLIT increased to 4% of the SCIT. Furthermore, the increase of specific IgG antibodies corresponds to a decrease of serum ECP during allergen exposure.

CONCLUSIONS

These preliminary data seem to indicate that: (i) pre-seasonal high-dose SLIT protocol without build-up phase is safe and well-tolerated by allergic patients; (ii) compared to IgG4 levels induced by SCIT, only a high-dose SLIT regimen results in an appreciable serum specific IgG4 increase.

Pollen immunotherapy: selection,prevention, and future directions

Pollens are an important cause of allergic rhinitis and asthma. Pollen immunotherapy is effective and potentially curative. It has been shown to prevent new sensitizations, to prevent the development of asthma in children, and to induce long-term benefit. Standardization of allergen extracts is necessary to improve immunotherapy safety and efficacy. Knowledge of the local plant taxonomy and allergen cross-reactivity is important in selecting clinically relevant vaccines. In general, allergenic cross-reactivities correspond to taxonomic relations. Tree and weed species demonstrate variable degrees of cross-reactivity. Most grasses have extensive allergenic cross-reactivity. Mechanism of action continues to be an area of investigation, including the induction of immunoglobulin G blocking antibodies. Sublingual immunotherapy, concurrent anti-immunoglobulin E use, hypoallergic peptides, and DNA vaccines are other promising technologies.

New insights in sublingual immunotherapy

Sublingual immunotherapy (SLIT) is accepted in the official documents and is currently used in many European countries. In recent years, new clinical data on efficacy and safety have been published, including meta-analyses in adults and children and surveys of safety in children younger than age 5 years. Moreover, it has been shown that, similar to the injection route, SLIT can prevent the onset of new sensitizations and the onset of asthma. Additionally, the mechanisms of action are beginning to be systematically studied. Some points need further investigation, such as the effect in asthma, the mechanisms of action, and the optimal dose to be administered.

Sublingual immunotherapy: efficacy--methodology and outcome of clinical trials

Using Medline we identified 39 placebo-controlled, double-blind sublingual immunotherapy (SLIT) studies providing symptom-medication score. These were retrospectively evaluated for evidence of clinical efficacy and quality of study presentation. Clinical efficacy was estimated according to statistical significance and graded as: unequivocal efficacy (statistically significant difference from placebo in both symptom and medication scores or the combined score), which was observed in 28% of studies, possible efficacy (significant improvement in either symptom or medication scores) seen in 33%, and no efficacy (no statistical difference between active treatment and the placebo group), as found in 38% of studies. Generally, studies were limited by the number of patients, showed a high frequency of withdrawals, a short duration of treatment, and insufficient data on randomization. The magnitude of efficacy additional to placebo treatment must be >20% in order to justify the treatment. This review concludes that future SLIT studies should be planned in accordance with international recommendations in order to be conclusive.

Future developments in sublingual immunotherapy

The increasing prevalence of allergic rhinitis and its progression to asthma has severe implications for patients and health care systems in many countries. An ideal therapy is one that is effective not only against symptoms but also towards the natural progression of the allergic disease. Immunotherapy is recognized to achieve both these aims. Administration of allergens by the sublingual route, a modality with a very low rate of systemic reactions, is widely considered a treatment of choice. However, if it is to be universally accepted, more developments are required. Although, it is effective against grass and other seasonal pollens, further controlled trials are needed to confirm its efficacy against perennial allergens. Additional studies, particularly in paediatric populations, are needed to confirm its long-term effects on disease progression. New vaccine developments, which take into account the increasing understanding of the underlying immune mechanisms and that exploit molecular engineering techniques will create allergens that are effective, stable, risk free and easy to administer.

Egg oral immunotherapy in nonanaphylactic children with egg allergy

BACKGROUND

There is no current active treatment for food allergy. Traditional injection immunotherapy has been proved unsafe, and thus there is a need for other forms of immunotherapy.

OBJECTIVE

The purpose was to study the safety and immunologic effects of egg oral immunotherapy (OIT). The short-term goal was to desensitize subjects to protect against accidental ingestion reactions. The eventual goal was to induce lasting clinical and immunologic tolerance.

METHODS

Subjects with a history of egg allergy but without a history of anaphylaxis to egg underwent a 24-month egg OIT protocol involving modified rush, build-up, and maintenance phases. Double-blind, placebo-controlled food challenges were performed at study conclusion. Egg-specific IgE and IgG concentrations were followed.

RESULTS

Seven subjects completed the protocol. Egg-specific IgG concentrations increased significantly, whereas egg-specific IgE concentrations did not significantly change. Three subjects tolerated known or possible accidental egg ingestions while receiving OIT. During double-blind, placebo-controlled food challenges at study conclusion, all tolerated significantly more egg protein than at study onset and than that found in the typical accidental exposure. Two subjects demonstrated oral tolerance.

CONCLUSION

This study provides proof of concept that OIT can be safely used for patients with egg allergy without a history of anaphylaxis to egg. Egg OIT does not heighten sensitivity to egg and might protect against reaction on accidental ingestion. Whether OIT will induce clinical oral tolerance cannot be concluded from this initial cohort.

CLINICAL IMPLICATIONS

Use of allergen-specific OIT to protect subjects with food allergy from reaction on accidental ingestion would represent a significant paradigm change in the treatment of food allergy.

Once-daily sublingual allergen-specific immunotherapy improves quality of life in patients with grass pollen-induced allergic rhinoconjunctivitis: a double-blind, randomised study

The effect of sublingual immunotherapy on quality of life (QoL) was examined in patients with grass pollen-induced rhinoconjunctivitis. Patients (n = 855) were randomised to once-daily grass allergen tablets (2,500; 25,000; or 75,000 SQ-T Phleum pratense extract; GRAZAX or placebo. Treatment was initiated 8 weeks before the start of the grass pollen season and continued throughout. If symptoms were present, patients received loratadine or placebo rescue medication. There were three major findings: in patients using loratadine, grass allergen tablets provided QOL benefits over placebo; Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) score was 17% (p = 0.006) and 20% (p = 0.020) greater with 75,000 SQ-T tablet than with placebo at first and second seasonal visit, respectively; in patients not using loratadine, grass allergen tablets improved QoL more than placebo; RQLQ score was 21% greater (p = 0.021) with 75,000 SQ-T tablet at second seasonal visit; grass tablets (without loratadine) had a greater effect on QoL than loratadine alone. RQLQ score was 26% (p = 0.014) greater with 75,000 SQ-T tablets than loratadine at second seasonal visit. These data show that sublingual immunotherapy with grass allergen tablets improves QOL in allergic rhinoconjunctivitis, reduces symptoms, and that this effect is greater than rescue antihistamine alone.

Clinical efficacy and safety of sublingual immunotherapy with tree pollen extract in children

BACKGROUND

Subcutaneous immunotherapy has been the principal approach of immunotherapy in the treatment of allergic diseases. Several clinical studies with birch, alder or hazel pollen extract conducted as subcutaneous immunotherapy have been published suggesting a well-tolerated and clinically effective treatment. Only a few clinical studies of sublingual immunotherapy (SLIT) with these allergens have been published. This study investigated the clinical efficacy, safety and dose-response relationship of SLIT in children suffering from rhinoconjunctivitis with/without asthma.

METHODS

Eighty-eight children (5-15 years) with a history of tree pollen-induced allergic rhinoconjunctivitis with/without seasonal asthma for >or=2 years were included. Allergy to tree pollen was confirmed by positive skin-prick test, positive specific IgE and positive conjunctival provocation test. The extract used was a glycerinated mixture of Betula verrucosa, Corylus avellana and Alnus glutinosa 100,000 SQ-U/ml. Children were randomized into three groups receiving SLIT 5 days a week for up to 18 months; dose group 1: accumulated weekly dose of 24,000 SQ-U; dose group 2: accumulated weekly dose of 200,000 SQ-U; and placebo.

RESULTS

In the birch pollen season, dose group 2 showed a significant reduction of symptom (P = 0.01) and medication scores (P = 0.04) compared with placebo. Dose group 1 showed a significant reduction of symptom scores (P = 0.03). There were no statistical differences between dose groups 1 and 2. All children tolerated the treatment well.

CONCLUSION

SLIT with tree pollen extract provided dose-dependent benefits in tree pollen-allergic children in terms of significantly reduced symptoms and medication use. The treatment was well tolerated.

Sublingual immunotherapy of allergic diseases

The only disease-modifying treatment that is available for allergic patients is allergen-specific immunotherapy. Two competing application forms are used: subcutaneous immunotherapy, which has been used for > 90 years, and a relatively new immunotherapy where the allergen is applied sublingually. Numerous studies have shown efficacy for subcutaneous immunotherapy and have identified possible mechanisms that are responsible for the observed reduction in allergic responses. In contrast, the efficacy of sublingual immunotherapy has not been documented to the same degree and the responsible immunological mechanisms have not yet been clearly defined. This review focuses on the published clinical and experimental data on sublingual immunotherapy and points at possible mechanisms of how sublingual immunotherapy may differ from subcutaneous immunotherapy in its mode of action, and also discusses the potential advantages and pit falls of both therapies.

Efficacy of sublingual immunotherapy in the treatment of allergic rhinitis in pediatric patients 3 to 18 years of age: a meta-analysis of randomized, placebo-controlled, double-blind trials

OBJECTIVE

To evaluate the efficacy of sublingual immunotherapy (SLIT) in the treatment of allergic rhinitis in children.

DATA SOURCES

A comprehensive search of the EMBASE, MEDLINE, LILACS, and CINAHL databases from January 1966 to February 10, 2006, was performed.

STUDY SELECTION

Randomized, double-blind, placebo-controlled trials of SLIT in the treatment of allergic rhinitis in patients 18 years or younger were selected. Outcomes measured were symptom scores and rescue medication use. Analysis was performed with standardized mean differences (SMDs) and a random-effects model.

RESULTS

Seventy articles were identified and reviewed. Ten studies, published between 1990 and 2004, fulfilled the selection criteria. Five hundred seventy-seven patients were initially included in the studies. Of these patients, 484 (245 SLIT and 239 placebo) had a final clinical evaluation and could be evaluated. A relevant heterogeneity due to widely differing scoring systems was found. Overall, there was a significant reduction in both symptoms (SMD, 0.56, 95% confidence interval, 1.01-0.10; P = .02) and medication use (SMD, 0.76; 95% confidence interval, 1.46-0.06; P = .03) after immunotherapy. The subanalyses performed for treatment duration and type of allergen showed that SLIT for more than 18 months and with pollen extracts was effective compared with SLIT courses shorter than 18 months and with mites.

CONCLUSION

The results of this meta-analysis showed that,compared with placebo, SLIT with standardized extracts is effective in pediatric patients with allergic rhinitis.

Multiple daily administrations of low-dose sublingual immunotherapy in allergic rhinoconjunctivitis

BACKGROUND

Sublingual immunotherapy (SLIT) is an efficacious treatment for allergic rhinoconjunctivitis.

OBJECTIVE

To investigate whether the number of daily administrations of SLIT can affect its efficacy.

METHODS

In an open study, 64 patients with allergic seasonal rhinoconjunctivitis to grass or birch pollens were assigned to the following 2-year daily treatment schedules: "3-3" group, 1 drop 3 times daily for 2 years; "2-3" group, 1 drop twice daily in year 1 and 1 drop 3 times daily in year 2; "1-3" group, 1 drop once daily in year 1 and 1 drop 3 times daily in year 2; and control group, no treatment. One fifth of the allergen concentration recommended by the manufacturer as maintenance treatment was used throughout the study. Patients were monitored for skin reactivity to the allergen used for SLIT using an end point dilution technique and for drug use.

RESULTS

No treatment-related adverse effects were observed. Skin reactivity to allergen decreased compared with controls in the first treatment year only in the "3-3" group and in all treated patients in year 2. Drug use decreased in the first treatment year in the "3-3" and "2-3" groups vs controls. This outcome extended to "1-3" patients in treatment year 2. Antihistamine use decreased significantly compared with baseline in year 1 in "3-3" and "2-3" patients and in all treated patients in year 2. No changes were observed in controls.

CONCLUSION

The number of daily administrations seems to correlate with the efficacy of SLIT.

Sublingual immunotherapy with Dermatophagoides monomeric allergoid down-regulates allergen-specific immunoglobulin E and increases both interferon-gamma- and interleukin-10-production

BACKGROUND

The clinical efficacy and safety of sublingual immunotherapy (SLIT) for aeroallergens has been demonstrated in several trials, whereas the immunological changes induced by this treatment, which may account for the clinical improvement, are still unclear.

OBJECTIVE

To investigate the effects of a successful SLIT on the in vitro allergen-driven T cell response and cytokine secretion as well as on the serum levels of chemokines and of IgE, IgG1 and IgG4 antibodies (Abs).

MATERIALS AND METHODS

Twenty-five Dermatophagoides pteronyssinus (Dp)-sensitive patients with perennial rhinitic and/or rhinitic and asthmatic symptoms were randomized into two groups (13 untreated (UT) and 12 SLIT-treated) for a 1 year and half study. The proliferative response of peripheral blood mononuclear cell (PBMC) to purified Der p1 allergen, their cytokines (IFN-gamma, IL-4, IL-10 and TGF-beta) production and serum levels of chemokines associated with T helper type 1 (Th1) (CXCL10) or T helper type 2 (Th2) (CCL22) responses and of Dp-specific IgE, IgG1 and IgG4 Abs were evaluated before and after 6 months of treatment.

RESULTS

SLIT induced a significant reduction of symptom medication scores after 6, 12 and 18 months of treatment in comparison with UT patients. SLIT-treated patients showed a significant decrease in serum levels of DP-specific IgE Abs, whereas total IgE, and specific IgG1 and IgG4 Abs remained unchanged. The proliferative response of allergen-specific T cells to Der p1 in vitro after 6 months of treatment was reduced, while no effect was observed on T cell proliferation to recall antigen (streptokinase). Moreover, Der p1-driven IFN-gamma and IL-10 were significantly increased in culture supernatants of PBMC from 6 month-treated patients in comparison with those detected at the beginning of therapy.

CONCLUSIONS

These data suggest that the allergen-driven enhancement of IL-10- and IFN-gamma-producing T cells precedes and associates with SLIT-induced down-regulation of specific IgE, thus providing a rationale to explain the clinical benefit of SLIT in allergic patients.

Novel ways for immune intervention in immunotherapy: mucosal allergy vaccines

Allergen-specific immunotherapy is currently the only curative treatment for allergy. Subcutaneous immunotherapy (SCIT) has been successfully used to treat patients who are allergic to insect venom, house dust mites, or tree or grass pollens. In the context of potentially severe, albeit infrequent, side effects associated with SCIT, mucosal routes of administration are being investigated to conduct allergenic desensitization. This article reviews recent developments in the field of nasal, oral, and sublingual immunotherapy as they relate to safety, clinical efficacy, and immune mechanisms of action. Implications for the design and development of improved allergy vaccines that could be used through such nonparenteral routes are discussed. Specifically, allergen presentation platforms and adjuvants facilitating the targeting of immune cells at mucosal surfaces to promote tolerance induction are reviewed.

Randomized double-blind controlled study with sublingual carbamylated allergoid immunotherapy in mild rhinitis due to mites

BACKGROUND

The clinical efficacy of sublingual immunotherapy (SLIT) in mite allergy and in mild disease is still a matter of debate, thus we performed a long-term clinical trial.

METHODS

The study was randomized, double-blind and placebo-controlled. After a 1-year assessment, 68 patients with mild rhinitis with/without asthma due to mites were randomized to drugs + placebo or drugs + SLIT for 2 years. Sublingual immunotherapy was given as soluble tablets of monomeric carbamylated allergoid. Clinical scores for asthma and rhinitis (0, absent to 3, severe) and drug consumption were assessed by diary card in the period November-February. Quality of life was assessed before and after each observation period and pharmaco-economy data were evaluated as well.

RESULTS

Fifty-six patients completed the study. The rate of dropouts was similar in the two groups. No relevant side effect was reported. There was a significant reduction of total clinical scores (P < 0.05) in the active group vs placebo at the first year, but not at the second whereas nasal obstruction significantly improved in both years (P < 0.05). The reduction of drug intake score was significant only at the first year. No change was observed concerning most of the Short Form-36 items, because at baseline all patients displayed a normal profile. A significant change in SLIT group was seen for the item 'change in health status'. The need for extra visits was significantly lower in the active group (25%vs 43%).

CONCLUSIONS

Sublingual immunotherapy was clinically effective and safe in mite-induced mild disease.

Molecular approaches for new vaccines against allergy

Type I allergy represents an important health problem that is currently affecting approximately 25% of the population in Western countries. Immunotherapy, the only causative treatment of Type I allergy, is currently performed with crude allergen extracts, which contain unpredictable amounts of allergenic, as well as nonallergenic, components. The application of molecular biology for allergen characterization has revealed the molecular nature of the most common allergens and allowed the production of recombinant allergens that equal natural allergens. Based on this knowledge, several different strategies to improve immunotherapy have become available. Until now, T-cell peptides, selected wild-type-like recombinant allergens and genetically modified hypoallergenic allergen derivatives have been evaluated in clinical trials in patients. Immunotherapy based on T-cell peptides has focused on allergen-specific T-cell responses, whereas genetically modified recombinant allergen molecules offer the advantage of combining T-cell and B-cell epitopes. Genetically modified recombinant birch pollen derivatives (Bet v 1-fragments, Bet v 1-trimer) have been evaluated in a double-blind, placebo-controlled, multicenter study. Vaccination with the Bet v 1-derivatives improved symptoms of birch pollen allergy, induced a healthy allergen-specific immunoglobulin G response and led to a significant reduction of seasonally induced boosts of immunoglobulin E.

Sublingual immunotherapy: a comprehensive review

Sublingual immunotherapy (SLIT) has been used with increasing frequency in Europe and is viewed with increasing interest by allergists in the United States. To address this interest, a Joint Task Force of the American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma and Immunology's Immunotherapy and Allergy Diagnostic Committees reviewed the available literature on SLIT and prepared this report. The task force concluded that despite clear evidence that SLIT is an effective treatment, many questions remained unanswered, including effective dose, treatment schedules, and overall duration of treatment. Until these have been determined, an assessment of the cost/benefit ratio of the treatment cannot be made. SLIT does appear to be associated with few serious side effects, but it has not been administered in high-risk asthmatic patients, nor in the studies reviewed has it been administered as a mixture of non-cross-reacting allergens. Furthermore, there is currently no allergy extract approved for this use in the United States, nor is there a Current Procedural Terminology code for billing purposes. All of these factors should be given careful consideration by anyone contemplating initiating SLIT treatment for their allergic patients.

Once daily sublingual immunotherapy without updosing--A new treatment schedule

BACKGROUND

Treatment regimens with specific immunotherapy include updosing. Due to excellent tolerance of sublingual immunotherapy (SLIT), it was hypothesized that administration of once-daily SLIT could be initiated safely without updosing. The objective was to evaluate tolerability of SLIT administered once daily without updosing.

METHODS

135 patients suffering from allergic rhinitis with/without asthma were included in a double-blind, placebo-controlled, parallel-group study. Patients were randomized into two groups. Group 1 (n = 69) received active treatment throughout the study, including 10 days updosing (T1), 20 days maintenance treatment (T2), and 2 consecutive months on maintenance treatment (T3 and T4). Group 2 (n = 66) obtained placebo updosing (T1), placebo maintenance (T2), initiated active treatment (maintenance) at T3, and continued active treatment until the end of the study (T4). Adverse events (AEs) were assessed at T1-T4. 66 grass- and 69 mite-allergic patients were evenly distributed between groups.

RESULTS

229 AEs were reported, 157 AEs were related to treatment. The most frequently reported AEs (>5% of patients in any group) related to treatment were oral itching, ocular itching, rhinitis, and sublingual edema. For group 1 at T2, the rate of all AEs related to treatment per dose administered was 1.79%, and for group 2 at T3 the rate was 1.33% (p = 0.37). For the most frequently reported AE, oral itching, the rate per dose administered was 1.01% for group 1 at T2, and 0.74% for group 2 at T3 (p = 0.53).

CONCLUSIONS

Once daily SLIT was well tolerated and can be safely initiated without updosing.

Sublingual immunotherapy for allergic rhinitis: an update

PURPOSE OF REVIEW

The inter-relationship between allergy and nasal diseases has long been known. Failure to address when allergy is a contributing factor diminishes the possibility of a successful surgical intervention. Sublingual immunotherapy is recommended by the World Health Organization to treat allergic rhinitis and is widely used in Europe. Many clinical trials and rigorous meta-analysis support its efficacy. The criteria, however, for the integration of this treatment (with the surgical management of those allergic patients who suffer chronic nasal obstruction, severe drug-resistant hypertrophy and increase in glandular structures of the inferior turbinates) are not fully established. We review here the most recent literature on the efficacy and safety of sublingual immunotherapy. The purpose is to stimulate the use of complementary approaches by ear, nose and throat doctors and allergologists, and to improve the management of patients with persistent allergic rhinitis.

RECENT FINDINGS

In addition to the results of clinical trials, postmarketing surveillance has confirmed the high safety profile of sublingual immunotherapy in adults and children, its positive impact on the quality of life, and the reduction of the personal and social cost of allergy. Sublingual immunotherapy can prevent new allergic sensitizations and maintain its beneficial effect for years after its discontinuation.

SUMMARY

Sublingual immunotherapy is a highly efficacious and well tolerated form of immunotherapy for allergic rhinitis, and it is capable of interfering with disease progression. Sublingual immunotherapy should be integrated with surgical intervention to achieve optimal outcomes in allergic subjects with chronic nasal obstruction.

Rhinitis and asthma in athletes: an ARIA document in collaboration with GA2LEN

This consensus document is aimed at reviewing evidence that the rhinitis-asthma links have peculiar features in athletes. Beside a review of epidemological data on the high prevalence of rhinitis and asthma in athletes, the effects on intense physical exercise on the immune system and repiratory functions are discussed, with special reference to the role of allergens and pollutants. In extending the Allergic Rhinitis and its Impact on Asthma (ARIA) recommendations to athletes, the issue is addressed of adapting diagnosis and management to criteria set by the International Olympic Committee (IOC) and regulations adopted by the World Anti-Doping Agency (WADA).

Advances in allergen-specific immunotherapy

Atopic disease affects approximately 30% of the population in western society. Allergen-specific immunotherapy (SIT) is the only treatment with a long-term effect available at the present time, and has been used successfully in the treatment of a number of allergies for almost 100 years. Despite this success, there is great demand for safer, faster and more effective approaches. At present, many studies are being conducted aiming to comply with this demand. The approaches used include conventional immunotherapy, using allergen extracts, as well as novel methods such as peptide immunotherapy, allergen DNA vaccines and non-injection routes of SIT. The clinical success of various treatments, new technical developments and a better understanding of the immunological mechanisms behind immunotherapy hold great potential for the broad application of allergen-SIT in the foreseeable future.

Update on sublingual immunotherapy

OBJECTIVE

To obtain a current understanding of the mechanisms, clinical indications, efficacy, and safety of sublingual immunotherapy (SLIT) for the treatment of children and adults with allergic rhinitis, asthma, and allergic conjunctivitis.

METHODS

A MEDLINE and Index Medicus search for peer-reviewed articles on SLIT was performed.

RESULTS

Since the approval of SLIT by the World Health Organization in 1988, the efficacy and safety of SLIT have been confirmed in several new double-blind, placebo-controlled studies for monosensitized patients who are allergic to house dust mites, grass pollens, ragweed, and birch pollen. Documented immunologic responses to SLIT have included a decrease in serum eosinophilic cationic protein and interleukin 13 (IL-13) levels, an elevation in IL-12 levels, a reduction in late-phase responses, and increases in IgG4/IgE ratios. A Cochrane review of 22 studies confirmed the efficacy and safety of SLIT for patients with allergic rhinitis. A long-term asthma study showed sustained efficacy 5 years after discontinuing the vaccine. The safety of SLIT has been confirmed in postmarketing studies, and severe systemic adverse effects have never been reported. In view of its safety profile, SLIT is taken by the patient at home (away from specialized centers), and no specialized resuscitation facilities are required.

CONCLUSION

SLIT is a safe and effective therapeutic option for patients with allergic rhinitis and asthma. Because of its efficacy, safety, and ease of administration, it has been accepted in Europe, Southern Africa, Australasia, Southeast Asia, and the Middle East as a promising therapeutic option that can significantly alter the natural history of allergic disease without the risks of injection immunotherapy.

Specific immunotherapy with SQ standardized grass allergen tablets in asthmatics with rhinoconjunctivitis

BACKGROUND

The best way to prevent allergy symptoms is to treat the allergic condition. Specific immunotherapy with grass allergen tablets 75,000 SQ-T (Grazax, Phleum pratense, ALK-Abelló) is safe and efficacious in rhinoconjunctivitis patients. As rhinoconjunctivitis often co-exists with asthma, we aimed to confirm safety and efficacy in grass allergic subjects with asthma and rhinoconjunctivitis.

METHODS

A randomized, double-blind, placebo-controlled, multicentre trial was performed 10-14 weeks prior to and during the grass pollen season 2004. About 114 subjects were randomized 2 : 1 to grass allergen tablets or placebo. The primary end points were average asthma medication and symptom scores during the grass pollen season, and secondary variables were average rhinoconjunctivitis symptom and medication scores during the grass pollen season. Additionally, number of well days was defined post hoc.

RESULTS

Differences in asthma medication and symptom scores between the treatment groups were negligible. The mean difference in asthma medication score was below 0.1 and 0.3 for asthma symptom score [a single inhalation of salbutamol (200 microg) was scored 2]. No serious adverse events were reported. A reduction in rhinoconjunctivitis symptom score of 37% (P = 0.004) and a 41% (P = 0.036) reduction in medication score was found in the grass pollen season for subjects treated with the grass allergen tablet compared with placebo. Well days increased by 54% (P = 0.002).

CONCLUSIONS

Self-administration of the grass allergen tablet was safe. The treatment did not impair asthma control and confirmed considerable symptom prevention and reduced medication use. It addresses the allergic condition and represents a baseline treatment for grass pollen allergy.

Safety of a SQ-standardised grass allergen tablet for sublingual immunotherapy: a randomized, placebo-controlled trial

BACKGROUND

Sublingual treatment of grass pollen induced rhinoconjunctivitis might provide easier access to specific immunotherapy (SIT) and minimize the risk of serious adverse events (AEs) compared to subcutaneous SIT.

AIM OF THE STUDY

To identify a safe dose range for once-daily administration of a grass allergen tablet in participants with grass pollen induced seasonal rhinoconjunctivitis.

METHODS

A randomized, double blind, placebo-controlled Phase I trial was conducted outside the grass pollen season. Seven dosage groups [25,000, 75,000, 150,000, 300,000, 500,000, 750,000, or 1,000,000 standardized quality tablet (SQ-T)], consisting of 12 participants randomized either to active treatment or placebo (3 : 1) daily for 28 days, commenced treatment in a staggered manner at intervals of approximately 1 week to allow for intermittent safety reviews.

RESULTS

The grass allergen tablet did not cause any serious, systemic or significant (leading to withdrawal) AEs. The overall incidence of AEs was 74% (1,013 events); all of mild or moderate intensity and most considered treatment-related. The most frequently reported treatment-related AEs, including irritation of the throat, and itching sensations in the mouth and ears, increased with dose. These were primarily mild in intensity, started shortly after medication intake and lasted for minutes to a few hours maximum. Objective oral findings were also dose-dependent. No clinically significant observations were found in safety laboratory, vital signs and 12-lead ECG.

CONCLUSIONS

A sublingual grass allergen tablet in doses up to 1,000,000 SQ-T daily caused no serious or systemic AEs displaying a safety profile that allows further investigation as once-daily self-medication.