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Passalacqua G, Rogkakou A, Mincarini M, Canonica GW. Allergen immunotherapy in asthma; what is new? Asthma Res Pract 2015; 1:6. [PMID: 27965760 PMCID: PMC4970380 DOI: 10.1186/s40733-015-0006-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/27/2015] [Indexed: 12/29/2022] Open
Abstract
The use and role of allergen immunotherapy (AIT) in asthma is still a matter of debate, and no definite recommendation about this is made in guidelines, both for the subcutaneous and sublingual routes. This is essentially due to the fact that most controlled randomised trials were not specifically designed for asthma, and that objective measures of pulmonary function were only occasionally considered. Nonetheless, in many trials, favourable results in asthma (symptoms, medication usage, bronchial reactivity) were consistently reported. There are also several meta analyses in favour of AIT, although their validity is limited by a relevant methodological heterogeneity. In addition to the crude clinical effect, a disease modifying action of AIT (prevention of asthma onset and long-lasting effects) have been reported. The safety is an important aspect to consider in asthma. Fatalities were rare: in Europe no fatality was reported in the last three decades, as in the United States in the last 4 years. Based on previous surveys, and common sense, uncontrolled asthma is still recognized as the most important risk factor for severe adverse events. On the contrary, there is no evidence that AIT can worsen or induce asthma. According to the available evidence, AIT can be safely used as add-on treatment when asthma is associated with rhinitis (a frequent condition), provided that asthma is adequately controlled by pharmacotherapy. AIT cannot be recommended or suggested as single therapy. When asthma is the unique manifestation of respiratory allergy, its use should be evaluated case by case.
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Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital-IST-University of Genoa, Padiglione Maragliano, L.go R.Benzi 10, Genoa, 16133 Italy
| | - Anthi Rogkakou
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital-IST-University of Genoa, Padiglione Maragliano, L.go R.Benzi 10, Genoa, 16133 Italy
| | - Marcello Mincarini
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital-IST-University of Genoa, Padiglione Maragliano, L.go R.Benzi 10, Genoa, 16133 Italy
| | - Giorgio Walter Canonica
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital-IST-University of Genoa, Padiglione Maragliano, L.go R.Benzi 10, Genoa, 16133 Italy
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153
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Cytokine Responses to Specific Immunotherapy in House Dust Mite-Induced Allergic Rhinitis Patients. Inflammation 2015; 38:2216-23. [DOI: 10.1007/s10753-015-0204-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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154
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Didier A, Malling HJ, Worm M, Horak F, Sussman GL. Prolonged efficacy of the 300IR 5-grass pollen tablet up to 2 years after treatment cessation, as measured by a recommended daily combined score. Clin Transl Allergy 2015; 5:12. [PMID: 26097680 PMCID: PMC4474569 DOI: 10.1186/s13601-015-0057-8] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/07/2015] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The 300IR (index of reactivity) 5-grass pollen tablet has favorable short-term and sustained clinical efficacy in patients with grass pollen-induced allergic rhinoconjunctivitis (ARC). Here, we report maintenance of efficacy and safety over 2 years following treatment discontinuation. METHODS Randomized, double-blind, placebo-controlled, parallel-group, multicenter Phase 3 trial in patients aged 18-50 years with ARC. During study years 1-3, patients received a daily sublingual tablet containing either 300IR 5-grass pollen extract or placebo, according to a discontinuous pre- and coseasonal protocol. Study years 4 and 5 were treatment-free. In response to health authorities' recommendations, the daily combined score (DCS) was assessed in a post-hoc analysis as the efficacy endpoint. Components of the DCS were daily rhinoconjunctivitis total symptom score (DRTSS) and daily rescue medication score (DRMS). RESULTS 633 patients with ARC were randomized to placebo (n = 219) or 300IR 5-grass pollen tablet, beginning 4 months (4 M, n = 207) or 2 months (2 M, n = 207) prior to the estimated start of the grass pollen season and continuing until season's end. During the first post-treatment year, a statistically significant difference versus placebo in least squares (LS) mean DCS was noted in patients previously receiving active treatment (300IR (2 M) point estimate: -0.16, 95% confidence interval (CI95%): [-0.26, -0.06], p = 0.0019; -31.1%; 300IR (4 M) point estimate: -0.13, CI95%: [-0.23, -0.03], p = 0.0103, -25.3%). During the second post-treatment year, patients in the 300IR (4 M) group, but not the 300IR (2 M) group, showed a statistically significant difference in LS mean DCS versus placebo (point estimate: -0.11, CI95%: [-0.21; 0.00], p = 0.0478, -28.1%). This significant efficacy seen during the post-treatment years in patients previously treated with 5-grass pollen tablet compared favorably with that during the 3 prior years of active treatment. A statistically significant difference versus placebo was also noted in secondary efficacy measures in both post-treatment years (except for DRTSS in year 5). In the absence of any active treatment, the safety profile was similar in the active groups versus placebo group during either post-treatment year. CONCLUSIONS In adults with grass pollen-associated ARC, 5-grass pollen tablet therapy beginning 4 months before the pollen season and continuing to season's end demonstrated efficacy across all variables during active treatment, and this effect was prolonged for up to 2 years post-treatment. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00418379.
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Affiliation(s)
- Alain Didier
- />Rangueil-Larrey Hospital, Department of Respiratory Diseases, 24 Chemin de Pouvourville, TSA 30030 31059 Toulouse, Cedex 9 France
| | | | - Margitta Worm
- />Department of Dermatology and Allergy, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Friedrich Horak
- />Vienna Challenge Chamber, Institute for Allergy Research, Vienna, Austria
| | - Gordon L Sussman
- />Division of Allergy and Clinical Immunology, University of Toronto, Toronto, ON Canada
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155
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Roche AM, Wise SK. Subcutaneous immunotherapy. Int Forum Allergy Rhinol 2015; 4 Suppl 2:S51-4. [PMID: 25182356 DOI: 10.1002/alr.21382] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 07/02/2014] [Accepted: 07/02/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Allergic rhinitis, asthma, and Hymenoptera sensitivity affect approximately 20%, 9%, and 0.66% to 3.3% of adults in the United States, respectively. Various environmental control measures and pharmacologic options are available for symptomatic treatment of allergic rhinitis and allergic asthma. However, allergen-specific immunotherapy is the only form of treatment that alters the natural history of allergic disease. METHODS A literature review was performed. Information from systematic reviews, meta-analyses, and practice parameters were closely examined and summarized, and they are included in this primer. RESULTS There is evidence that supports the use of subcutaneous immunotherapy (SCIT) for the treatment of perennial and seasonal allergic rhinitis, asthma, and Hymenoptera sensitivity. Efficacy of SCIT has been established in the adult and pediatric populations. Adverse reactions occur in up to 71% of patients. However, the rate of serious or fatal side effects is very rare. CONCLUSION SCIT is safe and effective in the treatment of allergic rhinitis, allergic asthma, and Hymenoptera sensitivity. Adverse reactions occur but, in general, SCIT is well tolerated, and the vast majority of reactions are mild and very rarely fatal.
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Affiliation(s)
- Ansley M Roche
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, GA
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156
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Shao J, Cui YX, Zheng YF, Peng HF, Zheng ZL, Chen JY, Li Q, Cao LF. Efficacy and safety of sublingual immunotherapy in children aged 3-13 years with allergic rhinitis. Am J Rhinol Allergy 2015; 28:131-9. [PMID: 24717951 DOI: 10.2500/ajra.2014.28.4006] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Sublingual immunotherapy (SLIT) is recommended for allergic diseases. However, clinical studies containing evidence-based data of this treatment in young children, which is rarely reported in the literature, are needed. This study was designed to assess the efficacy and safety of SLIT in children, including very young children. METHODS Two hundred sixty-four children aged 3-13 years old (133 children, 3-5 years old) with Dermatophagoides farinae-induced allergic rhinitis with or without asthma treated by standard pharmacotherapy had randomly received either SLIT (SLIT group) or no SLIT (control group) for 12 months. Symptoms, medications, visual analog scale (VAS) and presence of adverse events (AEs) were assessed at monthly visits. Skin-prick test and Dermatophagoides farinae-specific IgE and IgG4 were measured before and after treatment. RESULTS Both treatments were effective in the global clinical scores during the first seven visits when compared with baseline (all, p < 0.01), and SLIT showed lower symptoms scores and VAS scores throughout this period (all, p < 0.01). These improvements continued until the later visits only in the SLIT group. Also, the asthma medication consumption was decreased by SLIT treatment only at the end of study (p < 0.01). The specific IgG4 was significantly increased after SLIT treatment when compared with the control group, but no significant change of specific IgE was observed in either groups. In the SLIT group, there was no significant difference between children less than or more than 5 years old in terms of clinical efficacy, onset of action, immunologic parameters, and safety. No severe systemic AEs were reported. CONCLUSION SLIT is effective and well-tolerated in children with allergic rhinitis 3-13 years old.
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Affiliation(s)
- Jie Shao
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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157
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Zienkiewicz K, Alché JDD, Zienkiewicz A, Tormo A, Castro AJ. Identification of olive pollen allergens using a fluorescence-based 2D multiplex method. Electrophoresis 2015; 36:1043-50. [PMID: 25640071 DOI: 10.1002/elps.201400508] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 12/17/2014] [Accepted: 01/03/2015] [Indexed: 12/21/2022]
Abstract
Olive (Olea europaea L.) pollen is a major health concern in the Mediterranean countries and some olive growing regions in America and Australia. The molecular variability of pollen allergens constitutes a handicap for commercial extract standardization, which is the base of current diagnosis and vaccination procedures. In this paper, we report a time-saving and plant material saving multiplex detection method for the rapid and simultaneous analysis of Ole e 1, Ole e 2, and Ole e 5 allergen polymorphism on a single blot. This method combines high-resolution 2DE techniques with high-sensitive fluorescence-based detection methods. Using this strategy, we were capable to identify a higher number of allergen forms compared with classical 1D approach. The use of fluorescent probes and the increased resolution of 2D blots avoided overlapping effects, and allow estimating the amount of individual allergen forms. In addition, the pattern and identity of the IgE-reactive proteins of either a population or individual patients allergic to olive pollen was also effortlessly determined in a single additional step. This flexible method might be extended to a higher number of olive allergens and cultivars, and is also applicable to other allergogenic plant species and sources.
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Affiliation(s)
- Krzysztof Zienkiewicz
- Department of Biochemistry, Cell and Molecular Biology of Plants, Estación Experimental del Zaidín, Consejo Superior de Investigaciones Científicas (CSIC), Granada, Spain; Department of Cell Biology, Institute of General and Molecular Biology, Nicolaus Copernicus University, Toruń, Poland
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158
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Potter PC, Baker S, Fenemore B, Nurse B. Clinical and cytokine responses to house dust mite sublingual immunotherapy. Ann Allergy Asthma Immunol 2015; 114:327-34. [PMID: 25661658 DOI: 10.1016/j.anai.2014.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/28/2014] [Accepted: 12/22/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cytokine responses accompanying sublingual immunotherapy (SLIT) responder phenotypes have not previously been reported. OBJECTIVE To investigate clinical and cytokine responses of house dust mite (HDM) sensitive patients with allergic rhinitis receiving HDM SLIT or placebo for 2 years. METHODS Sixty adults were randomized to receive SLIT or placebo. Clinical symptoms were measured using the Total 5 Symptom Score (TSS5) and Juniper Rhinitis Quality of Life Questionnaire. HDM specific IgE, IgG, skin prick tests, and HDM-stimulated release of interleukin (IL) 5 and interferon γ (IFN-γ) in peripheral blood mononuclear cells was studied at 0, 6, 12, and 24 months and IL-13, IL-4, and IL-10 at 0 and 24 months. RESULTS A total of 32 of 39 SLIT and 16 of 21 placebo patients completed the study. There was significant clinical improvement in both the SLIT and placebo groups. Median T5SS decreased from 14.75 to 5.25 in the SLIT group (P < .001) and 12.7 to 6.0 in the placebo group (P = .003). The median quality-of-life score also decreased in the SLIT group (P < .001) and the placebo group (P < .001). A subgroup analysis of patients found a 60% or greater improvement (on the T5SS and the Juniper Rhinitis Quality of Life Questionnaire) in the good responders group and a 30% to 59% improvement or no improvement in the intermediate responders group. This subgroup analysis also found more good responders in the SLIT group (47%) compared with the placebo group (25%; P = .07). Significant decreases in the IL-5/IFN-γ (P < .001), IL-13/IFN-γ (P < .001), and IL-4/IFN-γ (P = .03) ratios were found in the combined good clinical improvement group at 24 months. CONCLUSION A good clinical response (≥60% improvement in both TSS5 and quality of life) is associated with significant decreases in IL-5, IL-13, and IL-4 relative to IFN-γ during 2 years of SLIT therapy for HDMs.
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Affiliation(s)
- Paul C Potter
- Allergy Diagnostic and Clinical Research Unit, University of Cape Town Lung Institute, Cape Town, South Africa.
| | - Sheila Baker
- Allergy Diagnostic and Clinical Research Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Bartha Fenemore
- Allergy Diagnostic and Clinical Research Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Barbara Nurse
- Division of Immunology, National Health Laboratory Service and Department of Clinical Laboratory Sciences, University of Cape Town, Cape Town, South Africa
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159
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Nolte H, Maloney J, Nelson HS, Bernstein DI, Lu S, Li Z, Kaur A, Zieglmayer P, Zieglmayer R, Lemell P, Horak F. Onset and dose-related efficacy of house dust mite sublingual immunotherapy tablets in an environmental exposure chamber. J Allergy Clin Immunol 2015; 135:1494-501.e6. [PMID: 25636947 DOI: 10.1016/j.jaci.2014.12.1911] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/25/2014] [Accepted: 12/16/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND The magnitude of effect of sublingual immunotherapy for house dust mite (HDM)-induced allergic rhinitis with or without conjunctivitis is uncertain, partly because there are few well-controlled trials with well-defined doses. OBJECTIVE We sought to determine the dose-related efficacy and onset of action of the HDM sublingual immunotherapy tablet MK-8237 (Merck/ALK-Abelló) using the Vienna Challenge Chamber. METHODS In this randomized, double-blind, single-site trial, adults with HDM-induced allergic rhinitis with or without conjunctivitis and with or without asthma (n = 124) received 12 developmental units (DU) of MK-8237, 6 DU of MK-8237, or placebo daily for 24 weeks. Subjects underwent 6-hour exposure challenges at screening and weeks 8, 16, and 24. The total nasal symptom score (TNSS) during chamber challenge at week 24 was the primary end point. The TNSS was the sum of 4 nasal symptom scores (maximum = 12). Total ocular symptom scores (TOSSs; 2 symptoms; maximum = 6) and total symptom scores (TSSs; TSS = TNSS plus TOSS; maximum = 18) were secondary end points. RESULTS Dose- and time-dependent improvements with MK-8237 versus placebo were observed. At week 24, TNSS improvement relative to placebo was 48.6% (95% CI, 35.3% to 60.2%) with 12 DU of MK-8237 and 26.6% (95% CI, 11.2% to 39.6%) with 6 DU of MK-8237. Statistically significant improvements for TNSSs were also observed at weeks 8 (12 DU of MK-8237) and 16 (6 and 12 DU of MK-8237) and for TOSSs and TSSs by both doses at week 24. MK-8237 was well tolerated. No investigator-assessed anaphylactic allergic reactions or reactions requiring epinephrine were observed. CONCLUSIONS MK-8237, 12 DU, reduced nasal and ocular symptoms and exceeded World Allergy Organization-established clinical efficacy criteria (≥20% improvement vs placebo). The onset of action for 12 DU of MK-8237 was week 8. MK-8237, 12 DU, is appropriate for further evaluation to determine the magnitude of effect in an uncontrolled allergen exposure environment.
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Affiliation(s)
| | | | - Harold S Nelson
- Department of Medicine, Division of Allergy and Immunology, National Jewish Health, Denver, Colo
| | - David I Bernstein
- Bernstein Allergy Group and the Division of Allergy and Immunology, University of Cincinnati, Cincinnati, Ohio
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160
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Pfaar O, Gerth van Wijk R. Mite-Allergic Rhinitis: How to Evaluate Clinical Efficacy in Allergen-Specific Immunotherapy Trials? CURRENT TREATMENT OPTIONS IN ALLERGY 2015; 2:1-9. [PMID: 25798370 PMCID: PMC4361724 DOI: 10.1007/s40521-014-0040-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
House dust mite (HDM) allergen exposure is the most important cause of perennial allergic rhinitis and/or asthma. Although allergen-specific immunotherapy (AIT) with HDM is well established, published studies have been characterized by substantial heterogeneity in clinical endpoints. Standardization in measuring clinical efficacy is required. Moreover, when designing an AIT trial with HDM allergens, several considerations have to be taken into account. The history of HDM allergy is less clear cut than the typical history of pollen allergy. In addition, clinical features of HDM allergy may differ from those of pollen allergy. Moreover, although not easily measurable, fluctuation in allergen exposure may cause variation in symptom severity and determine the timing of assessment of clinical effects of HDM AIT. Key points 1. A combined symptom and medication score (CSMS) is recommended as standard for the primary endpoint in future house dust mite (HDM) allergen-specific immunotherapy trials. 2. The diagnosis of HDM allergy is based on a carefully taken history in combination with sensitization to HDM allergens. 3. Eye symptoms are less prominent in patients with HDM-induced allergic rhinitis. Nasal symptoms, but not eye symptoms, should be included in the CSMS and in symptom scores as well. 4. As methods to determine allergen exposure vary and the efficacy of environmental control is a matter of debate, a practical approach consists of restraining patients from implementing HDM-reducing measures, such as removing carpets and introducing anti-mite covers, after the start of the study. 5. Efficacy evaluation in the period with the highest exposure to mites is recommended.
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Affiliation(s)
- Oliver Pfaar
- Center for Rhinology and Allergology Wiesbaden, Germany, An den Quellen 10, 65189 Wiesbaden, Germany ; Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Roy Gerth van Wijk
- Section of Allergology, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
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161
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Leitlinie zur (allergen-)spezifischen Immuntherapie bei IgE-vermittelten allergischen Erkrankungen. ALLERGO JOURNAL 2014. [DOI: 10.1007/s15007-014-0707-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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162
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Pajno GB, Nadeau KC, Passalacqua G, Caminiti L, Hobson B, Jay DC, Arasi S, Chiera F, Salzano G. The evolution of allergen and non-specific immunotherapy: past achievements, current applications and future outlook. Expert Rev Clin Immunol 2014; 11:141-54. [PMID: 25454510 DOI: 10.1586/1744666x.2015.977260] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Recent epidemiological studies estimated that more than 30% of European suffer from allergic rhinitis or conjunctivitis, while up to 20% suffer from asthma and 15% from allergic skin conditions, while for many other regions the prevalence is increasing. Allergen immunotherapy represents the only available treatment that can modify the allergic disease process, and thus is worth considering as a treatment in affected individuals. A beneficial effect of allergen immunotherapy has been shown in both adults and children affected by allergic rhinitis, allergic conjunctivitis, allergic asthma and hymenoptera venom allergy. The present study represents an overview on allergen immunotherapy, focusing on the principal aspects of the use of immunotherapy in the past, its recent clinical applications and future outlook.
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Affiliation(s)
- Giovanni B Pajno
- Department of Pediatrics- Allergy Unit, University of Messina, Via Consolare Valeria-Gazzi, 98124 Messina, Italy
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163
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Devillier P, Chassany O, Vicaut E, de Beaumont O, Robin B, Dreyfus JF, Bousquet PJ. The minimally important difference in the Rhinoconjunctivitis Total Symptom Score in grass-pollen-induced allergic rhinoconjunctivitis. Allergy 2014; 69:1689-95. [PMID: 25155425 DOI: 10.1111/all.12518] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2014] [Indexed: 01/07/2023]
Abstract
BACKGROUND The minimally important difference (MID) has been defined as the smallest improvement considered worthwhile by a patient. The MID has not been estimated for the Rhinoconjunctivitis Total Symptom Score (RTSS). METHODS In a prospective multicentre study, patients consulting for grass-pollen-induced allergic rhinitis (AR) recorded a 15-point global rating of change scale (GRCS) score and the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) score on a weekly basis and the individual symptom scores comprising the RTSS on a daily basis over two consecutive weeks. The MID in the RTSS was determined with anchor-based methods (using the GRCS and the RQLQ) and a distribution-based method [based on the RTSS' standard deviation (SD)]. RESULTS The study population comprised 806 patients (253 children, 250 adolescents and 303 adults). During the first week of the study, the mean ± SD RTSSs for these age groups were 6.5 ± 3.3, 6.8 ± 3.4 and 7.0 ± 3.4, respectively. For an improvement of 2 points in the GRCS or 0.5 points in the RQLQ score, the regression analysis yielded MIDs in the RTSS of 1.24 ± 0.17 and 1.12 ± 0.14 in children, 1.33 ± 0.14 and 1.20 ± 0.13 in adolescents and 1.13 ± 0.14 and 0.89 ± 0.12 in adults, respectively. When applying distribution-based methods, the MID ranged from 1.09 to 1.13 (based on 0.33 SDs of the first-week RTSS) and from 1.22 to 1.40 (based on 0.5 SDs of the difference in RTSSs between the first and second weeks). CONCLUSION The MID in the RTSS was consistently estimated as 1.1-1.3 (and could conceivably be rounded to 1) in patients with grass-pollen-induced AR.
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Affiliation(s)
- P. Devillier
- UPRES EA 220; Hôpital Foch; Université Versailles Saint-Quentin; Suresnes France
- Délégation à la Recherche Clinique et à l'Innovation; Unité de Méthodologie; Hôpital Foch; Suresnes France
| | - O. Chassany
- Patient-Reported Outcomes Unit; EA REMES; Université Paris-Diderot; Sorbonne Paris Cité; Paris France
- AP-HP; Département de la Recherche Clinique et du Développement; Hôpital Saint-Louis; Paris France
| | - E. Vicaut
- Unité de Recherche Clinique; Hôpital Fernand Vidal; Paris France
| | | | | | - J. F. Dreyfus
- Délégation à la Recherche Clinique et à l'Innovation; Unité de Méthodologie; Hôpital Foch; Suresnes France
| | - P. J. Bousquet
- Centre Hospitalier Régional Universitaire de Montpellier; Montpellier France
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164
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Klimek L, Uhlig J, Mösges R, Rettig K, Pfaar O. A high polymerized grass pollen extract is efficacious and safe in a randomized double-blind, placebo-controlled study using a novel up-dosing cluster-protocol. Allergy 2014; 69:1629-38. [PMID: 25130503 PMCID: PMC4238814 DOI: 10.1111/all.12513] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cluster immunotherapy represents an interesting alternative to conventional up-dosing schedules because it allows achieving the maintenance dose within a shorter time interval. In this study, the efficacy and safety of cluster immunotherapy with a high polymerized allergen extract of a grass/rye pollen mixture have been evaluated in a randomized, double-blind, placebo-controlled, multicenter study. METHODS In total, 121 patients with allergic rhinoconjunctivitis due to grass pollen were randomized 1 : 1 to verum or placebo group. A short cluster up-dosing schedule of only 1 week was applied to achieve the maintenance dose which was administered monthly during the study period of 1 year. Total combined symptom and medication score (TCS) was defined as primary outcome parameter. Secondary outcome parameters were individual symptom and medication scores, 'well days,' global improvement as well as immunological effects and nasal allergen challenge. The safety profile was evaluated based on the European academy of allergy and clinical immunology grading system. RESULTS Significant reduction in the verum compared to the placebo group (intention-to-treat, population, verum: n = 55; placebo: n = 47) was found regarding TCS (P = 0.005), rhinoconjunctivitis total symptom score (RTSS, P = 0.006), and total rescue medication score (TRMS, P = 0.002). Additionally, secondary outcomes such as 'well days,' nasal challenge results, and increase of specific IgG4 were in favor of the active treatment. All systemic adverse reactions (0.8% of all injections in the verum group) were of mild intensity. No severe reactions related to the study medication were observed. CONCLUSION Cluster immunotherapy with high polymerized grass pollen extracts resulted in significant clinical efficacy and has been shown to be a safe treatment for grass pollen-allergic patients.
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Affiliation(s)
- L Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
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165
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Zhong H, Deng X, Song Z, Darsow U, Chen W, Chen S, Luo N, Hao F. Immunological changes after ASIT in AD allergen-specific immunotherapy and their potential correlation with clinical response in patients with atopic dermatitis patients sensitized to house dust mite. J Eur Acad Dermatol Venereol 2014; 29:1318-24. [PMID: 25376542 DOI: 10.1111/jdv.12813] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 09/29/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Allergen-specific immunotherapy (ASIT) is the main treatment for inducing long-term immunological and clinical tolerance in patients with IgE-mediated allergic diseases. Recent open-label and controlled studies on the efficacy of ASIT in patients with atopic dermatitis (AD) have provided promising results. However, data about possible relationship between the improvement of clinical symptoms and changes of serum cytokines are limited. METHODS Seventy-nine patients with moderate to severe AD sensitized to house dust mite (HDM) were enrolled. Fifty-eight patients were treated with ASIT and 11 controls received only symptomatic treatment. The disease activity in AD patients was evaluated by using the patient-oriented eczema measure (POEM) system. Serum interleukin (IL)-4, IL-10, interferon (IFN)-γ, transforming growth factor (TGF) β1, total IgE, HDM-specific IgE (s-IgE) and HDM-specific IgG4 (s-IgG4) were measured before and after 2 years of therapy. RESULTS The mean patient-oriented eczema measure system (POEM) score of AD patients with ASIT significantly decreased after 2 years of treatment, compared to that in patients without ASIT. After ASIT, the serum levels of IL-10, TGF-β1, IFN-γ and s-IgG4 increased, while the level of IL-4 decreased. The change in the POEM score was negatively correlated with changes of serum concentration of TGF-β1, s-IgG4 and IFN-γ. Furthermore, s-IgG4 levels were positively correlated with changes in the IL-10 levels. No correlation between POEM score and serum IL-10 or IL-4 was observed. CONCLUSION Clinical symptoms and the quality of life of AD with HDM sensitization could be improved after 2 years of ASIT. Changes in serum IL-10, TGF-β1, s-IgG4 and IFN-γ might be considered as biomarkers to assist clinical evaluation of the therapeutic effects of ASIT in patients with AD.
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Affiliation(s)
- H Zhong
- Department of Dermatology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - X Deng
- Department of Dermatology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Z Song
- Department of Dermatology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - U Darsow
- Department of Dermatology and Allergy, Technische Universitaet Muenchen, Munich, Germany
| | - W Chen
- Department of Dermatology and Allergy, Technische Universitaet Muenchen, Munich, Germany
| | - S Chen
- Department of Dermatology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - N Luo
- Department of Dermatology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - F Hao
- Department of Dermatology, Southwest Hospital, Third Military Medical University, Chongqing, China
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166
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Kim SH, Mun SJ, Han DH, Kim JW, Kim DY, Rhee CS. Three-Year Follow-up Results of Sublingual Immunotherapy in Patients With Allergic Rhinitis Sensitized to House Dust Mites. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2014; 7:118-23. [PMID: 25729618 PMCID: PMC4341332 DOI: 10.4168/aair.2015.7.2.118] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 05/27/2014] [Accepted: 06/18/2014] [Indexed: 11/30/2022]
Abstract
Purpose This study investigated the long-term efficacy, safety, and compliance associated with sublingual immunotherapy (SLIT) in Korean patients with allergic rhinitis sensitized to house dust mites. Methods This is a retrospective cohort study. A total of 164 patients who were sensitized to Dermatophagoides pteronyssinus and Dermatophagoides farinae and who received SLIT were enrolled between November 2007 and January 2010. Each patient was followed up using a diary card, on which a symptom score, rescue medication score, and adverse events (AEs) were recorded. Results All allergic rhinitis symptoms improved after 3 years of SLIT (P<0.05), and the rescue medication score decreased with time (P<0.05). The incidence of AEs associated with SLIT was 31% (51 of 164 patients) during the first month of therapy, and there were no severe AEs. The dropout rate was 19.5% (32 of 164 patients) during the first month, 34% (56 of 164 patients) after 6 months, and 41% (68 of 164 patients) after 1 year of SLIT. The 3-year compliance rate was approximately 40% (65 of 164 patients). The most common causes of dropout during the first month of SLIT were high cost and inconvenience. The improvement in allergic symptoms was the most common cause of dropout after 6 months. Conclusions Allergic symptoms significantly decreased after 1 year of SLIT treatment, and this effect was sustained after 2 or 3 years of treatment. By increasing compliance through patient education, the 3-year use of SLIT for house dust mite allergies may be effective in the management of allergic rhinitis.
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Affiliation(s)
- Shin Hye Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sue Jean Mun
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Doo Hee Han
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Whun Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong-Young Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chae-Seo Rhee
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seongnam, Korea. ; Graduate School of Immunology, Seoul National University, Seoul, Korea. ; Sensory Organ Research Institute, Seoul National University, Seoul, Korea. ; Institute of Allergy and Clinical Immunology, Seoul National University Biomedical Research Institute, Seoul, Korea
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167
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Passalacqua G. Recommendations for appropriate sublingual immunotherapy clinical trials. World Allergy Organ J 2014; 7:21. [PMID: 25309678 PMCID: PMC4192398 DOI: 10.1186/1939-4551-7-21] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 07/21/2014] [Indexed: 11/10/2022] Open
Abstract
Sublingual immunotherapy is currently considered a viable alternative to the subcutaneous route. The body of evidence of its efficacy is based on the results of 77 clinical trials and 7 meta-analyses, that have been published so far. Nonetheless, the experimental evidence is partially weak due to the large heterogeneity of studies, namely: doses, regimens, patient selection, duration of treatment, outcomes and reporting. In addition, it is virtually impossible to compare the potency of extracts produced by different manufacturers. Also, there is large variability in reporting and in the classification of adverse events, either systemic or local, so that only a rough estimate can be provided. Considering all these aspects, efforts are needed to harmonize the methodology, outcome measures and reporting of SLIT clinical trials, to achieve the ability of comparing the results of various studies. International societies and the World Allergy Organization have recently provided general recommendations on how to design and conduct trials which can provide more interpretable and homogeneous data.
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Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS S.Martino Hospital – IST – University of Genoa, L.go R Benzi 10, Padiglione Maragliano, 16132 Genoa Italy
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168
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Calderon MA, Bernstein DI, Blaiss M, Andersen JS, Nolte H. A comparative analysis of symptom and medication scoring methods used in clinical trials of sublingual immunotherapy for seasonal allergic rhinitis. Clin Exp Allergy 2014; 44:1228-39. [DOI: 10.1111/cea.12331] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- M. A. Calderon
- Imperial College London - National Heart and Lung Institute; Royal Brompton Hospital NHS; London UK
| | - D. I. Bernstein
- Bernstein Clinical Research Center and University of Cincinnati College of Medicine; Cincinnati OH USA
| | - M. Blaiss
- University of Tennessee Health Science Center; Memphis TN USA
| | | | - H. Nolte
- Merck & Co., Inc.; Whitehouse Station NJ USA
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169
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Didier A, Wahn U, Horak F, Cox LS. Five-grass-pollen sublingual immunotherapy tablet for the treatment of grass-pollen-induced allergic rhinoconjunctivitis: 5 years of experience. Expert Rev Clin Immunol 2014; 10:1309-24. [PMID: 25205329 DOI: 10.1586/1744666x.2014.957677] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Oralair(®) (OA) (Stallergenes, Antony, France) is a unique pre- and co-seasonal 5-grass-pollen sublingual immunotherapy tablet launched in 2008, and now approved in 31 countries worldwide for the treatment of grass-pollen allergic rhinitis and rhinoconjunctivitis. OA is the first oral treatment with a consistent, well-balanced allergen extract that mimics natural exposure and sensitization. A wealth of data exists from over 5 years of clinical and real-world experience demonstrating the efficacy and safety of OA for grass-pollen-allergy treatment. OA is highly effective from the first pollen season in all patient subgroups, including children and those with comorbid mild asthma, irrespective of sensitization status and symptom severity. OA also has sustained long-term benefits for symptom control and quality of life. This article provides an overview of the pharmacodynamics and pharmacology of OA; its efficacy, safety, tolerability and cost-effectiveness for the treatment of allergic rhinitis and rhinoconjunctivitis and its role in clinical practice.
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Affiliation(s)
- Alain Didier
- Department of Respiratory Diseases, Rangueil-Larrey Hospital, 24 Chemin de Pouvourville - TSA 30030, 31059 Toulouse Cedex 9, France
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Abstract
PURPOSE OF REVIEW The aim is to review recent literature up to July 2013 concerning the effect of allergen-specific immunotherapy (AIT) on asthma. AIT, effective in combined allergic rhinitis and asthma, was previously described as a convenient approach able to improve clinical outcomes and reduce bronchial hyperresponsiveness. In addition, long-term and preventive effects on the onset of new sensitizations and progression from allergic rhinitis to asthma have been shown. RECENT FINDINGS Recent investigations, mainly based on observational or small open trials, confirmed previous findings, showing improvement in asthma control, symptoms and medication usage and steroid-sparing effects, sometimes inconsistent with changes in lung function. Some meta-analyses support the clinical benefit on adult and paediatric asthma. Only few trials, however, were specifically designed to explore asthma endpoints. SUMMARY Clinical studies primarily have focused on AIT, and research on asthma endpoints is scarce; however, the evidence of beneficial effect of AIT for the treatment of adults and children affected by allergic rhinitis with or without asthma suggests that this treatment can favourably affect asthma. In children, sublingual AIT has been more extensively investigated than injective. Confirmatory, adequately powered trials are needed to reinforce the evidence of efficacy for individual AIT products. The main drawback in using injective AIT for asthma is the risk of serious adverse reactions and uncontrolled asthma. The sublingual route is better tolerated and does not appear inferior. As standard controller pharmacotherapy seems unable to affect the natural course of asthma, the potentially disease-modifying effect of AIT represents an appealing perspective that requires further investigation.
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171
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Pfaar O, Demoly P, Gerth van Wijk R, Bonini S, Bousquet J, Canonica GW, Durham SR, Jacobsen L, Malling HJ, Mösges R, Papadopoulos NG, Rak S, Rodriguez del Rio P, Valovirta E, Wahn U, Calderon MA. Recommendations for the standardization of clinical outcomes used in allergen immunotherapy trials for allergic rhinoconjunctivitis: an EAACI Position Paper. Allergy 2014; 69:854-67. [PMID: 24761804 DOI: 10.1111/all.12383] [Citation(s) in RCA: 309] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Allergen immunotherapy (AIT) has been thoroughly documented in randomized controlled trials (RCTs). It is the only immune-modifying and causal treatment available for patients suffering from IgE-mediated diseases such as allergic rhinoconjunctivitis, allergic asthma and insect sting allergy. However, there is a high degree of clinical and methodological heterogeneity among the endpoints in clinical studies on AIT, for both subcutaneous and sublingual immunotherapy (SCIT and SLIT). At present, there are no commonly accepted standards for defining the optimal outcome parameters to be used for both primary and secondary endpoints. METHODS As elaborated by a Task Force (TF) of the European Academy of Allergy and Clinical Immunology (EAACI) Immunotherapy Interest Group, this Position Paper evaluates the currently used outcome parameters in different RCTs and also aims to provide recommendations for the optimal endpoints in future AIT trials for allergic rhinoconjunctivitis. RESULTS Based on a thorough literature review, the TF members have outlined recommendations for nine domains of clinical outcome measures. As the primary outcome, the TF recommends a homogeneous combined symptom and medication score (CSMS) as a simple and standardized method that balances both symptoms and the need for antiallergic medication in an equally weighted manner. All outcomes, grouped into nine domains, are reviewed. CONCLUSION A standardized and globally harmonized method for analysing the clinical efficacy of AIT products in RCTs is required. The EAACI TF highlights the CSMS as the primary endpoint for future RCTs in AIT for allergic rhinoconjunctivitis.
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Affiliation(s)
- O. Pfaar
- Center for Rhinology and Allergology Wiesbaden; Department of Otorhinolaryngology, Head and Neck Surgery; University Hospital Mannheim; Mannheim Germany
| | - P. Demoly
- Département de Pneumologie et Addictologie; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- Sorbonne Universités; UPMC Paris 06, UMR-S 1136, IPLESP; Equipe EPAR; Paris France
| | - R. Gerth van Wijk
- Section of Allergology; Department of Internal Medicine; Erasmus MC; Rotterdam the Netherlands
| | - S. Bonini
- Second University of Naples and Institute of Translational Pharmacology; Italian National Research Council (IFT-CNR); Rome Italy
| | - J. Bousquet
- Département de Pneumologie et Addictologie; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- 1018, Respiratory and Environmental Epidemiology Team; INSERM; CESP Centre for research in Epidemiology and Population Health; Villejuif France
| | - G. W. Canonica
- Respiratory Diseases & Allergy Clinic; University of Genova; IRCCS AOU San Martino; Genova Italy
| | - S. R. Durham
- Section of Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College; London UK
| | - L. Jacobsen
- ALC, Allergy Learning and Consulting; Copenhagen Denmark
| | - H. J. Malling
- Allergy Clinic; University Hospital Gentofte; Copenhagen Denmark
| | - R. Mösges
- Institute of Medical Statistics; Informatics and Epidemiology (IMSIE); University of Cologne; Cologne Germany
| | - N. G. Papadopoulos
- Allergy Department; 2nd Pediatric Clinic; University of Athens; Athens Greece
- Centre for Paediatrics and Child Health; Institute of Human Development; University of Manchester; Manchester UK
| | - S. Rak
- Department of Respiratory Medicine and Allergology; Sahlgrenska University Hospital; Goteborg Sweden
| | | | - E. Valovirta
- Department of Clinical Allergology and Pulmonary Diseases; University of Turku; Finland
- Suomen Terveystalo Allergy Clinic; Turku Finland
| | - U. Wahn
- Department for Pediatric Pneumology and Immunology; Charité Medical University; Berlin Germany
| | - M. A. Calderon
- Section of Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College; London UK
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Häfner D, Gödicke V, Narkus A. Allergen specific immunotherapy has no influence on standard chemistry and hematology laboratory parameters in clinical studies. Clin Transl Allergy 2014; 4:18. [PMID: 24955235 PMCID: PMC4064516 DOI: 10.1186/2045-7022-4-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 03/26/2014] [Indexed: 11/10/2022] Open
Abstract
Background A set of standard clinical chemistry and hematology parameters are usually measured during clinical studies. The major outcome of these standard tests is to control that the drug investigated does not lead to pathophysiological changes in respective organs or blood. In some cases based on scientific rationale such tests may not be needed. In this paper we report on a standard set of clinical chemistry and hematology laboratory parameters measured before and after treatment in three different immunotherapy studies, representing different routes of administration and different formulations. Methods Thirteen hematological laboratory parameters and eight clinical chemistry parameters were evaluated from three double-blind, placebo-controlled, randomized, multi-centre, phase III studies. The three studies include one with sublingual immunotherapy (n = 185), one subcutaneous immunotherapy trial with an aluminium hydroxide-adsorbed recombinant hypoallergenic Bet v1-FV (n = 211) and one with pre-seasonal subcutaneous immunotherapy with a 6-grass pollen allergoid (n = 154). Results Allergen specific immunotherapy with both administration forms and formulations respectively did not show any influence on any of the 21 laboratory parameters analyzed. Few patients had a change in laboratory parameters from within normal range at baseline to either below or above at end-of-treatment. No differences between active and placebo were seen with respect to number of patients with such a change. Conclusions This study with different preparations and routes of application indicates that the value of repeated measurements of standard clinical chemistry and hematology parameters during allergen immunotherapy should be discussed further.
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Affiliation(s)
- Dietrich Häfner
- Allergopharma GmbH & Co. KG, Hermann-Körner-Str. 52, 21465 Reinbek, Germany
| | - Viola Gödicke
- Allergopharma GmbH & Co. KG, Hermann-Körner-Str. 52, 21465 Reinbek, Germany
| | - Annemie Narkus
- Allergopharma GmbH & Co. KG, Hermann-Körner-Str. 52, 21465 Reinbek, Germany
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173
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Sublingual five-grass pollen tablets (Oralair®): a guide to their use as allergen immunotherapy for grass pollen-induced allergic rhinoconjunctivitis. DRUGS & THERAPY PERSPECTIVES 2014. [DOI: 10.1007/s40267-014-0131-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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174
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Devillier P, Dreyfus JF, Demoly P, Calderón MA. A meta-analysis of sublingual allergen immunotherapy and pharmacotherapy in pollen-induced seasonal allergic rhinoconjunctivitis. BMC Med 2014; 12:71. [PMID: 24885894 PMCID: PMC4101870 DOI: 10.1186/1741-7015-12-71] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 03/31/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The capacity of sublingual allergen immunotherapy (SLIT) to provide effective symptom relief in pollen-induced seasonal allergic rhinitis is often questioned, despite evidence of clinical efficacy from meta-analyses and well-powered, double-blind, placebo-controlled randomized clinical trials. In the absence of direct, head-to-head, comparative trials of SLIT and symptomatic medication, only indirect comparisons are possible. METHODS We performed a meta-analysis of classes of products (second-generation H1-antihistamines, nasal corticosteroids and grass pollen SLIT tablet formulations) and single products (the azelastine-fluticasone combination MP29-02, and the leukotriene receptor antagonist montelukast) for the treatment of seasonal allergic rhinitis in adults, adolescents and/or children. We searched the literature for large (n >100 in the smallest treatment arm) double-blind, placebo-controlled randomized clinical trials. For each drug or drug class, we performed a meta-analysis of the effect on symptom scores. For each selected trial, we calculated the relative clinical impact (according to a previously published method) on the basis of the reported post-treatment or season-long nasal or total symptom scores: 100 × (scorePlacebo - scoreActive)/scorePlacebo. RESULTS Twenty-eight publications on symptomatic medication trials and ten on SLIT trials met our selection criteria (total number of patients: n = 21,223). The Hedges' g values from the meta-analyses confirmed the presence of a treatment effect for all drug classes. In an indirect comparison, the weighted mean (range) relative clinical impacts were -29.6% (-23% to -37%) for five-grass pollen SLIT tablets, -19.2% (-6% to -29%) for timothy pollen SLIT tablets, -23.5% (-7% to -54%) for nasal corticosteroids, -17.1% (-15% to -20%) for MP29-02, -15.0% (-3% to -26%) for H1-antihistamines and -6.5% (-3% to -10%) for montelukast. CONCLUSIONS In an indirect comparison, grass pollen SLIT tablets had a greater mean relative clinical impact than second-generation antihistamines and montelukast and much the same mean relative clinical impact as nasal corticosteroids. This result was obtained despite the presence of methodological factors that mask the clinical efficacy of SLIT for the treatment of seasonal allergic rhinitis.
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Affiliation(s)
- Philippe Devillier
- UPRES EA 220 & Clinical Research Department, Foch Hospital, University of Versailles Saint-Quentin, Suresnes, France
- Biostatistics Unit, Clinical Research Department, Foch Hospital, Suresnes, France
| | | | - Pascal Demoly
- EPAR INSERM U707, Allergy Division, Pulmonology Department, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France, and Institut Pierre Louis d’Epidémiologie et de Santé Publique, Faculté de Médecine, Université Pierre et Marie Curie, Paris, France
| | - Moisés A Calderón
- Section of Allergy and Clinical Immunology, Imperial College London-NHLI, Royal Brompton Hospital, Dovehouse Street, London, UK
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175
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Canonica GW, Cox L, Pawankar R, Baena-Cagnani CE, Blaiss M, Bonini S, Bousquet J, Calderón M, Compalati E, Durham SR, van Wijk RG, Larenas-Linnemann D, Nelson H, Passalacqua G, Pfaar O, Rosário N, Ryan D, Rosenwasser L, Schmid-Grendelmeier P, Senna G, Valovirta E, Van Bever H, Vichyanond P, Wahn U, Yusuf O. Sublingual immunotherapy: World Allergy Organization position paper 2013 update. World Allergy Organ J 2014; 7:6. [PMID: 24679069 PMCID: PMC3983904 DOI: 10.1186/1939-4551-7-6] [Citation(s) in RCA: 322] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 02/07/2014] [Indexed: 02/07/2023] Open
Abstract
We have prepared this document, "Sublingual Immunotherapy: World Allergy Organization Position Paper 2013 Update", according to the evidence-based criteria, revising and updating chapters of the originally published paper, "Sublingual Immunotherapy: World Allergy Organization Position Paper 2009", available at http://www.waojournal.org. Namely, these comprise: "Mechanisms of sublingual immunotherapy;" "Clinical efficacy of sublingual immunotherapy" - reporting all the data of all controlled trials published after 2009; "Safety of sublingual immunotherapy" - with the recently published Grading System for adverse reactions; "Impact of sublingual immunotherapy on the natural history of respiratory allergy" - with the relevant evidences published since 2009; "Efficacy of SLIT in children" - with detailed analysis of all the studies; "Definition of SLIT patient selection" - reporting the criteria for eligibility to sublingual immunotherapy; "The future of immunotherapy in the community care setting"; "Methodology of clinical trials according to the current scientific and regulatory standards"; and "Guideline development: from evidence-based medicine to patients' views" - including the evolution of the methods to make clinical recommendations.Additionally, we have added new chapters to cover a few emerging crucial topics: "Practical aspects of schedules and dosages and counseling for adherence" - which is crucial in clinical practice for all treatments; "Perspectives and new approaches" - including recombinant allergens, adjuvants, modified allergens, and the concept of validity of the single products. Furthermore, "Raising public awareness about sublingual immunotherapy", as a need for our patients, and strategies to increase awareness of allergen immunotherapy (AIT) among patients, the medical community, all healthcare stakeholders, and public opinion, are also reported in detail.
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Affiliation(s)
- Giorgio Walter Canonica
- Respiratory and Allergy Clinic, DIMI—Department of Internal Medicine, University of Genoa, IRCCS Aou San Martino, Largo Rosanna Benzi 10, Genoa 1-16132, Italy
| | - Linda Cox
- Department of Medicine, Nova Southeastern University, College of Osteopathic Medicine, Davie Florida, USA
| | - Ruby Pawankar
- Division of Allergy, Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Carlos E Baena-Cagnani
- Research Center for Respiratory Medicine (CIMER), Catholic University, Fundación LIBRA, Córdoba, Argentina
| | - Michael Blaiss
- Department of Pediatrics and Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sergio Bonini
- Department of Medicine, Second University of Naples, Institute of Translational Pharmacology, Italian National Research Council, Rome, Italy
| | - Jean Bousquet
- Centre Hospitalier Regional Universitaire de Montpellier, Université de Montpellier, Montpellier, France
| | - Moises Calderón
- Section of Allergy and Clinical Immunology, Imperial College of London, National Heart and Lung Institute, Royal Brompton Hospital, London, UK
| | - Enrico Compalati
- Allergy and Respiratory Diseases Clinic, Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Stephen R Durham
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College of London, London, UK
| | - Roy Gerth van Wijk
- Department of Allergology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Harold Nelson
- National Jewish Health, University of Colorado – Denver School of Medicine, Denver, Colorado, USA
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino IST, University of Genoa, Genova, Italy
| | - Oliver Pfaar
- Center for Rhinology and Allergology Wiesbaden, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Nelson Rosário
- Pediatric Allergy and Immunology Division, Hospital de Clínicas, Federal University of Parana, Curitiba, Brazil
| | - Dermot Ryan
- Academic Centre of Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Lanny Rosenwasser
- Children’s Mercy Hospital, University of Missouri – Kansas City School of Medicine, Kansas City, Missouri
| | | | | | - Erkka Valovirta
- Department of Clinical Allergology and Pulmonary Diseases, University of Turku, Finland, and Allergy Clinic, Terveystalo, Turku, Finland
| | - Hugo Van Bever
- Department of Paediatrics, University Children’s Medical Institute, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Pakit Vichyanond
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ulrich Wahn
- Department of Pediatric Pneumology and Immunology, Charité, Humboldt University, Berlin, Germany
| | - Osman Yusuf
- The Allergy and Asthma Institute, Islamabad, Pakistan
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Health-Related Quality of Life and Rhinitis Control Measures in Allergic Rhinitis. CURRENT TREATMENT OPTIONS IN ALLERGY 2014. [DOI: 10.1007/s40521-013-0007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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177
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Allergen Immunotherapy: Clinical Outcomes Assessment. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:123-9; quiz 130. [DOI: 10.1016/j.jaip.2014.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/20/2014] [Accepted: 01/22/2014] [Indexed: 12/16/2022]
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Worm M, Rak S, de Blay F, Malling HJ, Melac M, Cadic V, Zeldin RK. Sustained efficacy and safety of a 300IR daily dose of a sublingual solution of birch pollen allergen extract in adults with allergic rhinoconjunctivitis: results of a double-blind, placebo-controlled study. Clin Transl Allergy 2014; 4:7. [PMID: 24517417 PMCID: PMC3928083 DOI: 10.1186/2045-7022-4-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 02/06/2014] [Indexed: 11/29/2022] Open
Abstract
Background Allergic rhinoconjunctivitis (ARC) due to birch pollen is a growing health concern in Europe. Here, we report the efficacy and safety of 300IR birch pollen sublingual solution administered discontinuously for 2 consecutive years to patients with birch-associated allergic rhinoconjunctivitis. Methods Birch pollen-allergic adults were randomized in this double blind study to 300IR birch pollen sublingual solution or placebo, daily, starting 4 months before and continuing through the pollen season for two pollen seasons. Randomization was stratified according to the presence or absence of oral allergy syndrome (OAS). The primary efficacy endpoint was the Average Adjusted Symptom Score (AAdSS) over the second pollen season and was analyzed by ANCOVA. Secondary efficacy endpoints included the AAdSS over the first pollen period. Safety was evaluated by means of adverse event monitoring. Results 574 patients (284 in the active group and 290 in the placebo group) were randomized and 496 completed the study. Over the second pollen period, the least square (LS) mean AAdSS was significantly lower in the 300IR group than in the placebo group (LS mean difference −2.04, 95% CI [−2.69, −1.40], (p <0.0001) with a relative reduction of 30.6%. Results were consistent in patients with and without OAS (−33.6% and −28.4%, respectively). A significant reduction in LS mean AAdSS was also observed over the first pollen season. The most frequently reported adverse events were application site reactions: oral pruritus, throat irritation, and mouth edema. There were no reports of anaphylaxis. Conclusions Pre- and co-seasonal treatment with 300IR birch pollen sublingual solution demonstrated sustained clinical efficacy over 2 pollen seasons and was well tolerated in adults with birch pollen-associated allergic rhinoconjunctivitis. Efficacy results were consistent in patients with and without oral allergy syndrome. Trial registration ClinicalTrials.gov: NCT01731249.
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Affiliation(s)
- Margitta Worm
- Allergy-Centre-Charité, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Sabina Rak
- Asthma and Allergy Research Group, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Frédéric de Blay
- Chest Diseases Department, Strasbourg University Hospital, Federation of Translational Medicine, University of Strasbourg, Strasbourg, France
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Malling HJ, Witten M, Poulsen LK. Reply: To PMID 24035151. J Allergy Clin Immunol 2014; 133:931-2. [PMID: 24439078 DOI: 10.1016/j.jaci.2013.11.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 11/25/2013] [Accepted: 11/26/2013] [Indexed: 10/25/2022]
Affiliation(s)
| | - Marianne Witten
- Allergy Clinic, Copenhagen University Hospital, Gentofte, Denmark
| | - Lars K Poulsen
- Allergy Clinic, Copenhagen University Hospital, Gentofte, Denmark.
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Dölle S, Berg J, Rasche C, Worm M. Tolerability and Clinical Outcome of Coseasonal Treatment withEscherichia coliStrain Nissle 1917 in Grass Pollen-Allergic Subjects. Int Arch Allergy Immunol 2014; 163:29-35. [DOI: 10.1159/000356328] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 09/30/2013] [Indexed: 11/19/2022] Open
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Pfaar O, Bachert C, Bufe A, Buhl R, Ebner C, Eng P, Friedrichs F, Fuchs T, Hamelmann E, Hartwig-Bade D, Hering T, Huttegger I, Jung K, Klimek L, Kopp MV, Merk H, Rabe U, Saloga J, Schmid-Grendelmeier P, Schuster A, Schwerk N, Sitter H, Umpfenbach U, Wedi B, Wöhrl S, Worm M, Kleine-Tebbe J, Kaul S, Schwalfenberg A. Guideline on allergen-specific immunotherapy in IgE-mediated allergic diseases: S2k Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Society for Pediatric Allergy and Environmental Medicine (GPA), the Medical Association of German Allergologists (AeDA), the Austrian Society for Allergy and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Dermatology (DDG), the German Society of Oto- Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), the German Society of Pediatrics and Adolescent Medicine (DGKJ), the Society for Pediatric Pneumology (GPP), the German Respiratory Society (DGP), the German Association of ENT Surgeons (BV-HNO), the Professional Federation of Paediatricians and Youth Doctors (BVKJ), the Federal Association of Pulmonologists (BDP) and the German Dermatologists Association (BVDD). ALLERGO JOURNAL INTERNATIONAL 2014; 23:282-319. [PMID: 26120539 PMCID: PMC4479478 DOI: 10.1007/s40629-014-0032-2] [Citation(s) in RCA: 285] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The present guideline (S2k) on allergen-specific immunotherapy (AIT) was established by the German, Austrian and Swiss professional associations for allergy in consensus with the scientific specialist societies and professional associations in the fields of otolaryngology, dermatology and venereology, pediatric and adolescent medicine, pneumology as well as a German patient organization (German Allergy and Asthma Association; Deutscher Allergie- und Asthmabund, DAAB) according to the criteria of the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). AIT is a therapy with disease-modifying effects. By administering allergen extracts, specific blocking antibodies, toler-ance-inducing cells and mediators are activated. These prevent further exacerbation of the allergen-triggered immune response, block the specific immune response and attenuate the inflammatory response in tissue. Products for SCIT or SLIT cannot be compared at present due to their heterogeneous composition, nor can allergen concentrations given by different manufacturers be compared meaningfully due to the varying methods used to measure their active ingredients. Non-modified allergens are used for SCIT in the form of aqueous or physically adsorbed (depot) extracts, as well as chemically modified allergens (allergoids) as depot extracts. Allergen extracts for SLIT are used in the form of aqueous solutions or tablets. The clinical efficacy of AIT is measured using various scores as primary and secondary study endpoints. The EMA stipulates combined symptom and medication scores as primary endpoint. A harmonization of clinical endpoints, e. g., by using the combined symptom and medication scores (CSMS) recommended by the EAACI, is desirable in the future in order to permit the comparison of results from different studies. The current CONSORT recommendations from the ARIA/GA2LEN group specify standards for the evaluation, presentation and publication of study results. According to the Therapy allergen ordinance (TAV), preparations containing common allergen sources (pollen from grasses, birch, alder, hazel, house dust mites, as well as bee and wasp venom) need a marketing authorization in Germany. During the marketing authorization process, these preparations are examined regarding quality, safety and efficacy. In the opinion of the authors, authorized allergen preparations with documented efficacy and safety, or preparations tradeable under the TAV for which efficacy and safety have already been documented in clinical trials meeting WAO or EMA standards, should be preferentially used. Individual formulations (NPP) enable the prescription of rare allergen sources (e.g., pollen from ash, mugwort or ambrosia, mold Alternaria, animal allergens) for specific immunotherapy. Mixing these allergens with TAV allergens is not permitted. Allergic rhinitis and its associated co-morbidities (e. g., bronchial asthma) generate substantial direct and indirect costs. Treatment options, in particular AIT, are therefore evaluated using cost-benefit and cost-effectiveness analyses. From a long-term perspective, AIT is considered to be significantly more cost effective in allergic rhinitis and allergic asthma than pharmacotherapy, but is heavily dependent on patient compliance. Meta-analyses provide unequivocal evidence of the efficacy of SCIT and SLIT for certain allergen sources and age groups. Data from controlled studies differ in terms of scope, quality and dosing regimens and require product-specific evaluation. Therefore, evaluating individual preparations according to clearly defined criteria is recommended. A broad transfer of the efficacy of certain preparations to all preparations administered in the same way is not endorsed. The website of the German Society for Allergology and Clinical Immunology (www.dgaki.de/leitlinien/s2k-leitlinie-sit; DGAKI: Deutsche Gesellschaft für Allergologie und klinische Immunologie) provides tables with specific information on available products for AIT in Germany, Switzerland and Austria. The tables contain the number of clinical studies per product in adults and children, the year of market authorization, underlying scoring systems, number of randomized and analyzed subjects and the method of evaluation (ITT, FAS, PP), separately given for grass pollen, birch pollen and house dust mite allergens, and the status of approval for the conduct of clinical studies with these products. Strong evidence of the efficacy of SCIT in pollen allergy-induced allergic rhinoconjunctivitis in adulthood is well-documented in numerous trials and, in childhood and adolescence, in a few trials. Efficacy in house dust mite allergy is documented by a number of controlled trials in adults and few controlled trials in children. Only a few controlled trials, independent of age, are available for mold allergy (in particular Alternaria). With regard to animal dander allergies (primarily to cat allergens), only small studies, some with methodological deficiencies are available. Only a moderate and inconsistent therapeutic effect in atopic dermatitis has been observed in the quite heterogeneous studies conducted to date. SCIT has been well investigated for individual preparations in controlled bronchial asthma as defined by the Global Initiative for Asthma (GINA) 2007 and intermittent and mild persistent asthma (GINA 2005) and it is recommended as a treatment option, in addition to allergen avoidance and pharmacotherapy, provided there is a clear causal link between respiratory symptoms and the relevant allergen. The efficacy of SLIT in grass pollen-induced allergic rhinoconjunctivitis is extensively documented in adults and children, whilst its efficacy in tree pollen allergy has only been shown in adults. New controlled trials (some with high patient numbers) on house dust mite allergy provide evidence of efficacy of SLIT in adults. Compared with allergic rhinoconjunctivitis, there are only few studies on the efficacy of SLIT in allergic asthma. In this context, newer studies show an efficacy for SLIT on asthma symptoms in the subgroup of grass pollen allergic children, adolescents and adults with asthma and efficacy in primary house dust mite allergy-induced asthma in adolescents aged from 14 years and in adults. Aspects of secondary prevention, in particular the reduction of new sensitizations and reduced asthma risk, are important rationales for choosing to initiate treatment early in childhood and adolescence. In this context, those products for which the appropriate effects have been demonstrated should be considered. SCIT or SLIT with pollen or mite allergens can be performed in patients with allergic rhinoconjunctivitis using allergen extracts that have been proven to be effective in at least one double-blind placebo-controlled (DBPC) study. At present, clinical trials are underway for the indication in asthma due to house dust mite allergy, some of the results of which have already been published, whilst others are still awaited (see the DGAKI table "Approved/potentially completed studies" via www.dgaki.de/Leitlinien/s2k-Leitlinie-sit (according to www.clinicaltrialsregister.eu)). When establishing the indication for AIT, factors that favour clinical efficacy should be taken into consideration. Differences between SCIT and SLIT are to be considered primarily in terms of contraindications. In individual cases, AIT may be justifiably indicated despite the presence of contraindications. SCIT injections and the initiation of SLIT are performed by a physician experienced in this type of treatment and who is able to administer emergency treatment in the case of an allergic reaction. Patients must be fully informed about the procedure and risks of possible adverse events, and the details of this process must be documented (see "Treatment information sheet"; available as a handout via www.dgaki.de/Leitlinien/s2k-Leitlinie-sit). Treatment should be performed according to the manufacturer's product information leaflet. In cases where AIT is to be performed or continued by a different physician to the one who established the indication, close cooperation is required in order to ensure that treatment is implemented consistently and at low risk. In general, it is recommended that SCIT and SLIT should only be performed using preparations for which adequate proof of efficacy is available from clinical trials. Treatment adherence among AIT patients is lower than assumed by physicians, irrespective of the form of administration. Clearly, adherence is of vital importance for treatment success. Improving AIT adherence is one of the most important future goals, in order to ensure efficacy of the therapy. Severe, potentially life-threatening systemic reactions during SCIT are possible, but - providing all safety measures are adhered to - these events are very rare. Most adverse events are mild to moderate and can be treated well. Dose-dependent adverse local reactions occur frequently in the mouth and throat in SLIT. Systemic reactions have been described in SLIT, but are seen far less often than with SCIT. In terms of anaphylaxis and other severe systemic reactions, SLIT has a better safety profile than SCIT. The risk and effects of adverse systemic reactions in the setting of AIT can be effectively reduced by training of personnel, adhering to safety standards and prompt use of emergency measures, including early administration of i. m. epinephrine. Details on the acute management of anaphylactic reactions can be found in the current S2 guideline on anaphylaxis issued by the AWMF (S2-AWMF-LL Registry Number 061-025). AIT is undergoing some innovative developments in many areas (e. g., allergen characterization, new administration routes, adjuvants, faster and safer dose escalation protocols), some of which are already being investigated in clinical trials. Cite this as Pfaar O, Bachert C, Bufe A, Buhl R, Ebner C, Eng P, Friedrichs F, Fuchs T, Hamelmann E, Hartwig-Bade D, Hering T, Huttegger I, Jung K, Klimek L, Kopp MV, Merk H, Rabe U, Saloga J, Schmid-Grendelmeier P, Schuster A, Schwerk N, Sitter H, Umpfenbach U, Wedi B, Wöhrl S, Worm M, Kleine-Tebbe J. Guideline on allergen-specific immunotherapy in IgE-mediated allergic diseases - S2k Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Society for Pediatric Allergy and Environmental Medicine (GPA), the Medical Association of German Allergologists (AeDA), the Austrian Society for Allergy and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Dermatology (DDG), the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), the German Society of Pediatrics and Adolescent Medicine (DGKJ), the Society for Pediatric Pneumology (GPP), the German Respiratory Society (DGP), the German Association of ENT Surgeons (BV-HNO), the Professional Federation of Paediatricians and Youth Doctors (BVKJ), the Federal Association of Pulmonologists (BDP) and the German Dermatologists Association (BVDD). Allergo J Int 2014;23:282-319.
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Affiliation(s)
- Oliver Pfaar
- />Center for Rhinology and Allergology, Wiesbaden, Germany
- />Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany
- />Center for Rhinology and Allergology Wiesbaden, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, An den Quellen 10, 65189 Wiesbaden, Germany
| | - Claus Bachert
- />Department of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
| | - Albrecht Bufe
- />Department of Experimental Pneumology, Ruhr-University Bochum, Bochum, Germany
| | - Roland Buhl
- />Pulmonary Department, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Christof Ebner
- />Outpatient Clinic for Allergy and Clinical Immunology, Vienna, Austria
| | - Peter Eng
- />Department of Children and Adolescent Medicine, Aarau and Children‘s Hospital Lucerne, Lucerne, Switzerland
| | - Frank Friedrichs
- />Pediatric and Adolescent Medicine Practice, Laurensberg, Germany
| | - Thomas Fuchs
- />Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Eckard Hamelmann
- />Department of Pediatric and Adolescent Medicine, Pediatric Center Bethel, Evangelical Hospital, Bielefeld, Germany
| | | | - Thomas Hering
- />Pulmonary Outpatient Practice, Tegel, Berlin, Germany
| | - Isidor Huttegger
- />Department of Pediatric and Adolescent Medicine, Paracelsus Private Medical University, Salzburg Regional Hospitals, Salzburg, Austria
| | | | - Ludger Klimek
- />Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Matthias Volkmar Kopp
- />Clinic of Pediatric and Adolescent Medicine, Lübeck University, Airway Research Center North (ARCN), Member of the German Lung Center (DZL), Lübeck, Germany
| | - Hans Merk
- />Department of Dermatology and Allergology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Uta Rabe
- />Department of Allergology, Johanniter-Krankenhaus im Fläming Treuenbrietzen GmbH, Treuenbrietzen Germany, Treuenbrietzen, Germany
| | - Joachim Saloga
- />Department of Dermatology, University Medical Center, Johannes-Gutenberg University, Mainz, Germany
| | | | - Antje Schuster
- />Center for Pediatric and Adolescent Medicine, University Medical Center, Düsseldorf, Germany
| | - Nicolaus Schwerk
- />University Children’s hospital, Department of Pediatric Pneumology, Allergology and Neonatology, Hanover Medical University, Hannover, Germany
| | - Helmut Sitter
- />Institute for Theoretical Surgery, Marburg University, Marburg, Germany
| | | | - Bettina Wedi
- />Department of Dermatology, Allergology and Venereology, Hannover Medical University, Hannover, Germany
| | | | - Margitta Worm
- />Allergy-Centre-Charité, Department of Dermatology, Venereology, and Allergology, Charité University Hospital, Berlin, Germany
| | | | - Susanne Kaul
- />Division of Allergology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
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Bergmann KC, Demoly P, Worm M, Fokkens WJ, Carrillo T, Tabar AI, Nguyen H, Montagut A, Zeldin RK. Efficacy and safety of sublingual tablets of house dust mite allergen extracts in adults with allergic rhinitis. J Allergy Clin Immunol 2013; 133:1608-14.e6. [PMID: 24388010 DOI: 10.1016/j.jaci.2013.11.012] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 11/08/2013] [Accepted: 11/18/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Preliminary studies have suggested the efficacy of sublingual tablets of house dust mite (HDM) extracts in adults with allergic rhinitis. OBJECTIVES We sought to assess the efficacy and safety of 2 doses of HDM sublingual tablets over 1 treatment year and the subsequent immunotherapy-free year. METHODS Adults with HDM-associated allergic rhinitis were randomized in a double-blind, placebo-controlled study to receive 500 index of reactivity (IR) tablets, 300IR tablets, or placebo administered once daily for 1 year and were followed for the subsequent year. The primary efficacy variable was the Average Adjusted Symptom Score over the year 1 primary period (ie, October 1 to December 31). Symptoms and rescue medication scores, onset of action, patient-reported outcomes, and safety were secondary variables. The same end points were evaluated during the immunotherapy-free year. The primary efficacy end point was analyzed by using analysis of covariance. RESULTS Five hundred nine participants were randomized, and 427 continued in the immunotherapy-free year. Both the 500IR and 300IR HDM sublingual tablets significantly reduced mean Average Adjusted Symptom Scores compared with placebo by -20.2% (P = .0066) and -17.9% (P = .0150), respectively. Efficacy of both doses was maintained during the treatment-free follow-up phase. The onset of action was at 4 months. Participants' global evaluation of treatment success was significantly higher in the 500IR and 300IR groups compared with the placebo group (P = .0206 and P = .0001, respectively). Adverse events were generally application-site reactions. There were no reports of anaphylaxis. CONCLUSIONS Twelve months of treatment with 500IR and 300IR sublingual tablets of HDM allergen extracts was efficacious and well tolerated. Efficacy was maintained during the treatment-free follow-up year.
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Affiliation(s)
| | - Pascal Demoly
- Allergology Department, CHU Montpellier, Montpellier, France
| | - Margitta Worm
- Allergy-Centre-Charité, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Wytske J Fokkens
- Academic Medical Centre, Otorhinolaryngology, Amsterdam, The Netherlands
| | - Teresa Carrillo
- Allergology Department, Hospital Universitario de Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Spain
| | - Ana I Tabar
- Department of Allergy, Compleio Hospitalario de Navarra, Pamplona, Spain
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Narkus A, Lehnigk U, Haefner D, Klinger R, Pfaar O, Worm M. The placebo effect in allergen-specific immunotherapy trials. Clin Transl Allergy 2013; 3:42. [PMID: 24360060 PMCID: PMC3878370 DOI: 10.1186/2045-7022-3-42] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 12/09/2013] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Double-blind, placebo-controlled (DBPC) trials are the gold standard for demonstrating clinical efficacy and tolerability. The placebo effect, although an important feature in placebo-controlled studies, has never been systematically investigated in allergen-specific immunotherapy (SIT) studies. This study was performed to examine the placebo response in SIT trials that employed a baseline observational period and two treatment years using a symptom-medication-score (SMS) as the primary endpoint. METHODS The placebo effect was evaluated in six DBPC SIT studies (five studies using subcutaneous SIT (SCIT) and one sublingual (SLIT)), two grass, two birch and two house dust mite (HDM) SIT, including a total of 472 adult patients treated with a placebo. The results were reported as changes from baseline of the SMS area under the curve after two years of perennial placebo therapy during the respective evaluation periods. Pollen counts and IgG4 levels were additionally analysed. RESULTS Subcutaneously treated placebo patients displayed a marked decrease in the SMS. The mean placebo effect in the SCIT trials with comparable allergen exposure was up to 41% in the second treatment year and, in contrast, reached only 1% in the SLIT trial. Allergen exposure had an inverse influence on the placebo effect. No changes from baseline in allergen specific IgG4 antibodies were observed in the placebo-treated patients. CONCLUSIONS SIT studies display a significant placebo effect, mainly observed in subcutaneous immunotherapy, with high variability depending on the route of application and allergen exposure. Our findings indicate the differential role of the placebo effect in SIT efficacy depending on the route of administration and pollen exposure.
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Affiliation(s)
- Annemie Narkus
- Medical Department, Allergopharma GmbH & Co KG, Reinbek, Germany
| | - Ulrike Lehnigk
- Medical Department, Allergopharma GmbH & Co KG, Reinbek, Germany
| | - Dietrich Haefner
- Medical Department, Allergopharma GmbH & Co KG, Reinbek, Germany
| | - Regine Klinger
- Department of Clinical Psychology, Behaviour Therapy, University of Hamburg, Hamburg, Germany
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Margitta Worm
- Allergy-Center-Charité, Department of Dermatology and Allergy, Charité-Campus Mitte, Universitätsmedizin, Berlin, Germany
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Creticos PS, Esch RE, Couroux P, Gentile D, D'Angelo P, Whitlow B, Alexander M, Coyne TC. Randomized, double-blind, placebo-controlled trial of standardized ragweed sublingual-liquid immunotherapy for allergic rhinoconjunctivitis. J Allergy Clin Immunol 2013; 133:751-8. [PMID: 24332263 DOI: 10.1016/j.jaci.2013.10.041] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 10/15/2013] [Accepted: 10/24/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Sublingual immunotherapy with liquid extracts provides an appealing alternative to subcutaneous immunotherapy for the treatment of allergic rhinoconjunctivitis (ARC), but a lack of robust evidence has deterred its use in North America. OBJECTIVE To determine the efficacy and tolerability of standardized glycerinated short ragweed sublingual allergen immunotherapy liquid (RW-SAIL) extract in subjects with ragweed-related ARC. METHODS This phase 3, randomized, placebo-controlled trial was conducted in North America. Subjects (age range, 18-55 years) with or without asthma were selected based on ARC symptom severity and erythema skin prick reaction to short ragweed. Subjects self-administered the maximum tolerated dose of RW-SAIL (n = 218) or placebo (n = 211) daily beginning approximately 8 to 16 weeks before and through the end of the ragweed pollen season. The primary end point was subject-assessed total combined daily rhinoconjunctivitis symptom and medication scores (TCS). RESULTS During the entire season, there was a 43% decrease in TCS in subjects treated with RW-SAIL compared with placebo. Similar decreases were observed in TCS between the 2 groups during peak season (42%) and in daily symptom scores during the entire (42%) and peak (41%) seasons. The occurrence of adverse events was similar between the treatment groups; most were mild in severity. Treatment-related oromucosal local application site reactions occurred early and were transient and self-limited. No anaphylaxis occurred. CONCLUSIONS This is the first successful North American confirmatory phase 3 clinical trial to demonstrate the safety and efficacy of a sublingual standardized ragweed allergen immunotherapy liquid extract for the treatment of ARC.
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Affiliation(s)
- Peter S Creticos
- Creticos Research Group, Crownsville, and Allergy & Asthma Specialists of Greater Washington, Warrenton, Va.
| | | | | | - Deborah Gentile
- Department of Medicine, Division of Allergy, Asthma and Immunology, Allegheny General Hospital, Pittsburgh, Pa
| | - Pina D'Angelo
- Novum Pharmaceutical Research Services, Pittsburgh, Pa
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Peng W, Liu E. Factors influencing the response to specific immunotherapy for asthma in children aged 5-16 years. Pediatr Int 2013; 55:680-4. [PMID: 23809249 DOI: 10.1111/ped.12175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 06/13/2013] [Accepted: 06/19/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the factors predicting the response to allergen-specific immunotherapy (ASIT) in children with asthma. METHODS The case notes of children with asthma who received ASIT for 2 years were retrospectively reviewed. The cases were then divided into an effective clinical response group, defined as absence of asthma symptoms without requirement for medication for at least 6 months during follow up; and an ineffective clinical response group. At the time of initiating treatment, blood was collected for analysis of serum total IgE. Family history of atopy, history of passive smoking, onset age of wheezing and so on was obtained from each patient. Ten factors that may influence children's response were analyzed on logistic regression analysis and compared between groups. RESULTS A total of 99 children with asthma received ASIT s.c. for 2 years during September 2007-February 2010. The average age was 8.66 ± 0.30 years. Good response to ASIT was found in 72 cases, while an inadequate response was found in 27 cases. Of the 10 factors tested for correlation with clinical response to ASIT, a significant correlation was found with onset age of wheezing and airway hyperresponsiveness (AHR). The odds ratio for the onset age of wheezing was 2.81 (95% confidence interval [CI]: 1.40-5.65, P = 0.004) and that for AHR was 1.33 (95%CI: 1.04-1.70, P = 0.021). CONCLUSION Potential predictors for the response to ASIT in children with asthma were identified. Onset age of wheezing and AHR may influence response to ASIT.
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Affiliation(s)
- Wansheng Peng
- Department of Pediatrics, First Affiliation Hospital of Bengbu Medical College, Bengbu, China
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186
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Abstract
BACKGROUND The prescription of allergen immunotherapy (SIT) in asthma remains a matter of debate and official guidelines often do not provide clear recommendations in this regard. METHODS An extensive review of the literature was untaken. RESULTS There are many robust studies with SCIT and SLIT showing positive results related to improving asthma symptoms, in particular when asthma was associated with rhinitis. In addition, there are several favourable meta-analyses, although their validity is limited by the heterogeneity of the trials included. The disease modifying effect of SIT (prevention of asthma onset and long-lasting effects) should be considered when prescribing this treatment. Regarding safety, fatalities seem to be rare: in Europe no fatality has been reported over the last two decades, and the same has been observed in USA in the last 4 years. Uncontrolled asthma is universally recognized as the most important risk factor for severe adverse events, but there is no clear demonstration that SIT can worsen or induce asthma. In contrast, of the few studies specifically designed to evaluate asthma, none had a formal sample size calculation, and pulmonary function was assessed as primary outcome only sporadically. CONCLUSIONS According to the presently available evidence, SLIT and SCIT can be used in asthma associated with rhinitis (the most common condition), provided that asthma is adequately controlled by pharmacotherapy. In such cases, a measurable clinical benefit on asthma symptoms can be expected. SIT cannot be presently recommended as single therapy when asthma is the unique manifestation of respiratory allergy.
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Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino, IST, University of Genoa , Genoa , Italy
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Myszkowska D, Stobiecki M, Dyga W, Majewska R, Czarnobilska E. A two year survey of the practical application of pollen monitoring in immunotherapy with grass allergens. ALLERGO JOURNAL 2013. [DOI: 10.1007/s15007-013-0401-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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188
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Pfaar O, Biedermann T, Klimek L, Sager A, Robinson DS. Depigmented-polymerized mixed grass/birch pollen extract immunotherapy is effective in polysensitized patients. Allergy 2013; 68:1306-13. [PMID: 23991896 DOI: 10.1111/all.12219] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although many patients with allergic rhinoconjunctivitis have symptoms due to sensitization with more than one pollen allergen, and mixed pollen extracts are widely used for allergen immunotherapy in practice, there are few published trials. METHODS We performed a 2-year multicentre, double-blind, placebo-controlled trial of subcutaneous immunotherapy with mixed depigmented-polymerized birch and grass pollen extract in 285 patients with allergic rhinoconjunctivitis symptomatic during both birch and grass pollen seasons. Primary outcome was combined symptom and medication score (SMS) assessed by daily visual analogue scales (VAS). Analysis included a placebo-based analysis examining the effect of treatment only on days when placebo patients were symptomatic. RESULTS There was a significant reduction in median SMS for actively treated patients (median 5.70 (interquartile range 2.62-10.02) compared with 7.07 (3.47-10.71) for placebo, P = 0.0385). Rhinitis quality-of-life scores were significantly better for active compared with placebo, and other secondary endpoints were not significantly different. Placebo-based analysis showed a 33.7% reduced SMS at year 2 for active treatment compared with placebo on days when placebo patients were symptomatic. Both birch pollen- and grass pollen-specific IgG4 increased with active treatment. CONCLUSIONS This study shows efficacy of mixed pollen extracts for immunotherapy for patients symptomatic to both birch and grass pollen allergens. The relatively modest effect may reflect 50% dose reduction for each allergen in the mixture. It supports VAS for symptom assessment and placebo-based analysis as useful for the analysis of immunotherapy trials. The safety of modified extracts may allow study of mixed extracts without dose reduction to improve efficacy.
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Affiliation(s)
- O. Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery; Center for Rhinology and Allergology; University Hospital Mannheim; Wiesbaden; Germany
| | - T. Biedermann
- Clinic for Dermatology; University Hospital Tübingen; Tübingen; Germany
| | - L. Klimek
- Department of Otorhinolaryngology, Head and Neck Surgery; Center for Rhinology and Allergology; University Hospital Mannheim; Wiesbaden; Germany
| | | | - D. S. Robinson
- Leukocyte Biology Section; National Heart and Lung Institute; Imperial College London; London; UK
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189
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Witten M, Malling HJ, Blom L, Poulsen BC, Poulsen LK. Is intralymphatic immunotherapy ready for clinical use in patients with grass pollen allergy? J Allergy Clin Immunol 2013; 132:1248-1252.e5. [PMID: 24035151 DOI: 10.1016/j.jaci.2013.07.033] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 07/03/2013] [Accepted: 07/17/2013] [Indexed: 01/03/2023]
Affiliation(s)
- Marianne Witten
- Allergy Clinic, Copenhagen University Hospital, Gentofte, Denmark
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190
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Baena-Cagnani CE, Larenas Linnemann D, Gómez M, Díaz SG, Solé D, Borges MS, Bousquet J, Sisul JC, Canonica GW, Gereda J, Passalacqua G. Allergy training and immunotherapy in Latin America: results of a regional overview. Ann Allergy Asthma Immunol 2013; 111:415-419.e1. [PMID: 24125151 DOI: 10.1016/j.anai.2013.08.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 08/13/2013] [Accepted: 08/13/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND One main practice gap in allergology that has been detected in several regions of the world is the application of specific immunotherapy (SIT). The prescription and practice of SIT should characterize allergologic specialists, but there are regional discrepancies in such practice. A detailed knowledge of the regulatory and legislation aspects and drawbacks would help improve and harmonize SIT practice. OBJECTIVE To describe in Latin America the level of allergy training and the characteristics of the use of SIT, including the medical and legal aspects. METHODS Three sources were used: a 24-item questionnaire sent to 22 allergologic leaders in 11 Latin American countries, 2 face-to-face meetings, and information from health authorities involved in the approval of medical substances. RESULTS In 56% of countries, the specialty of allergology is a third-level care specialty and/or a subspecialty. Two countries have a special training program for pediatric allergists. Passing a board examination is mandatory in 3 countries, and recertification every 2 to 5 years occurs without examination. Sublingual and subcutaneous SITs are available in all Latin American countries. No legislation restricts SIT prescription and it can be performed by nonspecialists in 7 of 11 countries. In 90% of countries, allergists use allergen extracts from the United States (subcutaneous immunotherapy) and Europe (sublingual and subcutaneous immunotherapies), and 50% also manufacture extracts locally. Only 1 country has legal requirements for the quality of raw materials. CONCLUSION The present analysis helps to identify gaps in the field of allergologic training and SIT in Latin America, many of them amendable.
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Affiliation(s)
- Carlos E Baena-Cagnani
- Research Center for Respiratory Medicine (CIMER), Catholic University, Fundación LIBRA, Córdoba, Argentina
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191
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Slovick A, Douiri A, Kelly J, Guerra A, Muir R, Tsioulos K, Murphy C, Shamji MH, Ying S, Durham SR, Till SJ. Protocol for a double-blind randomised controlled trial of low dose intradermal grass pollen immunotherapy versus a histamine control on symptoms and medication use in adults with seasonal allergic rhinitis (PollenLITE). Clin Transl Allergy 2013; 3:27. [PMID: 23965180 PMCID: PMC3765857 DOI: 10.1186/2045-7022-3-27] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 08/11/2013] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Subcutaneous immunotherapy with high dose grass pollen (typically microgram quantities) was first described over 100 years ago. This treatment suppresses allergen-induced cutaneous late responses, with lesser effects on early responses. We previously reported that repeated 2-weekly intradermal injections of grass pollen - containing approximately 7 ng of major allergen Phl p 5 - led to a progressive suppression of the allergen-induced cutaneous response, and that by the sixth injection, this was inhibited by over 90%. The purpose of this trial is to investigate the clinical efficacy of intradermal desensitisation with low doses (i.e. nanogram quantities) of grass pollen allergen for seasonal allergic rhinitis. METHODS/DESIGN The Pollen Low dose Intradermal therapy Evaluation (PollenLITE) is a single centre double-blind randomised parallel group controlled trial of the efficacy and safety of intradermal grass pollen injections plus standard treatment, versus histamine injections plus standard treatment, in adults with moderate-severe grass pollen-induced allergic rhinitis ('summer hay fever'). A minimum of ninety adults with a history of moderate-severe persistent allergic rhinitis during the UK grass pollen season will be randomised into two equal groups to receive 7 or 8 intradermal injections of grass pollen extract (containing approximately 7 ng of major allergen Phl p 5) or histamine, before the grass pollen season. In the summer, participants will score their symptoms, medication requirements, visual analogue scores, and complete EuroQOL (EQ-5D-5 L) and mini Rhinoconjunctivitis Quality of Life Questionnaires. Global assessments will also be recorded at the end of the pollen season. Blood samples will be collected from all participants for mechanistic immune assays. Skin punch biopsies will also be collected in 40 participants selected at random from intradermal injection sites after the grass pollen season for mechanistic assays. Finally, to investigate if the desensitising effect of intradermal immunotherapy on cutaneous responses is long-lasting, all participants will be randomised to receive a follow up intradermal injection after 3, 6 or 12 months with measurement of early and late response sizes. DISCUSSION Randomisation began in February 2013 and the final participant will complete the trial protocol in August 2014. TRIAL REGISTRATION ISRCTN 78413121EudraCT number 2012-002193-31.
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Affiliation(s)
- Anna Slovick
- Division of Asthma, Allergy & Lung Biology, King's College London, 5th Floor Tower Wing, Guy's Hospital Campus, London SE1 9RT, UK
- MRC and Asthma UK Centre for Allergic Mechanisms of Asthma, London SE1 9RT, UK
| | - Abdel Douiri
- Department of Primary Care and Public Health Sciences, King’s College London, 42 Weston St, London SE1 3QD, UK
| | - Joanna Kelly
- King’s Clinical Trials Unit, King’s College London, Institute of Psychiatry, 16 De Crespigny Park, London SE5 8AF, UK
| | - Andrea Guerra
- Division of Asthma, Allergy & Lung Biology, King's College London, 5th Floor Tower Wing, Guy's Hospital Campus, London SE1 9RT, UK
- MRC and Asthma UK Centre for Allergic Mechanisms of Asthma, London SE1 9RT, UK
| | - Rachel Muir
- Clinical Research Facility, NIHR Biomedical Research Centre, Guy’s Hospital, London SE1 9RT, UK
| | - Konstantinos Tsioulos
- Division of Asthma, Allergy & Lung Biology, King's College London, 5th Floor Tower Wing, Guy's Hospital Campus, London SE1 9RT, UK
- MRC and Asthma UK Centre for Allergic Mechanisms of Asthma, London SE1 9RT, UK
| | - Caroline Murphy
- King’s Clinical Trials Unit, King’s College London, Institute of Psychiatry, 16 De Crespigny Park, London SE5 8AF, UK
| | - Mohamed H Shamji
- Section of Allergy and Clinical Immunology, National Heart and Lung Institute, Faculty of Medicine, Imperial College, Dovehouse Street, London SW3 6LY, UK
- MRC and Asthma UK Centre for Allergic Mechanisms of Asthma, London SE1 9RT, UK
| | - Sun Ying
- Division of Asthma, Allergy & Lung Biology, King's College London, 5th Floor Tower Wing, Guy's Hospital Campus, London SE1 9RT, UK
- MRC and Asthma UK Centre for Allergic Mechanisms of Asthma, London SE1 9RT, UK
| | - Stephen R Durham
- Section of Allergy and Clinical Immunology, National Heart and Lung Institute, Faculty of Medicine, Imperial College, Dovehouse Street, London SW3 6LY, UK
- MRC and Asthma UK Centre for Allergic Mechanisms of Asthma, London SE1 9RT, UK
| | - Stephen J Till
- Division of Asthma, Allergy & Lung Biology, King's College London, 5th Floor Tower Wing, Guy's Hospital Campus, London SE1 9RT, UK
- MRC and Asthma UK Centre for Allergic Mechanisms of Asthma, London SE1 9RT, UK
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Erekosima N, Suarez-Cuervo C, Ramanathan M, Kim JM, Chelladurai Y, Segal JB, Lin SY. Effectiveness of subcutaneous immunotherapy for allergic rhinoconjunctivitis and asthma: a systematic review. Laryngoscope 2013; 124:616-27. [PMID: 23832632 DOI: 10.1002/lary.24295] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 06/10/2013] [Accepted: 06/14/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To systematically review the effectiveness and safety of subcutaneous immunotherapy (SCIT) for treatment of allergic rhinoconjunctivitis and asthma, using formulations currently approved in the United States. STUDY DESIGN We searched the following databases up to May 21, 2012: MEDLINE, Embase, LILACS, and the Cochrane Central Register of Controlled Trials. METHODS We included randomized controlled trials published in English comparing SCIT to placebo, pharmacotherapy, or other SCIT regimens that reported clinical outcomes of interest. Studies of adults or mixed age populations were included. Studies were excluded if the diagnosis of allergy and/or asthma was not confirmed with objective testing. Paired reviewers selected articles for inclusion and extracted data. We assessed the risk of bias for each study and graded the strength of evidence for each outcome as high, moderate, or low. RESULTS Sixty-one studies met our inclusion criteria. Majority of the studies (66%) evaluated single-allergen immunotherapy regimens. The literature provides high-grade evidence that SCIT reduces asthma symptoms, asthma medication usage, rhinitis/rhinoconjunctivitis symptoms, conjunctivitis symptoms, and rhinitis/rhinoconjunctivitis disease-specific quality of life in comparison to placebo or usual care. There is moderate evidence that SCIT decreases rhinitis/rhinoconjunctivitis medication usage. Respiratory reactions were the most common systemic reaction. There were few reports of anaphylaxis; no deaths were reported. CONCLUSIONS Generally moderate to strong evidence supports the effectiveness of SCIT for treatment of allergic rhinitis and asthma, particularly with single-allergen immunotherapy regimens. Adverse reactions to SCIT are common, but no deaths were reported in the included studies.
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Affiliation(s)
- Nkiruka Erekosima
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
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193
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Rosewich M, Arendt S, El Moussaoui S, Schulze J, Schubert R, Zielen S. Bronchial allergen provocation: a useful method to assess the efficacy of specific immunotherapy in children. Pediatr Allergy Immunol 2013; 24:434-40. [PMID: 23578317 DOI: 10.1111/pai.12068] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND The clinical efficacy of subcutaneous allergen-specific immunotherapy (SCIT) varies between patients. New preparations are under development, and an objective tool with which to evaluate their efficacies in individual patients has become necessary. Our primary research question is whether bronchial allergen provocation (BAP) can be used to assess the efficacy of SCIT. METHODS In 42 house dust mite (HDM) allergic children (average age: 8.6 yr) with asthma, we analysed the clinical and objective improvements of a standardised HDM allergoid. All patients underwent two BAPs, one before SCIT and another 1 yr after SCIT. Fourteen patients who were recommended but chose not to undergo SCIT represented the control group. The total and specific IgE were analysed before SCIT; in addition, after SCIT, specific IgG and IgG4 were analysed. RESULTS After SCIT, the patients' allergen-specific bronchial hyper-reactivity (BHR) was significantly improved; specifically, their PD(20) FEV(1) was 34.4 AU before and 63.3 AU after SCIT (p < 0.01). The PD(20) FEV(1) of the control group remained unchanged. Although BHR improved significantly in the treatment group, we were able to differentiate between the responders (n = 17, 60.7%) and non-responders (n = 11, no improvement in BAP). The patients in both groups stated that SCIT had led to a subjective improvement in their symptoms, in contrast to the untreated control group, but only the responders required less medication after SCIT (p < 0.01). CONCLUSIONS After 1 yr of SCIT against HDM, 60.7% of the patients observed in this study exhibited significant improvements, as defined by BAP. However, BAP was also able to identify the non-responders to treatment. Thus, BAP is a useful and objective method of estimating the effectiveness of SCIT and is not influenced by a placebo effect.
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Affiliation(s)
- Martin Rosewich
- Children's Hospital, Department of Allergy, Pneumology and Cystic fibrosis, Goethe University, Frankfurt/Main, Germany.
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194
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Calderón MA, Casale T, Cox L, Akdis CA, W. Burks A, Nelson HS, Jutel M, Demoly P. Allergen immunotherapy: a new semantic framework from the European Academy of Allergy and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL consensus report. Allergy 2013; 68:825-8. [PMID: 24010140 DOI: 10.1111/all.12180] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M. A. Calderón
- Imperial College London - National Heart and Lung Institute, Royal Brompton Hospital; London; UK
| | - T. Casale
- Creighton University; Omaha; NE; USA
| | - L. Cox
- Nova Southeastern University; Davie; FL; USA
| | - C. A. Akdis
- Swiss Institute of Allergy and Asthma Research, University of Zurich, Christine Kühne-Center for Allergy Research and Education; Davos; Switzerland
| | - A. W. Burks
- The University of North Carolina at Chapel Hill School of Medicine; Chapel Hill; NC; USA
| | | | - M. Jutel
- Wroclaw Medical University; Wroclaw; Poland
| | - P. Demoly
- Hôpital Arnaud de Villeneuve, University Hospital of Montpellier; Montpellier; France
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195
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First annual register of allergenic pollen in Talca, Chile. Allergol Immunopathol (Madr) 2013; 41:233-8. [PMID: 23141838 DOI: 10.1016/j.aller.2012.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 06/10/2012] [Accepted: 06/26/2012] [Indexed: 01/03/2023]
Abstract
BACKGROUND There are no data on atmospheric pollen in Talca. In the present work, our aim is to describe the amount of pollen grain in the atmosphere of the city of Talca likely to cause pollinosis of its inhabitants. METHODS A volumetric Hirst sampler (Burkard seven-day recording device) was used to study pollen levels. It was placed in the centre of Talca from May 2007 to April 2008. RESULTS The highest airborne presence of pollen, as measured in weekly averages, was Platanus acerifolia with a maximum weekly daily average of 203 grains/m³ registered during September and October. The second highest was Acer pseudoplatanus with a maximum weekly daily average of 116 grains/m³. Populus spp. had a maximum weekly daily average 103 grains/m³. Olea europaea reached 19 grains/m³ in November. Grasses presented high levels of pollen counts with a maximum weekly daily average of 27 grains/m³ from the end of August until the end of January. Pollens of Plantago spp. Rumex acetosella and Chenopodium spp. had a similar distribution and were present from October to April with maximum weekly daily average of 7 grains/m³, 7 grains/m³ and 3 grains/m³ respectively. Significant concentrations of Ambrosia artemisiifolia were detected from February until April. CONCLUSION The population of Talca was exposed to high concentrations of allergenic pollen, such as P. acerifolia, A. pseudoplatanus, and grasses in the months of August through November. The detection of O. europaea and A. artemisiifolia is important as these are emergent pollens in the city of Talca. Aerobiological monitoring will provide the community with reliable information about the level of allergenic pollens, improving treatment and quality of life of patients with respiratory allergy.
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196
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Tsuji Kanatani K, Slingsby BT, Mukaida K, Kitano H, Adachi Y, Haefner D, Nakayama T. Translation and linguistic validation of the Allergy-CONTROL-ScoreTM for use in Japan. Allergol Int 2013; 62:337-341. [PMID: 23793503 DOI: 10.2332/allergolint.12-oa-0519] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 03/06/2013] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Symptom and medication scores are recommended to measure the primary outcome on allergies. The Allergy Control Score was proved to be a valid and reliable instrument to assess allergy severity in clinical trials and may be used in observational studies of respiratory allergic diseases in many countries. We translated the Allergy Control Score and adapted it for use in Japan. METHODS We translated the original English version into Japanese according to the Mapi approach to linguistic validation: conceptual definition, forward translation by two native Japanese speakers, reconciliation, back-translation by an independent translator, review in consultation with original developer, and pilot testing on 12 patients of an allergy clinic and 3 volunteers with seasonal/non-seasonal allergic rhinitis and/or asthma. RESULTS Two of the ten back-translated items needed slight modifications and some words were revised. In the pilot test, the average time required to complete the questionnaire was 55 seconds for the section on symptoms and 25 seconds for the section on medication. All participants were able to self-complete the questionnaire. CONCLUSIONS By applying the Mapi approach to linguistic validation, we ensured a close match between the Japanese and English versions of the Allergy Control Score. The Allergy Control Score Japanese version is accessible and acceptable to persons with respiratory allergic symptoms in Japan.
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Affiliation(s)
- Kumiko Tsuji Kanatani
- Health Informatics, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan. kanatani.kumiko.2r@kyoto−u.ac.jp
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Kiotseridis H, Cilio CM, Bjermer L, Tunsäter A, Jacobsson H, Dahl A. Grass pollen allergy in children and adolescents-symptoms, health related quality of life and the value of pollen prognosis. Clin Transl Allergy 2013; 3:19. [PMID: 23799882 PMCID: PMC3699361 DOI: 10.1186/2045-7022-3-19] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 06/03/2013] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION An association between pollen count (Poaceae) and symptoms is well known, but to a lesser degree the importance of priming and lag effects. Also, threshold levels for changes in symptom severity need to be validated. The present study aims to investigate the relationship between pollen counts, symptoms and health related quality of life (HRQL), and to validate thresholds levels, useful in public pollen warnings. MATERIAL AND METHODS Children aged 7-18 with grass pollen allergy filled out a symptom diary during the pollen season for nose, eyes and lung symptoms, as well as a HRQL questionnaire every week. Pollen counts were monitored using a volumetric spore trap. RESULTS 89 (91%) of the included 98 children completed the study. There was a clear association between pollen count, symptom severity and HRQL during the whole pollen season, but no difference in this respect between early and late pollen season. There was a lag effect of 1-3 days after pollen exposure except for lung symptoms. We found only two threshold levels, at 30 and 80 pollen grains/m(3) for the total symptom score, not three as is used today. The nose and eyes reacted to low doses, but for the lung symptoms, symptom strength did hardly change until 50 pollen grains/m(3). CONCLUSION Grass pollen has an effect on symptoms and HRQL, lasting up to 5 days after exposure. Symptoms from the lungs appear to have higher threshold levels than the eyes and the nose. Overall symptom severity does not appear to change during the course of season. Threshold levels need to be revised. We suggest a traffic light model for public pollen warnings directed to children, where green signifies "no problem", yellow signifies "can be problems, especially if you are highly sensitive" and red signifies "alert - take action".
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Affiliation(s)
- Hampus Kiotseridis
- Pediatric Clinic, Malmö, Skåne University Hospital, Lund University, Lund, Sweden ; Departments of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Corrado M Cilio
- Pediatric Clinic, Malmö, Skåne University Hospital, Lund University, Lund, Sweden
| | - Leif Bjermer
- Departments of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Alf Tunsäter
- Departments of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Helene Jacobsson
- Competence Centre for Clinical Research, Skåne University Hospital, Lund, Sweden
| | - Aslög Dahl
- Departments of Biological and Environmental Sciences, Gothenburg University, Gothenburg, Sweden
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Murphy K, Gawchik S, Bernstein D, Andersen J, Pedersen MR. A phase 3 trial assessing the efficacy and safety of grass allergy immunotherapy tablet in subjects with grass pollen-induced allergic rhinitis with or without conjunctivitis, with or without asthma. J Negat Results Biomed 2013; 12:10. [PMID: 23725348 PMCID: PMC3689082 DOI: 10.1186/1477-5751-12-10] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 05/10/2013] [Indexed: 11/24/2022] Open
Abstract
Background Design and execution of immunotherapy trials for seasonal allergies may be complicated by numerous factors including variable allergy testing methods, pollen levels, and timing and intensity of other seasonal allergens. We evaluated grass allergy immunotherapy tablet (AIT) treatment in North American adults with grass pollen-induced allergic rhinitis with or without conjunctivitis (AR/C), with/without asthma. Methods Subjects age 18–65 with clinical history of grass pollen–induced AR/C, with/without asthma were randomized 1:1 to once-daily 2800 BAU Timothy grass AIT (oral lyophilisate, Phleum pratense, 75,000 SQ-T, containing approximately 15 μg of Phl p 5) or placebo. The AR/C symptom and medication scores were recorded daily. The primary end point was the average AR/C daily symptom score (DSS) during the entire grass pollen season (GPS). Ranked key secondary end points were Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) score, daily medication score (DMS), and percentage of well days, all over entire GPS. Safety was monitored through adverse event reporting. Results Efficacy analysis included 289 subjects. Over the entire GPS, mean DSS was 6% lower with AIT versus placebo (5.69 vs. 6.06), but this difference was not statistically significant (p = 0.3475) despite significantly higher immunological response in the grass AIT group. No significant between-group differences were seen for key secondary end points. In general, DSS was high before GPS began and no clear relationship between DSS and grass pollen counts was seen during GPS. In post hoc analysis of subjects with pre-seasonal DSS ≤3, mean DSS and DMS were both significantly lower with grass AIT versus placebo (27%; p = 0.0327 and 68%; p = 0.0060, respectively). In this subgroup a relationship between DSS and grass pollen counts was observed. Grass AIT was generally well tolerated, with no events of anaphylactic shock or respiratory compromise. Conclusions In this trial, 2800 BAU grass AIT did not demonstrate significant symptom improvement versus placebo. Lack of relationship between pollen count and symptom score in the study population, and post hoc findings among subjects with low pre-seasonal symptoms, suggest that the symptoms reported in this study were not primarily reflective of the effects of grass pollen exposure. Trial registration NCT00421655
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Bonvalet M, Moussu H, Wambre E, Ricarte C, Horiot S, Rimaniol AC, Kwok WW, Horak F, de Beaumont O, Baron-Bodo V, Moingeon P. Allergen-specific CD4+ T cell responses in peripheral blood do not predict the early onset of clinical efficacy during grass pollen sublingual immunotherapy. Clin Exp Allergy 2013. [PMID: 23181790 DOI: 10.1111/cea.12015] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Surrogate biomarkers of efficacy are needed in support of allergen-specific immunotherapy. OBJECTIVE The aim of this study was to relate changes in peripheral CD4(+) T cell responses to clinical efficacy during sublingual immunotherapy (SLIT). METHODS Allergen-specific CD4(+) T cell responses were assessed in peripheral blood mononuclear cells (PBMCs) from 89 grass pollen-allergic individuals enrolled in a double-blind placebo-controlled SLIT study conducted in an allergen exposure chamber (ClinicalTrials.gov NCT00619827). Surface phenotype, proliferative responses, cytokine production and gene expression were analysed in coded samples at baseline, and after 2 and 4 months of SLIT, in PBMCs after in vitro allergen stimulation or among MHC class II/peptide (pMHCII)-tetramer-positive CD4(+) T cells. RESULTS SLIT induced a 29.3% improvement of the average rhinoconjunctivitis total symptom score in the active group, when compared to the placebo group. In parallel, only minor changes in proportions of CD4(+) T cells expressing Th1 (CCR5(+), CXCR3(+)), Th2 (CRTh2(+), CCR4(+)) and Treg (CD25(+), CD127(-), Foxp3(+)) markers were detected. A down-regulation of IL-4 and IL-10 gene expression and IL-10 secretion (P < 0.001) were observed, as well as a decrease in the frequency of potential "pro-allergic" CD27(-) Th2 cells from patients receiving active tablets (P < 0.001), but without any correlation with clinical benefit. pMHCII-tetramer analyses failed to document any major impact in both numbers and polarization of circulating Phl p 1- and Phl p 5-specific CD4(+) T cells, confirming that early clinical improvement during SLIT is not associated with dramatic alterations in T lymphocyte responses. CONCLUSION & CLINICAL RELEVANCE Changes in patterns of peripheral CD4(+) T cells are not markers for the early onset of efficacy during SLIT.
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Tworek D, Bochenska-Marciniak M, Kuprys-Lipinska I, Kupczyk M, Kuna P. Perennial is more effective than preseasonal subcutaneous immunotherapy in the treatment of seasonal allergic rhinoconjunctivitis. Am J Rhinol Allergy 2013; 27:304-8. [PMID: 23636036 DOI: 10.2500/ajra.2013.27.3935] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Two different regimens of subcutaneous immunotherapy (IT), perennial or preseasonal, may be used in the treatment of seasonal allergy. The aim of this study was to compare the efficacy and safety of perennial IT (PIT) and preseasonal IT (PSIT) in patients suffering from seasonal rhinoconjunctivitis. METHODS The study was planned as a randomized, double-blind, comparative study on the efficacy and safety of PIT and PSIT. The study group comprised 120 patients allergic to grass and rye pollen. After the observational season they were randomized to receive PIT or PSIT for 3 years. The effect of IT was assessed based on symptom severity and medication use recorded in diaries. RESULTS Ninety-nine patients completed the study. No difference was seen between the groups regarding combined symptom medication score (SMS) in the first season of IT. During the second season, the difference between PIT and PSIT regarding combined SMS was 27.9% (p = 0.063) and reached 42.7% (p = 0.012) in favor of PIT in the third season. Both treatments had a similar safety profile. CONCLUSION PIT was more effective than PSIT in the treatment of rhinoconjunctivitis in patients allergic to grass and rye pollens.
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Affiliation(s)
- Damian Tworek
- Divisiont of Internal Diseases, Asthma and Allergy, Barlicki University Hospital, Lodz, Poland.
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