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Abstract
Allergies are steadily gaining in importance in the Western world. For over one hundred years, immunology has been the only causal treatment. Specific immunotherapy (SIT) aims at the cure of allergy or at least freedom from allergy symptoms. In association with this, adherence poses a complex problem. Both treatment applications commonly used in Germany-sublingual and subcutaneous immunotherapy-show poor persistence on the part of the patients. In most cases, SIT is not carried out to the end of the recommended duration and instead is discontinued prematurely. Corresponding figures from 3‑year studies in the literature range from 41- 93% for uncompleted SLIT and from 40-77% for uncompleted SCIT. Patient adherence is subject to influencing factors of various dimensions that are interdependent in complex relationships. The physician-patient relationship is just as decisive a factor for treatment success as the patient's understanding of allergy, treatment, and the importance of adherence.
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202
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Marogna M, Massolo A, Passalacqua G. Effect of adjuvanted and standard sublingual immunotherapy on respiratory function in pure rhinitis due to house dust mite over a 5-year period. World Allergy Organ J 2017; 10:7. [PMID: 28232857 PMCID: PMC5307763 DOI: 10.1186/s40413-016-0132-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 12/12/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Allergen-specific immunotherapy (AIT) still remains the only causal treatment for IgE mediated respiratory diseases (rhinitis/asthma) In addition to the observed clinical decrease in symptoms, AIT can provide a long-lasting and preventive effect. In particular it can modify the progression from rhinitis to asthma. METHODS The study was observational, open, non randomized, controlled, prospective and performed in a real-life setting. Patients with pure mite-induced allergic rhinitis were followed-up, receiving adjuvanted SLIT (aSLIT), standard SLIT (sSLIT) or drug treatment alone, according to their preference starting between 2008 and 2009. The possible onset of asthma, changes in pulmonary function and bronchial hyperreactivity (BHR) were assessed over a 5-year horizon. Also the onset of new sensitizations and symptoms-medication score (SMS) were evaluated. RESULTS One hundred forty two patients fulfilling the inclusion criteria were assessed at baseline, and 124 had the 5-year evaluation (age range 8-57, 69 male). After 5 years of treatment, new sensitizations appeared differentially among treatments with 58.1% of new sensitizations in the drug treatment group, 13.2% in the sSLIT patients, and 8.1% in the aSLIT patients. At the end of 5 years, SMS significantly changed (P < 0.001) in all groups, with a negative trend for controls, as compared to the SLIT treatments. The SMS decreased in both SLIT groups at 5 years, with no change in patients on drug treatment alone. The use of salbutamol (absent at baseline), showed an overall increase only in the group receiving drugs alone with a significant difference at 5 years (P < 0.001). Considering the MCh challenge, there was a difference among treatments (P < 0.001) in PD20 after 5 years: the control group had a lower PD20 at 5 years. No significant difference in PD20 was detected between sSLIT and aSLIT. The FEV1 significantly decreased in controls, with no change in the sSLIT group and a significant increase in aSLIT as compared to sSLIT. DISCUSSION Despite the limitations inherent to a real-life setting study (absence of randomization and control, small sample size, lack of intermediate timepoint assessment) the results of this study evidenced that the investigated SLIT product, either adjuvanted or not, had a positive effect on the evolution of respiratory allergy due to house dust mite. CONCLUSION In the real life setting, considering a 5-year period, aSLIT and sSLIT reduced the onset of new sensistizations and maintained intact the pulmonary function, as compared to patients receiving drug treatment alone.
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Affiliation(s)
- Maurizio Marogna
- Pneumology Unit, Cuasso al Monte, Macchi Hospital Foundation, Varese, Italy
| | - Alessandro Massolo
- Department of Ecosystem and Public Health, Faculty of Veterinary Medicine, University of Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary, Alberta, Canada
| | - Giovanni Passalacqua
- Department of Internal Medicine, Allergy and Respiratory Diseases, IRCCS San Martino-IST-University of Genoa, Pad. Maragliano, Ospedale San Martino, L.go R. Benzi 10, 16133 Genova, Italy
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203
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Turkalj M, Banic I, Anzic SA. A review of clinical efficacy, safety, new developments and adherence to allergen-specific immunotherapy in patients with allergic rhinitis caused by allergy to ragweed pollen ( Ambrosia artemisiifolia). Patient Prefer Adherence 2017; 11:247-257. [PMID: 28243068 PMCID: PMC5317300 DOI: 10.2147/ppa.s70411] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Allergic rhinitis is a common health problem in both children and adults. The number of patients allergic to ragweed (Ambrosia artemisiifolia) is on the rise throughout Europe, having a significant negative impact on the patients' and their family's quality of life. Allergen-specific immunotherapy (AIT) has disease-modifying effects and can induce immune tolerance to allergens. Both subcutaneous immunotherapy and sublingual immunotherapy with ragweed extracts/preparations have clear positive clinical efficacy, especially over pharmacological treatment, even years after the treatment has ended. AIT also has very good safety profiles with extremely rare side effects, and the extracts/preparations used in AIT are commonly well tolerated by patients. However, patient adherence to treatment with AIT seems to be quite low, mostly due to the fact that treatment with AIT is relatively time-demanding and, moreover, due to patients not receiving adequate information and education about the treatment before it starts. AIT is undergoing innovations and improvements in clinical efficacy, safety and patient adherence, especially with new approaches using new adjuvants, recombinant or modified allergens, synthetic peptides, novel routes of administration (epidermal or intralymphatic), and new protocols, which might make AIT more acceptable for a wider range of patients and novel indications. Patient education and support (eg, recall systems) is one of the most important goals for AIT in the future, to further enhance treatment success.
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Affiliation(s)
- Mirjana Turkalj
- Children’s Hospital Srebrnjak, Zagreb
- Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
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Scadding GW, Calderon MA, Shamji MH, Eifan AO, Penagos M, Dumitru F, Sever ML, Bahnson HT, Lawson K, Harris KM, Plough AG, Panza JL, Qin T, Lim N, Tchao NK, Togias A, Durham SR. Effect of 2 Years of Treatment With Sublingual Grass Pollen Immunotherapy on Nasal Response to Allergen Challenge at 3 Years Among Patients With Moderate to Severe Seasonal Allergic Rhinitis: The GRASS Randomized Clinical Trial. JAMA 2017; 317:615-625. [PMID: 28196255 PMCID: PMC5479315 DOI: 10.1001/jama.2016.21040] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Sublingual immunotherapy and subcutaneous immunotherapy are effective in seasonal allergic rhinitis. Three years of continuous treatment with subcutaneous immunotherapy and sublingual immunotherapy has been shown to improve symptoms for at least 2 years following discontinuation of treatment. OBJECTIVE To assess whether 2 years of treatment with grass pollen sublingual immunotherapy, compared with placebo, provides improved nasal response to allergen challenge at 3-year follow-up. DESIGN, SETTING, AND PARTICIPANTS A randomized double-blind, placebo-controlled, 3-parallel-group study performed in a single academic center, Imperial College London, of adult patients with moderate to severe seasonal allergic rhinitis (interfering with usual daily activities or sleep). First enrollment was March 2011, last follow-up was February 2015. INTERVENTIONS Thirty-six participants received 2 years of sublingual immunotherapy (daily tablets containing 15 µg of major allergen Phleum p 5 and monthly placebo injections), 36 received subcutaneous immunotherapy (monthly injections containing 20 µg of Phleum p 5 and daily placebo tablets) and 34 received matched double-placebo. Nasal allergen challenge was performed before treatment, at 1 and 2 years of treatment, and at 3 years (1 year after treatment discontinuation). MAIN OUTCOMES AND MEASURES Total nasal symptom scores (TNSS; range; 0 [best] to 12 [worst]) were recorded between 0 and 10 hours after challenge. The minimum clinically important difference for change in TNSS within an individual is 1.08. The primary outcome was TNSS comparing sublingual immunotherapy vs placebo at year 3. Subcutaneous immunotherapy was included as a positive control. The study was not powered to compare sublingual immunotherapy with subcutaneous immunotherapy. RESULTS Among 106 randomized participants (mean age, 33.5 years; 34 women [32.1%]), 92 completed the study at 3 years. In the intent-to-treat population, mean TNSS score for the sublingual immunotherapy group was 6.36 (95% CI, 5.76 to 6.96) at pretreatment and 4.73 (95% CI, 3.97 to 5.48) at 3 years, and for the placebo group, the score was 6.06 (95% CI, 5.23 to 6.88) at pretreatment and 4.81 (95% CI, 3.97 to 5.65) at 3 years. The between-group difference (adjusted for baseline) was -0.18 (95% CI, -1.25 to 0.90; [P = .75]). CONCLUSIONS AND RELEVANCE Among patients with moderate to severe seasonal allergic rhinitis, 2 years of sublingual grass pollen immunotherapy was not significantly different from placebo in improving the nasal response to allergen challenge at 3-year follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01335139; EudraCT Number: 2010-023536-16.
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Affiliation(s)
- Guy W Scadding
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | - Moises A Calderon
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | - Mohamed H Shamji
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | - Aarif O Eifan
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | - Martin Penagos
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | - Florentina Dumitru
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Henry T Bahnson
- Rho Federal Systems Division, Chapel Hill, North Carolina3currently with the Immune Tolerance Network, Benaroya Research Institute, Seattle, Washington
| | - Kaitie Lawson
- Rho Federal Systems Division, Chapel Hill, North Carolina
| | | | | | | | - Tielin Qin
- Immune Tolerance Network, Bethesda, Maryland
| | - Noha Lim
- Immune Tolerance Network, Bethesda, Maryland
| | - Nadia K Tchao
- Immune Tolerance Network, San Francisco, California7currently with the Department of Early Development Hematology/Oncology, Amgen, San Francisco, California
| | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, Rockville, Maryland
| | - Stephen R Durham
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
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205
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Kumar MS, Oh MS, Leader B, Rotella M, Stillman L, DelGaudio JM, Wise SK. Perceived compliance and barriers to care in sublingual immunotherapy. Int Forum Allergy Rhinol 2017; 7:525-529. [DOI: 10.1002/alr.21920] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/09/2016] [Accepted: 12/13/2016] [Indexed: 11/05/2022]
Affiliation(s)
| | | | - Brittany Leader
- Department of Otolaryngology-Head and Neck Surgery; University of Cincinnati College of Medicine; Cincinnati OH
| | - Melissa Rotella
- Department of Otolaryngology-Head and Neck Surgery; Emory University School of Medicine; Atlanta GA
| | - Leisa Stillman
- Department of Otolaryngology-Head and Neck Surgery; Emory University School of Medicine; Atlanta GA
| | - John M. DelGaudio
- Department of Otolaryngology-Head and Neck Surgery; Emory University School of Medicine; Atlanta GA
| | - Sarah K. Wise
- Department of Otolaryngology-Head and Neck Surgery; Emory University School of Medicine; Atlanta GA
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Ventura MT, Scichilone N, Paganelli R, Minciullo PL, Patella V, Bonini M, Passalacqua G, Lombardi C, Simioni L, Ridolo E, Del Giacco SR, Gangemi S, Canonica GW. Allergic diseases in the elderly: biological characteristics and main immunological and non-immunological mechanisms. Clin Mol Allergy 2017; 15:2. [PMID: 28174512 PMCID: PMC5290673 DOI: 10.1186/s12948-017-0059-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 01/06/2017] [Indexed: 02/08/2023] Open
Abstract
Life expectancy and the number of elderly people are progressively increasing around the world. Together with other pathologies, allergic diseases also show an increasing incidence in geriatric age. This is partly due to the growing emphasis on a more accurate and careful diagnosis of the molecular mechanisms that do not allow to ignore the real pathogenesis of many symptoms until now unknown, and partly to the fact that the allergic people from 20 years ago represent the elderly population now. Moreover, environmental pollution predisposes to the onset of allergic asthma and dermatitis which are the result of internal pathologies more than the expression of allergic manifestations. At the same time the food contamination permits the onset of allergic diseases related to food allergy. In this review we provide the state of the art on the physiological changes in the elderly responsible for allergic diseases, their biological characteristics and the major immunological and extra immunological mechanisms. Much emphasis is given to the management of several diseases in the elderly, including anaphylactic reactions. Moreover, some new features are discussed, such as management of asthma with the support of physical activity and the use of the AIT as prevention of respiratory diseases and for the purpose of a real and long lasting benefit. The mechanisms of adverse reactions to drugs are also discussed, due to their frequency in this age, especially in polytherapy regimens. Study of the modifications of the immune system is also of great importance, as regards to the distribution of the lymphocytes and also the presence of a chronic inflammatory disease related to the production of cytokines, especially in prevision of all the possible therapies to be adopted to allow an active and healthy aging.
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Affiliation(s)
- Maria Teresa Ventura
- Interdisciplinary Department of Medicine, Unit of Geriatric Immunoallergology, University of Bari Medical School, Bari, Italy
| | | | - Roberto Paganelli
- Laboratory of Immunology and Allergy, Department of Medicine and Sciences of Aging, University of G. d’Annunzio, Chieti, Italy
| | - Paola Lucia Minciullo
- Division and School of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University Hospital of Messina, Messina, Italy
| | - Vincenzo Patella
- Division of Allergy and Clinical Immunology, Department of Medicine, Battipaglia Hospital, Battipaglia, Salerno, Italy
- School of Allergy and Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Matteo Bonini
- National Heart and Lung Institute (NHLI), Imperial College London & Royal Brompton Hospital, London, UK
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino-IST-University of Genoa, Genoa, Italy
| | - Carlo Lombardi
- Departmental Unit of AllergologyClinical Immunology & Pneumology, Fondazione Poliambulanza Hospital, Brescia, Italy
| | - Livio Simioni
- Department of Medicine, Allergy Service, ULSS 2 Feltre, Belluno, Italy
| | - Erminia Ridolo
- Experimental and Clinical Medicine, University of Parma, Parma, Italy
| | | | - Sebastiano Gangemi
- Division and School of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University Hospital of Messina, Messina, Italy
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207
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Wang T, Li Y, Wang F, Zhou C. Nonadherence to sublingual immunotherapy in allergic rhinitis: a real-life analysis. Int Forum Allergy Rhinol 2017; 7:389-392. [PMID: 28151587 DOI: 10.1002/alr.21909] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/23/2016] [Accepted: 12/13/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND To sustain the long-lasting beneficial effects of allergen-specific sublingual immunotherapy (SLIT), an adequate duration of treatment is required. Nevertheless, many patients discontinue prematurely and therefore fail to obtain satisfactory therapeutic effect in clinical practice. The aim of this study was to analyze the causes leading to premature discontinuation of SLIT in allergic rhinitis (AR), and to provide the corresponding countermeasures for the following SLIT course. METHODS We performed a retrospective analysis of data from 142 patients with AR who started SLIT during the period from December 2009 to February 2015. Patients were contacted at 1, 3, 6, and 12 months into SLIT as part of our standard of care. The patients who claimed to have stopped treatment were asked to provide a reason during one of the phone calls. RESULTS Overall, 76 (54%) patients with AR terminated immunotherapy during the first year of treatment. Among the 76 patients, the following reasons were cited for nonadherence to immunotherapy: patients could not be reached (25%); ineffectiveness (24%); the long course (18%); improvement of symptoms (13%); side effects (4%); lack of confidence in the treatment (4%); or other reasons (12%). CONCLUSION Fifty-four percent of AR patients terminated their treatment within the first year of SLIT. The top reasons for treatment discontinuation included patients not be reached, ineffectiveness, and length of course.
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Affiliation(s)
- Ting Wang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yue Li
- Department of Otorhinolaryngology, The First Affiliated Hospital of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Feng Wang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Chengyong Zhou
- Department of Otorhinolaryngology, The First Affiliated Hospital of Chinese People's Liberation Army General Hospital, Beijing, China
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208
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Rodríguez Del Río P, Vidal C, Just J, Tabar AI, Sanchez-Machin I, Eberle P, Borja J, Bubel P, Pfaar O, Demoly P, Calderón MA. The European Survey on Adverse Systemic Reactions in Allergen Immunotherapy (EASSI): A paediatric assessment. Pediatr Allergy Immunol 2017; 28:60-70. [PMID: 27637414 DOI: 10.1111/pai.12660] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Safety data on 'real-life' allergen immunotherapy (AIT) in children and adolescents is usually extrapolated from studies in adults. METHODS Patients aged 18 or under initiating aeroallergen AIT were evaluated in a prospective European survey. Patient profiles and systemic reactions (SRs) were recorded. Descriptive, univariate and multivariate analyses were used to identify risk factors for SRs. RESULTS A total of 1563 patients (mean ± SD age: 11.7 ± 3.9 years; rhinitis: 93.7%; asthma: 61.5%; polysensitization: 62.5%) and 1578 courses of AIT were assessed. Single-allergen AIT was administered in 89.5% of cases (n = 1412; mites: 49%; grass pollen: 25.8%; tree pollen: 8.7%; Alternaria: 4.6%; dander: 0.8%; weed pollen: 0.6%). Subcutaneous AIT (SCIT) was used in 71.4% (n = 1127) of the treatments, including 574 (50.9%) with natural extracts. Sublingual AIT (SLIT) was used for the remaining 451 treatments (drops: 73.8%; tablets: 26.2%). The mean ± SD follow-up period was 12.9 ± 3.3 months. The estimated total number of doses was 19,669 for SCIT and 131,550 for SLIT. Twenty-four patients (1.53%) experienced 29 SRs. Respiratory (55.7%) and skin symptoms (37.9%) were most frequent. Anaphylaxis was diagnosed in 3 SRs (10.3%), and adrenaline was administered in 2 of these cases. In a univariate analysis, the risk of SRs was lower in mite-sensitized patients and higher in cases of pollen polysensitization (>3), grass pollen extracts and the use of natural extracts (vs. allergoids). CONCLUSIONS In a real-life paediatric setting, AIT is safe. SRs are infrequent and generally not severe. Pollen polysensitization, grass pollen extracts and natural extracts (vs. allergoids) were risk factors for AIT-associated SRs.
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Affiliation(s)
| | - Carmen Vidal
- Allergy Department, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Jocelyne Just
- Centre de l'Asthme et des Allergies, Hôpital d'enfant Armand Trousseau, Paris, France
| | - Ana I Tabar
- Allergy Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | | | | | - Jesus Borja
- Allergy Section, Hospital General Universitario, Ciudad Real, Spain
| | - Petra Bubel
- Ear, Nose and Throat Practice, Lutherstadt, Eisleben, Germany
| | - Oliver Pfaar
- Center for Rhinology and Allergology, Wiesbaden, Germany.,Department of Otorhinolaryngology and Head and Neck Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Mannheim, Germany
| | - Pascal Demoly
- Département de Pneumologie et Addictologie, UMR-S 1136, IPLESP, Equipe EPAR, Hôpital Arnaud de Villeneuve, UPMC Paris 06, University Hospital of Montpellier, Sorbonne Universités, Paris, France
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209
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Pajno GB, Bernardini R, Peroni D, Arasi S, Martelli A, Landi M, Passalacqua G, Muraro A, La Grutta S, Fiocchi A, Indinnimeo L, Caffarelli C, Calamelli E, Comberiati P, Duse M. Clinical practice recommendations for allergen-specific immunotherapy in children: the Italian consensus report. Ital J Pediatr 2017; 43:13. [PMID: 28257631 PMCID: PMC5347813 DOI: 10.1186/s13052-016-0315-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 11/25/2016] [Indexed: 02/07/2023] Open
Abstract
Allergen-specific immunotherapy (AIT) is currently recognized as a clinically effective treatment for allergic diseases, with a unique disease-modifying effect. AIT was introduced in clinical practice one century ago, and performed in the early years with allergenic extracts of poor quality and definition. After the mechanism of allergic reaction were recognized, the practice of AIT was refined, leading to remarkable improvement in the efficacy and safety profile of the treatment. Currently AIT is accepted and routinely prescribed worldwide for respiratory allergies and hymenoptera venom allergy. Both the subcutaneous (SCIT) and sublingual (SLIT) routes of administration are used in the pediatric population.AIT is recommended in allergic rhinitis/conjunctivitis with/without allergic asthma, with an evidence of specific IgE-sensitization towards clinically relevant inhalant allergens. Long-term studies provided evidence that AIT can also prevent the onset of asthma and of new sensitizations. The favorable response to AIT is strictly linked to adherence to treatment, that lasts 3-5 years. Therefore, several factors should be carefully evaluated before starting this intervention, including the severity of symptoms, pharmacotherapy requirements and children and caregivers' preference and compliance.In recent years, there have been increasing interest in the role of AIT for the treatment of IgE-associated food allergy and extrinsic atopic dermatitis. A growing body of evidence shows that oral immunotherapy represents a promising treatment option for IgE-associated food allergy. On the contrary, there are still controversies on the effectiveness of AIT for patients with atopic dermatitis.This consensus document was promoted by the Italian Society of Pediatric Allergy and Immunology (SIAIP) to provide evidence-based recommendations on AIT in order to implement and optimize current prescription practices of this treatment for allergic children.
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Affiliation(s)
- Giovanni Battista Pajno
- Department of Pediatrics, Allergy Unit, University of Messina, Via Consolare Valeria-Gazzi, Messina, 98124 Italy
| | | | | | - Stefania Arasi
- Department of Pediatrics, Allergy Unit, University of Messina, Via Consolare Valeria-Gazzi, Messina, 98124 Italy
- Molecular Allergology and Immunomodulation- Department of Pediatric Pneumology and Immunology, Charité Medical University Berlin, Berlin, Germany
| | - Alberto Martelli
- Pediatric Unit, Hospital “G. Salvini”, Garbagnate Milanese, Italy
| | - Massimo Landi
- National Pediatric Healthcare System, Turin, Italy
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino-IST-University of Genoa, Genoa, Italy
| | - Antonella Muraro
- Food Allergy Referral Centre Veneto Region, Department of Women and Child Health, Padua General University Hospital, Padua, Italy
| | - Stefania La Grutta
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | | | | | - Carlo Caffarelli
- Pediatric Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | | | | | - Marzia Duse
- Department of Pediatrics, University “La Sapienza”, Rome, Italy
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210
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Qi S, Chen H, Huang N, Li W, Liu G, Wang Y, Hu L, Wang X, Zhang W, Zhu R. Early Intervention Improves Clinical Responses to House Dust Mite Immunotherapy in Allergic Rhinitis Patients. Int Arch Allergy Immunol 2017; 171:234-240. [PMID: 28049194 DOI: 10.1159/000452333] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 10/10/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Allergen immunotherapy (AIT) is the unique causal treatment for respiratory allergy. As AIT is expensive and of long duration, the availability of a marker predicting AIT responders is of crucial relevance. OBJECTIVE To investigate clinical parameters correlated with effective AIT in allergic rhinitis (AR) patients. METHODS This is a prospective, nonrandomized open study in which a total of 284 AR patients who had received house dust mite (HDM) subcutaneous AIT were enrolled from January 2011 to December 2015, and then followed up for 3 consecutive years. Demographic data, clinical history, laboratory tests (specific and total IgE levels), symptoms score, concomitant medication, and adverse reactions during AIT were collected. An AIT responder patient was defined when a visual analog score (assessing global symptoms) had decreased by >30% compared to baseline and concomitant medication was equal to or less than before AIT. RESULTS Thirty-three patients dropped out, so 251 patients were analyzed; 175 (69.7%) patients were responders. This group had a higher baseline symptom score than the AIT nonresponder group (7.5 vs. 6.9). A significant negative correlation was found between AR symptom duration and the clinical response to AIT. Local reactions (LRs) during AIT had a positive correlation. Other variables such as a family history of atopy, combined asthma history, and the levels of specific and total IgE had no correlations with effective AIT. CONCLUSION Early intervention with AIT helps to improve the efficacy of AR treatment. LRs might predict successful AIT. Highly symptomatic AR patients may develop increased clinical responses to AIT.
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Affiliation(s)
- Shanshan Qi
- Department of Allergy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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211
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Tsabouri S, Mavroudi A, Feketea G, Guibas GV. Subcutaneous and Sublingual Immunotherapy in Allergic Asthma in Children. Front Pediatr 2017; 5:82. [PMID: 28484690 PMCID: PMC5399038 DOI: 10.3389/fped.2017.00082] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/05/2017] [Indexed: 12/15/2022] Open
Abstract
This review presents up-to-date understanding of immunotherapy in the treatment of children with allergic asthma. The principal types of allergen immunotherapy (AIT) are subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT). Both of them are indicated for patients with allergic rhinitis and/or asthma, who have evidence of clinically relevant allergen-specific IgE, and significant symptoms despite reasonable avoidance measures and/or maximal medical therapy. Studies have shown a significant decrease in asthma symptom scores and in the use of rescue medication, and a preventive effect on asthma onset. Although the safety profile of SLIT appears to be better than SCIT, the results of some studies and meta-analyses suggest that the efficacy of SCIT is better and that SCIT has an earlier onset than SLIT in children with allergic asthma. Severe, not controlled asthma, and medical error were the most frequent causes of SCIT-induced adverse events.
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Affiliation(s)
- Sophia Tsabouri
- Child Health Department, University of Ioannina School of Medicine, Ioannina, Greece
| | - Antigoni Mavroudi
- Allergy Unit of the 3rd Pediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Gavriela Feketea
- General Hospital of Ilias, Amaliada Hospital Unit, Amaliada, Greece
| | - George V Guibas
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.,Allergy Department, University Hospitals South Manchester NHS Trust, Manchester, UK
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Bachmann MF, Kündig TM. Allergen-specific immunotherapy: is it vaccination against toxins after all? Allergy 2017; 72:13-23. [PMID: 27558586 DOI: 10.1111/all.12890] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2016] [Indexed: 01/16/2023]
Abstract
IgE-mediated allergies, in particular allergic rhinoconjunctivitis and asthma, have reached epidemic proportions, affecting about one-third of the population in developed countries. The most effective treatment for allergies is specific immunotherapy (SIT), which involves the injection of increasing doses of an allergen extract to allergic individuals. The current form of SIT was first introduced in 1911 and recently celebrated its 100th birthday for the treatment of hay fever. The concept of this therapy at the time was straightforward, as it was believed that pollen contained toxins against which the patient could be vaccinated. However, the understanding became blurred with the discovery that IgE antibodies were the effector molecules of the allergic response. Subsequent research focused on the idea that SIT should induce tolerance keeping the IgE antibodies at bay. In this review, we will discuss the various hypotheses for the mechanism of SIT and we will put forward the concept that allergens may be viewed as 'protoxins' which need to be activated by IgE antibodies. Within this framework, protoxin-neutralizing antibodies are the key effector molecules while a shift to Th1 or Treg cells mainly contributes to the efficacy of SIT by helping B cells to produce neutralizing IgG antibodies.
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Affiliation(s)
- M. F. Bachmann
- Immunology; RIA; University Hospital Bern; Bern Switzerland
- The Jenner Institute; University of Oxford; Oxford UK
| | - T. M. Kündig
- Department of Dermatology; University Hospital Zürich; Zürich Switzerland
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213
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Hüser C, Dieterich P, Singh J, Shah‐Hosseini K, Allekotte S, Lehmacher W, Compalati E, Mösges R. A 12-week DBPC dose-finding study with sublingual monomeric allergoid tablets in house dust mite-allergic patients. Allergy 2017; 72:77-84. [PMID: 27068870 PMCID: PMC5217067 DOI: 10.1111/all.12913] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND In sublingual immunotherapy, optimal doses are a key factor for therapeutic outcomes. The aim of this study with tablets containing carbamylated monomeric house dust mite allergoids was to determine the most effective and safe dose. METHODS In this double-blind, placebo-controlled dose-finding study, 131 patients with house dust mite-induced allergic rhinoconjunctivitis were randomized to 12-week treatments with 300 UA/day, 1000 UA/day, 2000 UA/day, 3000 UA/day or placebo. Conjunctival provocation tests (CPT) were performed before, during and after treatment. The change in mean allergic severity (primary endpoint), calculated from the severity of the CPT reaction, and the proportion of patients with an improved CPT threshold (secondary endpoint) determined the treatment effect. RESULTS The mean allergic severity decreased in all groups, including the placebo group. It was lower in all active treatment groups (300 UA/day: 0.14, 1000 UA/day: 0.15, 2000 UA/day: 0.10, 3000 UA/day: 0.15) than in the placebo group (0.30). However, this difference was not statistically significant (P < 0.1). The percentage of patients with an improved CPT threshold was higher in the active treatment groups (300 UA/day: 73.9%; 1000 UA/day: 76.0%; 2000 UA/day: 88.5%; 3000 UA/day: 76.0%) than in the placebo group (64.3%). The difference between placebo and 2000 UA/day was statistically significant (P = 0.04). In 13 (10%) exposed patients, a total of 20 treatment-related adverse events of mild severity were observed. CONCLUSIONS The 12-week daily treatment using 2000 UA/day monomeric allergoid sublingual tablets is well tolerated and reduces the CPT reaction in house dust mite-allergic patients.
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Affiliation(s)
- C. Hüser
- Institute for Medical Statistics, Informatics and EpidemiologyFaculty of MedicineUniversity of CologneCologneGermany
| | - P. Dieterich
- Institute for Medical Statistics, Informatics and EpidemiologyFaculty of MedicineUniversity of CologneCologneGermany
| | - J. Singh
- Institute for Medical Statistics, Informatics and EpidemiologyFaculty of MedicineUniversity of CologneCologneGermany
| | - K. Shah‐Hosseini
- Institute for Medical Statistics, Informatics and EpidemiologyFaculty of MedicineUniversity of CologneCologneGermany
| | - S. Allekotte
- Institute for Medical Statistics, Informatics and EpidemiologyFaculty of MedicineUniversity of CologneCologneGermany
| | - W. Lehmacher
- Institute for Medical Statistics, Informatics and EpidemiologyFaculty of MedicineUniversity of CologneCologneGermany
| | | | - R. Mösges
- Institute for Medical Statistics, Informatics and EpidemiologyFaculty of MedicineUniversity of CologneCologneGermany
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214
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Nelson HS, Durham SR. Allergen Immunotherapy for a Teenager with Seasonal Allergic Rhinitis Due to Grass Pollen: Subcutaneous or Sublingual Route? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:52-57. [DOI: 10.1016/j.jaip.2016.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 10/25/2016] [Accepted: 10/26/2016] [Indexed: 11/29/2022]
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Lemberg ML, Berk T, Shah-Hosseini K, Kasche EM, Mösges R. Sublingual versus subcutaneous immunotherapy: patient adherence at a large German allergy center. Patient Prefer Adherence 2017; 11:63-70. [PMID: 28115832 PMCID: PMC5221545 DOI: 10.2147/ppa.s122948] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Many placebo-controlled studies have demonstrated that allergen immunotherapy (AIT) is an effective therapy for treating allergies. Both commonly used routes, subcutaneous (SCIT) and sublingual immunotherapy (SLIT), require high patient adherence to be successful. In the literature, numbers describing adherence vary widely; this investigation compares these two routes of therapy directly. METHODS All data were retrieved from the patient data management system of a center for dermatology, specific allergology, and environmental medicine in Germany. All 330 patients (aged 13-89 years) included in this study had commenced AIT between 2003 and 2011, thus allowing a full 3-year AIT cycle to be considered for each investigated patient. RESULTS In this specific center, SCIT was prescribed to 62.7% and SLIT to 37.3% of all included patients. The total dropout rate of the whole patient cohort was 34.8%. Overall, SLIT patients showed a higher dropout rate (39.0%) than did SCIT patients (32.4%); however, the difference between these groups was not significant. Also, no significant difference between the overall dropout rates for men and for women was observed. A Kaplan-Meier curve of the patient collective showed a remarkably high dropout rate for the first year of therapy. CONCLUSION The analysis presented in this single-center study shows that most patients who discontinue AIT do so during the first year of therapy. Patients seem likely to finish the 3-year therapy cycle if they manage to adhere to treatment throughout the first year. Strategies for preventing nonadherence in AIT, therefore, need to be developed and standardized in future investigations.
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Affiliation(s)
- Marie-Luise Lemberg
- Faculty of Medicine, Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | - Till Berk
- Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Kija Shah-Hosseini
- Faculty of Medicine, Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | - Elena-Manja Kasche
- Faculty of Medicine, Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
- Center for Dermatology, Specific Allergology and Environmental Medicine, Hamburg, Germany
| | - Ralph Mösges
- Faculty of Medicine, Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
- Correspondence: Ralph Mösges, Faculty of Medicine, Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Lindenburger Allee 42, Cologne 50931, Germany, Tel +49 221 478 82929, Fax +49 221 478 82940, Email
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216
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Demoly P, Makatsori M, Casale TB, Calderon MA. The Potential Role of Allergen Immunotherapy in Stepping Down Asthma Treatment. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:640-648. [PMID: 28042004 DOI: 10.1016/j.jaip.2016.11.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/22/2016] [Accepted: 11/23/2016] [Indexed: 12/17/2022]
Abstract
For patients whose asthma is controlled and who have a low risk for future exacerbations, current guidelines recommend gradually stepping down pharmacotherapy to identify the lowest dose needed to maintain control. This review article will discuss the benefits and risks of step down in asthma management and the different strategies of achieving step down with particular focus on allergen immunotherapy (AIT). A literature search was conducted to identify studies that assessed the effect of AIT on asthma step down and evaluated this and asthma control as one of the outcomes. Six studies were identified: 2 subcutaneous and 4 sublingual AIT studies. Five studies assessed house dust mite-induced asthma, whereas 1 study focused on birch-induced seasonal asthma. Regarding house dust mite-induced asthma, the AIT studies reviewed suggest that individuals with moderate rather than mild asthma are the patients who are more likely to benefit from the addition of AIT for their asthma condition. The potential value of AIT is likely to be in enabling successful step down of the inhaled corticosteroid dose in Global Initiative for Asthma step 3 or 4. It is important to further explore this effect so that affected individuals can benefit from this treatment.
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Affiliation(s)
- Pascal Demoly
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France; Sorbonne Universités, Paris, France
| | - Melina Makatsori
- Section of Allergy and Clinical Immunology, Imperial College London, National Heart and Lung Institute, Royal Brompton Hospital, London, United Kingdom.
| | - Thomas B Casale
- Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Moises A Calderon
- Section of Allergy and Clinical Immunology, Imperial College London, National Heart and Lung Institute, Royal Brompton Hospital, London, United Kingdom
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217
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Wahn U, Calderon MA, Demoly P. Real-life clinical practice and management of polysensitized patients with respiratory allergies: a large, global survey of clinicians prescribing allergen immunotherapy. Expert Rev Clin Immunol 2016; 13:283-289. [DOI: 10.1080/1744666x.2017.1277142] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Ulrich Wahn
- Department of Paediatric Pulmonology and Immunology, Charité Virchow-Klinikum, Humboldt University, Berlin, Germany
| | - Moises A. Calderon
- Section of Allergy and Clinical Immunology, Imperial College London–National Heart and Lung Institute, Royal Brompton Hospital, London, UK
| | - Pascal Demoly
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier and Sorbonne Universités, UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, Paris, France
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218
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Cox L. The role of allergen immunotherapy in the management of allergic rhinitis. Am J Rhinol Allergy 2016; 30:48-53. [PMID: 26867530 DOI: 10.2500/ajra.2016.30.4253] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the role of allergen immunotherapy (AIT) in the treatment of allergic rhinitis (AR). METHOD Individual studies, systematic reviews, and practice guidelines that included information on sublingual AIT (SLIT) and subcutaneous AIT (SCIT) in the treatment of AR were considered. RESULTS AIT via the SLIT or SCIT route has been shown to be effective in treating AR symptoms with resultant improvements in overall quality of life, comorbid illnesses, and medication requirements. Persistent clinical benefits have been demonstrated years after AIT treatment discontinuation. AIT may prevent the progression of AR to asthma. In addition, studies that evaluated the pharmacoeconomics of AR treatment indicate that AIT may be more cost effective than pharmacotherapy. The AIT cost savings are likely underestimated in that few cost comparison studies considered AIT's long-term benefits or preventive effects. CONCLUSION Multiple individual studies and systematic reviews provide strong evidence for the clinical effectiveness of AIT in the treatment of AR. Cost-effectiveness and disease modification are additional advantages of AIT compared with standard drug treatment in the management of AR.
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Affiliation(s)
- Linda Cox
- Department of Medicine, Nova Southeastern University, Davie, Florida, USA
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219
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Caillot N, Bouley J, Jain K, Mariano S, Luce S, Horiot S, Airouche S, Beuraud C, Beauvallet C, Devillier P, Chollet-Martin S, Kellenberger C, Mascarell L, Chabre H, Batard T, Nony E, Lombardi V, Baron-Bodo V, Moingeon P. Sialylated Fetuin-A as a candidate predictive biomarker for successful grass pollen allergen immunotherapy. J Allergy Clin Immunol 2016; 140:759-770.e13. [PMID: 27965111 DOI: 10.1016/j.jaci.2016.10.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 08/19/2016] [Accepted: 10/12/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Eligibility to immunotherapy is based on the determination of IgE reactivity to a specific allergen by means of skin prick or in vitro testing. Biomarkers predicting the likelihood of clinical improvement during immunotherapy would significantly improve patient selection. METHODS Proteins were differentially assessed by using 2-dimensional differential gel electrophoresis and label-free mass spectrometry in pretreatment sera obtained from clinical responders and nonresponders within a cohort of 82 patients with grass pollen allergy receiving sublingual immunotherapy or placebo. Functional studies of Fetuin-A (FetA) were conducted by using gene silencing in a mouse asthma model, human dendritic cell in vitro stimulation assays, and surface plasmon resonance. RESULTS Analysis by using quantitative proteomics of pretreatment sera from patients with grass pollen allergy reveals that high levels of O-glycosylated sialylated FetA isoforms are found in patients exhibiting a strong decrease in rhinoconjunctivitis symptoms after sublingual immunotherapy. Although FetA is involved in numerous inflammatory conditions, its potential role in allergy is unknown. In vivo silencing of the FETUA gene in BALB/c mice results in a dramatic upregulation of airway hyperresponsiveness, lung resistance, and TH2 responses after allergic sensitization to ovalbumin. Both sialylated and nonsialytated FetA bind to LPS, but only the former synergizes with LPS and grass pollen or mite allergens to enhance the Toll-like receptor 4-mediated proallergic properties of human dendritic cells. CONCLUSIONS As a reflection of the patient's inflammatory status, pretreatment levels of sialylated FetA in the blood are indicative of the likelihood of clinical responses during grass pollen immunotherapy.
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Affiliation(s)
| | - Julien Bouley
- Research Department, Stallergenes Greer, Antony, France
| | - Karine Jain
- Research Department, Stallergenes Greer, Antony, France
| | | | - Sonia Luce
- Research Department, Stallergenes Greer, Antony, France
| | | | - Sabi Airouche
- Research Department, Stallergenes Greer, Antony, France
| | - Chloé Beuraud
- Research Department, Stallergenes Greer, Antony, France
| | | | - Philippe Devillier
- UPRES EA 220 and Clinical Research Department, Foch Hospital, Suresnes, France
| | | | | | | | - Henri Chabre
- Research Department, Stallergenes Greer, Antony, France
| | | | - Emmanuel Nony
- Research Department, Stallergenes Greer, Antony, France
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220
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Grouin JM, Vicaut E, Devillier P. Comparison of scores associating symptoms and rescue medication use for evaluating the efficacy of allergy immunotherapy in seasonal allergic rhinoconjunctivitis: results from five trials. Clin Exp Allergy 2016; 47:254-263. [PMID: 27790763 DOI: 10.1111/cea.12845] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 09/22/2016] [Accepted: 10/02/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Over the past decade, regulatory bodies and scientific societies recommended, as primary efficacy outcome, a score that reflects both symptom severity and use of rescue medication for clinical trials in allergy immunotherapy (AIT). OBJECTIVE We sought to compare the results obtained with two subject-specific scores, the Combined Score (CS) and the Adjusted Symptom Score (AdSS), for assessment of AIT in seasonal allergic rhinoconjunctivitis due to birch and grass pollen allergens. METHODS CS and AdSS were evaluated in subjects receiving a 300IR dose of allergen extract daily, by sublingual route, in four clinical trials with the 5-grass pollen tablet (NCT00367640, NCT00409409, NCT00955825 and NCT00418379) and one with the birch pollen solution (NCT01731249). The CS is derived from the Rhinoconjunctivitis Total Symptom Score (RTSS) and the Rescue Medication Score (RMS) giving equal weight to symptoms and medication use. The AdSS is a symptom score adjusting for rescue medication use. Efficacy end-points were analysed using an analysis of covariance linear model. RESULTS In all trials, despite the different constructs of the two scores, Combined Score or Adjusted Symptom Score were similarly reduced in the 300IR group compared to the placebo group. Treatment effect was consistently demonstrated with both scores, CS and AdSS, used as either daily scores or average of the daily scores over the pollen season. Minor differences with the same statistical conclusions were observed between the results, leading to the same interpretation. CONCLUSIONS AND CLINICAL RELEVANCE The two scores, combined and adjusted scores, for evaluation of clinical efficacy of AIT have led to similar results, with similar statistical conclusions and similar interpretation.
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Affiliation(s)
- J-M Grouin
- INSERM 1219, University of Rouen, Rouen, France
| | - E Vicaut
- Clinical Research Unit Saint-Louis Lariboisière Fernand-Widal, University of Paris-Diderot, Paris, France
| | - P Devillier
- UPRES EA 220, Clinical Research Unit, Airway Diseases Department, Foch Hospital, University of Versailles Saint-Quentin, University Paris Saclay, Suresnes, France
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221
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Optimizing Allergen Immunotherapy Safety: What Do We Know and What Are the Unmet Needs. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0108-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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222
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Mastrorilli C, Posa D, Cipriani F, Caffarelli C. Asthma and allergic rhinitis in childhood: what's new. Pediatr Allergy Immunol 2016; 27:795-803. [PMID: 27862336 DOI: 10.1111/pai.12681] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2016] [Indexed: 12/23/2022]
Abstract
Novel approaches are currently offered for the diagnostic workup and therapeutic management of allergic rhinitis and asthma. New predictive biomarkers of allergy and asthma are available. Primary and secondary prevention, earlier intervention, and modification of the natural history of allergic rhinitis and asthma are being intensively investigated. This review highlights advances in the understanding of the etiology, diagnosis, and management of atopic airway diseases in childhood, as well as prenatal and early-life risk factors and strategies for prevention.
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Affiliation(s)
- Carla Mastrorilli
- Pediatric Clinic, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy.,Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin, Berlin, Germany
| | - Daniela Posa
- Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin, Berlin, Germany
| | - Francesca Cipriani
- Pediatric Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carlo Caffarelli
- Pediatric Clinic, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
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223
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Lyseng-Williamson KA. Standardized quality house dust mite sublingual tablets (Acarizax®): a guide to their use as sublingual allergy immunotherapy in Europe. DRUGS & THERAPY PERSPECTIVES 2016. [DOI: 10.1007/s40267-016-0349-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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224
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New Pharmacologic Strategies for Allergic Rhinitis. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0105-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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225
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Abstract
Allergen-specific immunotherapy (AIT) has been used to treat allergic diseases for over a century. It is the only treatment that addresses immune dysfunction underlying allergic responses rather than simply treating symptoms or suppressing inflammation. Its safety and efficacy in allergic rhinitis, asthma and insect allergy has been documented in a number of systematic reviews but its cost effectiveness is less clear. AIT reduces symptoms and requirement for medication, while improving quality of life. Further, the effect continues for years after discontinuation of treatment. However, evidence regarding cost effectiveness is limited. During AIT, allergen extracts are administered through a subcutaneous or sublingual route for 3-5 years. Subcutaneous immunotherapy is more effective in inducing long-term remission but systemic reactions do occur occasionally. Sublingual immunotherapy is safer and more convenient for the patient but evidence regarding its long-term efficacy is patchy. AIT is used widely in western Europe and the USA. In the UK, subcutaneous immunotherapy is often used for bee and wasp allergy, while both subcutaneous and sublingual immunotherapies are used for severe allergic rhinitis and occasionally for house dust mite and pet allergies. In conclusion, AIT is safe and effective and should be considered as a treatment option for those with allergic diseases.
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226
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THE CLINICAL EFFICACY OF SUBLINGUAL ALLERGEN-SPECIFIC IMMUNOTHERAPY IN CHILDREN AGED 3-5 YEARS. EUREKA: HEALTH SCIENCES 2016. [DOI: 10.21303/2504-5679.2016.00225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim of this study was to determine the efficacy of sublingual allergen–specific immunotherapy (SLIT) in Ukrainian children younger than 5 years old with allergic rhinitis and bronchial asthma sensitized to house dust mite allergens.
Material and methods: Four hundred and fifty children aged 28 months up to 5 years with rhinitis or asthma were examined. One hundred and twenty five children sensitized to house dust mites Dermatophagoides pteronyssinus and/or Dermatophagoides farina were included. In vivo and in vitro tests were made with a standard inhalant allergens panel.
Results: The high information value of molecular diagnostics methods applied prior to prescription of the given therapy in children is analyzed. It has been found that in children under 5 sensitized to allergens of house dust mites Dermatophagoides pteronyssinus and/or Dermatophagoides farinae the application of sublingual allergen–specific immunotherapy therapy allows gaining control over the symptoms of the disease during the first 6 months.
Conclusion: The high safety of SLIT in children has been proven. Comparative analysis in the group of patients not receiving SLIT shows a high frequency of symptoms of the disease after “free-of-symptoms interval” against full or partial baseline therapy denial.
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227
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Canonica GW, Senna G, Mitchell PD, O'Byrne PM, Passalacqua G, Varricchi G. Therapeutic interventions in severe asthma. World Allergy Organ J 2016; 9:40. [PMID: 27942351 PMCID: PMC5125042 DOI: 10.1186/s40413-016-0130-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 11/04/2016] [Indexed: 12/29/2022] Open
Abstract
The present paper addresses severe asthma which is limited to 5-10% of the overall population of asthmatics. However, it accounts for 50% or more of socials costs of the disease, as it is responsible for hospitalizations and Emergency Department accesses as well as expensive treatments. The recent identification of different endotypes of asthma, based on the inflammatory pattern, has led to the development of tailored treatments that target different inflammatory mediators. These are major achievements in the perspective of Precision Medicine: a leading approach to the modern treatment strategy. Omalizumab, an anti-IgE antibody, has been the only biologic treatment available on the market for severe asthma during the last decade. It prevents the linkage of the IgE and the receptors, thereby inhibiting mast cell degranulation. In clinical practice omalizumab significantly reduced the asthma exacerbations as well as the concomitant use of oral glucocorticoids. In the "Th2-high asthma" phenotype, the hallmarks are increased levels of eosinophils and other markers (such as periostin). Because anti-IL-5 in this condition plays a crucial role in driving eosinophil inflammation, this cytokine or its receptors on the eosinophil surface has been studied as a potential target for therapy. Two different anti-IL-5 humanized monoclonal antibodies, mepolizumab and reslizumab, have been proven effective in this phenotype of asthma (recently they both came on the market in the United States), as well as an anti-IL-5 receptor alpha (IL5Rα), benralizumab. Other monoclonal antibodies, targeting different cytokines (IL-13, IL-4, IL-17 and TSLP) are still under evaluation, though the preliminary results are encouraging. Finally, AIT, Allergen Immunotherapy, a prototype of Precision Medicine, is considered, also in light of the recent evidences of Sublingual Immunotherapy (SLIT) tablet efficacy and safety in mite allergic asthma patients. Given the high costs of these therapies, however, there is an urgent need to identify biomarkers that can predict the clinical responders.
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Affiliation(s)
- Giorgio Walter Canonica
- Allergy & Respiratory Disease Clinic, DIMI Department of Internal Medicine, IRCCS AOU San Martino-IST, University of Genoa, Genova, Italy
| | - Gianenrico Senna
- Allergy Unit, Verona University and General Hospital, Verona, Italy
| | - Patrick D Mitchell
- Firestone Institute of Respiratory Health and Department of Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario Canada
| | - Paul M O'Byrne
- Firestone Institute of Respiratory Health and Department of Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario Canada
| | - Giovanni Passalacqua
- Allergy & Respiratory Disease Clinic, DIMI Department of Internal Medicine, IRCCS AOU San Martino-IST, University of Genoa, Genova, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, Division of Clinical Immunology and Allergy, University of Naples Federico II, Naples, Italy
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228
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Calderon MA, Demoly P, Casale T, Akdis CA, Bachert C, Bewick M, Bilò BM, Bohle B, Bonini S, Bush A, Caimmi DP, Canonica GW, Cardona V, Chiriac AM, Cox L, Custovic A, De Blay F, Devillier P, Didier A, Di Lorenzo G, Du Toit G, Durham SR, Eng P, Fiocchi A, Fox AT, van Wijk RG, Gomez RM, Haathela T, Halken S, Hellings PW, Jacobsen L, Just J, Tanno LK, Kleine-Tebbe J, Klimek L, Knol EF, Kuna P, Larenas-Linnemann DE, Linneberg A, Matricardi M, Malling HJ, Moesges R, Mullol J, Muraro A, Papadopoulos N, Passalacqua G, Pastorello E, Pfaar O, Price D, Del Rio PR, Ruëff R, Samolinski B, Scadding GK, Senti G, Shamji MH, Sheikh A, Sisul JC, Sole D, Sturm GJ, Tabar A, Van Ree R, Ventura MT, Vidal C, Varga EM, Worm M, Zuberbier T, Bousquet J. Allergy immunotherapy across the life cycle to promote active and healthy ageing: from research to policies: An AIRWAYS Integrated Care Pathways (ICPs) programme item (Action Plan B3 of the European Innovation Partnership on active and healthy ageing) and the Global Alliance against Chronic Respiratory Diseases (GARD), a World Health Organization GARD research demonstration project. Clin Transl Allergy 2016; 6:41. [PMID: 27895895 PMCID: PMC5120439 DOI: 10.1186/s13601-016-0131-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 11/02/2016] [Indexed: 12/17/2022] Open
Abstract
Allergic diseases often occur early in life and persist throughout life. This life-course perspective should be considered in allergen immunotherapy. In particular it is essential to understand whether this al treatment may be used in old age adults. The current paper was developed by a working group of AIRWAYS integrated care pathways for airways diseases, the model of chronic respiratory diseases of the European Innovation Partnership on active and healthy ageing (DG CONNECT and DG Santé). It considered (1) the political background, (2) the rationale for allergen immunotherapy across the life cycle, (3) the unmet needs for the treatment, in particular in preschool children and old age adults, (4) the strategic framework and the practical approach to synergize current initiatives in allergen immunotherapy, its mechanisms and the concept of active and healthy ageing.
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Affiliation(s)
- M A Calderon
- National Heart and Lung Institute, Royal Brompton Hospital NHS, Imperial College London, London, UK
| | - P Demoly
- Unité d'allergologie, Département de Pneumologie et AddictologieHôpital Arnaud de Villeneuve, CHRU de Montpellier, Sorbonne Universités, UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, 75013 Paris, France
| | - T Casale
- University of South Florida Morsani College of Medicine, Tampa, FL USA
| | - C A Akdis
- Christine Kühne Center for Allergy Research and Education (CK-CARE), Swiss Institute of Allergy and Asthma Research (SIAF)University of Zurich, Davos, Switzerland
| | - C Bachert
- Upper Airways Research Laboratory (URL), ENT Department, University Hospital Ghent, Ghent, Belgium
| | - M Bewick
- iQ4U consultants Ltd, London, UK
| | - B M Bilò
- Allergy Unit, Department of Internal Medicine, University Hosp Ospedali Riuniti, Ancona, Italy
| | - B Bohle
- Department of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - S Bonini
- Second University of Naples and IFT-CNR, Rome, Italy
| | - A Bush
- National Heart and Lung Institute, Royal Brompton Hospital NHS, Imperial College London, London, UK
| | - D P Caimmi
- Unité d'allergologie, Département de Pneumologie et AddictologieHôpital Arnaud de Villeneuve, CHRU de Montpellier, Sorbonne Universités, UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, 75013 Paris, France
| | - G W Canonica
- Allergy and Respiratory Diseases Clinic, DIMI, University of Genoa, IRCCS AOU San Martino-IST, Genoa, Italy
| | - V Cardona
- Allergy Section, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - A M Chiriac
- Division of Allergy, Hôpital Arnaud de Villeneuve, Department of Pulmonology, University Hospital of Montpellier, Montpellier - UPMC Univ Paris 06, UMRS 1136, Equipe - EPAR - IPLESP, Sorbonne Universités, Paris, France
| | - L Cox
- Nova Southeastern University, Ft. Lauderdale, FL USA
| | - A Custovic
- National Heart and Lung Institute, Royal Brompton Hospital NHS, Imperial College London, London, UK
| | - F De Blay
- Allergy Division, Chest Disease Department, University Hospital of Strasbourg, Strasbourg, France
| | - P Devillier
- University Versailles Saint-Quentin and Clinical Pharmacology Unit, UPRES EA 220, Department of Airway Diseases, Foch Hospital, Suresnes, France
| | - A Didier
- Respiratory Diseases Department, Rangueil-Larrey Hospital, Toulouse, France
| | - G Di Lorenzo
- Dipartimento BioMedico di Medicina Interna e Specialistica (Di.Bi.M.I.S), University of Palermo, Palermo, Italy
| | - G Du Toit
- Guy's and St. Thomas' NHS Trust, Kings College, London, UK
| | - S R Durham
- Allergy and Clinical Immunology Section, National Heart and Lung Institute, Imperial College London, London, UK
| | - P Eng
- Department of Pediatric Pulmonology and Allergy, Children's Hospital, Aarau, Switzerland
| | - A Fiocchi
- Division of Allergy, Department of Pediatrics, Bambino Gesù Pediatric Hospital, Vatican City, Rome, Italy
| | - A T Fox
- King's College London Allergy Academy, London, UK
| | - R Gerth van Wijk
- Section of Allergology, Department of Internal Medicine, Erasmus Medical Center, Building Rochussenstraat, Rotterdam, The Netherlands
| | - R M Gomez
- Unidad Alergia and Asma, Hospital San Bernardo, Salta, Argentina
| | - T Haathela
- Skin and Allergy Hospital, Helsinki University Hospital, Helsinki, Finland
| | - S Halken
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - P W Hellings
- Clinical Department of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, KU Leuven, Louvain, Belgium
| | - L Jacobsen
- Allergy Learning and Consulting, Secretary Immunotherapy Interest Group EAACI, Copenhagen, Denmark
| | - J Just
- Allergology Department, Centre de l'Asthme et des Allergies, Hôpital d'Enfants Armand-Trousseau, INSERM, UMR_S 1136, Sorbonne Universités, UPMC Univ Paris, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Equipe EPAR, Paris, France
| | - L K Tanno
- Hospital Sírio Libanês, São Paulo, Brazil ; University Hospital of Montpellier, Montpellier, France ; UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, Sorbonne Universités, Paris, France
| | - J Kleine-Tebbe
- Allergy and Asthma Center Westend, Outpatient Clinic and Clinical Research Center, Ackermann, Hanf, & Kleine-Tebbe, Berlin, Germany
| | - L Klimek
- Center for Rhinology and Allergology, German Society for Otorhinolaryngology HNS, Wiesbaden, Germany
| | - E F Knol
- Departments of Immunology and Dermatology/Allergology, University Medical Center Utrecht, Heidelberglaan, Utrecht, The Netherlands
| | - P Kuna
- Medical University of Lodz, Lodz, Poland
| | | | - A Linneberg
- Research Centre for Prevention and Health, The Capital Region of Denmark, Copenhagen, Denmark ; Department of Clinical Experimental Research, Rigshospitalet, Copenhagen, Denmark ; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - M Matricardi
- Pediatric Pneumology and Immunology, Charité Medical University, Berlin, Germany
| | - H J Malling
- Danish Allergy Centre, Allergy Clinic, Gentofte University Hospital, Hellerup, Denmark
| | - R Moesges
- IMSIE, Klinikum der Universität zu Köln A. ö. R., Cologne, Germany
| | - J Mullol
- Unitat de Rinologia i Clínica de l'Olfacte, ENT Department, Hospital Clínic, Clinical and Experimental Respiratory Immunoallergy, IDIBAPS, CIBERES, Barcelona, Catalonia Spain
| | - A Muraro
- Department of Women and Child Health, Food Allergy Referral Centre Veneto Region, Padua General University Hospital, Padua, Italy
| | - N Papadopoulos
- Allergy Unit, 2nd Pediatric Clinic, University of Athens, Athens, Greece
| | - G Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino-IST, Univesity of Genoa, Genoa, Italy
| | - E Pastorello
- ASST Grande Ospedale Metropolitano Niguarda, P.zza Ospedale Maggiore, Milan, Italy
| | - O Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Mannheim, Germany ; Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany ; Center for Rhinology and Allergology, Wiesbaden, Germany
| | - D Price
- Division of Applied Health Sciences, Primary Care Respiratory Medicine, Academic Primary Care, University of Aberdeen, Aberdeen, Scotland, UK ; Research in Real Life (RiRL), Oakington, Cambridge, UK ; Optimum Patient Care Ltd, Singapore, Singapore
| | | | - R Ruëff
- Department of Dermatology and Allergology, Ludwig-Maximillian University, Munich, Germany
| | - B Samolinski
- Department of Prevention of Environmental Hazards and Allergology, Medical University of Warsaw, Warsaw, Poland
| | - G K Scadding
- Royal National Throat, Nose and Ear Hospital, London, UK ; University College London, London, UK
| | - G Senti
- Clinical Trials Center, University Hospital of Zurich, Zurich, Switzerland
| | - M H Shamji
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Inflammation, Repair and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK ; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - A Sheikh
- Asthma UK Centre for Applied Research, Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG UK
| | | | - D Sole
- Programa de Pòs-Graduação em Pediatria e Ciências Aplicadas à Pediatria, Departamento de Pediatria EPM, UNIFESP, São Paulo, Brazil
| | - G J Sturm
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria ; Allergy Outpatient Clinic Reumannplatz, Vienna, Austria
| | - A Tabar
- Servicio de Alergologia, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - R Van Ree
- Departments of Experimental Immunology and Otorhinolaryngology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M T Ventura
- Unit of Geriatric Immunoallergology, Interdisciplinary Department of Medicine, University of Bari Medical School, Bari, Italy
| | - C Vidal
- Allergy Department, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - E M Varga
- Respiratory and Allergic Disease Division, Department of Paediatrics, Medical University of Graz, Graz, Austria
| | - M Worm
- Allergie-Centrum-Charité, Klinik für Dermatologie, Venerologie und Allergologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - T Zuberbier
- Allergie-Centrum-Charité, Klinik für Dermatologie, Venerologie und Allergologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - J Bousquet
- University Hospital of Montpellier, Montpellier, France ; Contre les MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon, European Innovation Partnership on Active and Healthy Ageing Reference Site, Paris, France ; INSERM, VIMA, U1168, Ageing and Chronic Diseases, Epidemiological and Public Health Approaches, Paris, France ; UVSQ, UMR-S 1168, Université Versailles St-Quentin-en-Yvelines, Versailles Cedex, France ; CHRU, 371 Avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France
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229
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Nolte H, Casale TB, Lockey RF, Fogh BS, Kaur A, Lu S, Nelson HS. Epinephrine Use in Clinical Trials of Sublingual Immunotherapy Tablets. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:84-89.e3. [PMID: 27838323 DOI: 10.1016/j.jaip.2016.08.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 08/09/2016] [Accepted: 08/23/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Allergy immunotherapy can result in systemic allergic reactions and even life-threatening anaphylaxis requiring epinephrine administration. OBJECTIVE The objective of this study was to describe epinephrine use in the clinical trial development programs of 3 rapidly dissolving sublingual immunotherapy tablets (SLIT-tablets; Merck & Co., Inc., Kenilworth, NJ/ALK, Hørsholm, Denmark/Torii Pharmaceutical Co., Ltd., Tokyo, Japan). METHODS Data on epinephrine use were collected from 13 timothy grass SLIT-tablet trials (MK-7243; ≤2800 bioequivalent allergen units/75,000 SQ-T dose, n = 2497; placebo, n = 2139), 5 short ragweed SLIT-tablet trials (MK-3641; ≤12 Amb a 1-U, n = 1725; placebo, n = 770), and 11 house dust mite (HDM) SLIT-tablet trials (MK-8237; ≤12 SQ-HDM; n = 3930; placebo, n = 2246). RESULTS In grass SLIT-tablet trials, epinephrine was used 13 times (grass SLIT-tablet, n = 10; placebo, n = 3). Eight administrations were for grass SLIT-tablet-related adverse events (AEs): 4 for systemic allergic reactions and 4 for local mouth and/or throat swelling. In ragweed SLIT-tablet trials, epinephrine was used 9 times in 8 subjects (ragweed SLIT-tablet, n = 7; placebo, n = 1 [2 administrations for protracted anaphylaxis]). Four administrations were for ragweed SLIT-tablet-related AEs: 1 for systemic allergic reaction and 3 for local mouth and/or pharynx/throat swelling. In HDM SLIT-tablet trials, epinephrine was administered 13 times (HDM SLIT-tablet, n = 8; placebo, n = 5). Four administrations were for HDM SLIT-tablet-related AEs: 1 for systemic allergic reaction and 3 for local events. Of the 16 epinephrine administrations for events related to SLIT-tablet treatment, 11 occurred within the first week of treatment (7 administrations on day 1) and 5 were subject self-administered. CONCLUSIONS Epinephrine administrations in response to SLIT-tablet-related reactions in clinical trials are uncommon, typically occur within the first week of treatment, and are rarely self-administered. All SLIT-tablet-related events treated with epinephrine were nonserious.
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Affiliation(s)
- Hendrik Nolte
- Research and Development, Merck & Co., Inc., Kenilworth, NJ.
| | - Thomas B Casale
- Division of Allergy & Immunology, University of South Florida Morsani College of Medicine, Tampa, Fla
| | - Richard F Lockey
- Division of Allergy & Immunology, University of South Florida Morsani College of Medicine, Tampa, Fla
| | | | - Amarjot Kaur
- Research and Development, Merck & Co., Inc., Kenilworth, NJ
| | - Susan Lu
- Research and Development, Merck & Co., Inc., Kenilworth, NJ
| | - Harold S Nelson
- Department of Medicine, National Jewish Health, Denver, Colo
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Creticos PS, Bernstein DI, Casale TB, Lockey RF, Maloney J, Nolte H. Coseasonal Initiation of Allergen Immunotherapy: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:1194-1204.e4. [DOI: 10.1016/j.jaip.2016.05.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 05/16/2016] [Accepted: 05/25/2016] [Indexed: 10/21/2022]
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231
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Epstein TG, Calabria C, Cox LS, Dreborg S. Current Evidence on Safety and Practical Considerations for Administration of Sublingual Allergen Immunotherapy (SLIT) in the United States. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:34-40.e2. [PMID: 27815065 DOI: 10.1016/j.jaip.2016.09.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/06/2016] [Accepted: 09/13/2016] [Indexed: 12/17/2022]
Abstract
Liquid sublingual allergen immunotherapy (SLIT) has been used off-label for decades, and Food and Drug Administration (FDA)-approved grass and ragweed SLIT tablets have been available in the United States since 2014. Potentially life-threatening events from SLIT do occur, although they appear to be very rare, especially for FDA-approved products. Practice guidelines that incorporate safety precautions regarding the use of SLIT in the United States are needed. This clinical commentary attempts to address unresolved issues including controversy regarding the FDA mandate for the prescription of epinephrine autoinjectors for patients on SLIT; how to approach polysensitized patients; optimal timing and duration of SLIT administration; how to address gaps in therapy; whether antihistamines can prevent local reactions, if certain patient populations (such as persistent asthmatics) should not receive SLIT; and when to instruct patients to self-administer epinephrine. Key points are that physicians should focus on educating patients regarding: (1) when not to administer SLIT; (2) how to recognize a potentially serious allergic reaction to SLIT; and (3) when to administer epinephrine and seek emergency care.
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Affiliation(s)
- Tolly G Epstein
- Division of Immunology, Allergy, and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | | | - Linda S Cox
- University of Miami Miller School of Medicine at Holy Cross Hospital, Ft. Lauderdale, Fla
| | - Sten Dreborg
- Department of Pediatric Allergy, Women's and Children's Health, University of Uppsala, Uppsala, Sweden
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232
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Tortajada-Girbés M, Mesa Del Castillo M, Larramona H, Lucas JM, Álvaro M, Tabar AI, Jerez MJ, Martínez-Cañavate A. Evidence in immunotherapy for paediatric respiratory allergy: Advances and recommendations. Allergol Immunopathol (Madr) 2016; 44 Suppl 1:1-32. [PMID: 27776895 DOI: 10.1016/j.aller.2016.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 09/05/2016] [Indexed: 01/26/2023]
Abstract
Allergic respiratory diseases are major health problems in paediatric population due their high level of prevalence and chronicity, and to their relevance in the costs and quality of life. One of the most important risk factors for the development of airway diseases in children and adolescents is atopy. The mainstays for the treatment of these diseases are avoiding allergens, controlling symptoms, and preventing them through sustained desensitization by allergen immunotherapy (AIT). AIT is a treatment option that consists in the administration of increasing amounts of allergens to modify the biological response to them, inducing long-term tolerance even after treatment has ended. This treatment approach has shown to decrease symptoms and improve quality of life, becoming cost effective for a large number of patients. In addition, it is considered the only treatment that can influence the natural course of the disease by targeting the cause of the allergic inflammatory response. The aim of this publication is to reflect the advances of AIT in the diagnosis and treatment of allergic respiratory diseases in children and adolescents reviewing articles published since 2000, establishing evidence categories to support the strength of the recommendations based on evidence. The first part of the article covers the prerequisite issues to understand how AIT is effective, such as the correct etiologic and clinical diagnosis of allergic respiratory diseases. Following this, the article outlines the advancements in understanding the mechanisms by which AIT achieve immune tolerance to allergens. Administration routes, treatment regimens, dose and duration, efficacy, safety, and factors associated with adherence are also reviewed. Finally, the article reviews future advances in the research of AIT.
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Affiliation(s)
- M Tortajada-Girbés
- Paediatric Allergology and Pulmonology Unit, Dr. Peset University Hospital, Valencia, Spain; Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, Valencia, Spain.
| | - M Mesa Del Castillo
- Paediatric Allergology and Neumology Unit, Hospital El Escorial, Madrid, Spain
| | - H Larramona
- Paediatric Allergology and Pulmonology Unit, Department of Paediatrics, University Autonoma of Barcelona, and Corporacio Sanitaria Parc Tauli, Hospital of Sabadell, Barcelona, Spain
| | - J M Lucas
- Pediatric Allergy and Immunology Unit, Virgen Arrixaca Clinic Universitary Hospital, Murcia, Spain
| | - M Álvaro
- Allergy and Clinical Immunology Section, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - A I Tabar
- Servicio de Alergología. Complejo Hospitalario de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), RETIC de Asma, Reacciones adversas y Alérgicas (ARADYAL), Pamplona, Spain
| | - M J Jerez
- Publications Office of the European Union, Luxembourg
| | - A Martínez-Cañavate
- Paediatric Allergology and Neumology Unit, Complejo Hospitalario Universitario de Granada, Spain
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233
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Lin X, Lin H, Wei X, Huang Q. WITHDRAWN: The efficacy and safety of sublingual immunotherapy in children and adult patients with allergic rhinitis. Am J Otolaryngol 2016. [DOI: 10.1016/j.amjoto.2016.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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234
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Shakya AK, Chowdhury MYE, Tao W, Gill HS. Mucosal vaccine delivery: Current state and a pediatric perspective. J Control Release 2016; 240:394-413. [PMID: 26860287 PMCID: PMC5381653 DOI: 10.1016/j.jconrel.2016.02.014] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/21/2016] [Accepted: 02/05/2016] [Indexed: 12/30/2022]
Abstract
Most childhood infections occur via the mucosal surfaces, however, parenterally delivered vaccines are unable to induce protective immunity at these surfaces. In contrast, delivery of vaccines via the mucosal routes can allow antigens to interact with the mucosa-associated lymphoid tissue (MALT) to induce both mucosal and systemic immunity. The induced mucosal immunity can neutralize the pathogen on the mucosal surface before it can cause infection. In addition to reinforcing the defense at mucosal surfaces, mucosal vaccination is also expected to be needle-free, which can eliminate pain and the fear of vaccination. Thus, mucosal vaccination is highly appealing, especially for the pediatric population. However, vaccine delivery across mucosal surfaces is challenging because of the different barriers that naturally exist at the various mucosal surfaces to keep the pathogens out. There have been significant developments in delivery systems for mucosal vaccination. In this review we provide an introduction to the MALT, highlight barriers to vaccine delivery at different mucosal surfaces, discuss different approaches that have been investigated for vaccine delivery across mucosal surfaces, and conclude with an assessment of perspectives for mucosal vaccination in the context of the pediatric population.
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Affiliation(s)
| | | | - Wenqian Tao
- Department of Chemical Engineering, Texas Tech University, Lubbock, TX 79409, USA
| | - Harvinder Singh Gill
- Department of Chemical Engineering, Texas Tech University, Lubbock, TX 79409, USA.
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Kowalski ML, Ansotegui I, Aberer W, Al-Ahmad M, Akdis M, Ballmer-Weber BK, Beyer K, Blanca M, Brown S, Bunnag C, Hulett AC, Castells M, Chng HH, De Blay F, Ebisawa M, Fineman S, Golden DBK, Haahtela T, Kaliner M, Katelaris C, Lee BW, Makowska J, Muller U, Mullol J, Oppenheimer J, Park HS, Parkerson J, Passalacqua G, Pawankar R, Renz H, Rueff F, Sanchez-Borges M, Sastre J, Scadding G, Sicherer S, Tantilipikorn P, Tracy J, van Kempen V, Bohle B, Canonica GW, Caraballo L, Gomez M, Ito K, Jensen-Jarolim E, Larche M, Melioli G, Poulsen LK, Valenta R, Zuberbier T. Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement. World Allergy Organ J 2016; 9:33. [PMID: 27777642 PMCID: PMC5062928 DOI: 10.1186/s40413-016-0122-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 08/19/2016] [Indexed: 01/14/2023] Open
Abstract
One of the major concerns in the practice of allergy is related to the safety of procedures for the diagnosis and treatment of allergic disease. Management (diagnosis and treatment) of hypersensitivity disorders involves often intentional exposure to potentially allergenic substances (during skin testing), deliberate induction in the office of allergic symptoms to offending compounds (provocation tests) or intentional application of potentially dangerous substances (allergy vaccine) to sensitized patients. These situations may be associated with a significant risk of unwanted, excessive or even dangerous reactions, which in many instances cannot be completely avoided. However, adverse reactions can be minimized or even avoided if a physician is fully aware of potential risk and is prepared to appropriately handle the situation. Information on the risk of diagnostic and therapeutic procedures in allergic diseases has been accumulated in the medical literature for decades; however, except for allergen specific immunotherapy, it has never been presented in a systematic fashion. Up to now no single document addressed the risk of the most commonly used medical procedures in the allergy office nor attempted to present general requirements necessary to assure the safety of these procedures. Following review of available literature a group of allergy experts within the World Allergy Organization (WAO), representing various continents and areas of allergy expertise, presents this report on risk associated with diagnostic and therapeutic procedures in allergology and proposes a consensus on safety requirements for performing procedures in allergy offices. Optimal safety measures including appropriate location, type and required time of supervision, availability of safety equipment, access to specialized emergency services, etc. for various procedures have been recommended. This document should be useful for allergists with already established practices and experience as well as to other specialists taking care of patients with allergies.
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Affiliation(s)
- Marek L. Kowalski
- Department of Immunology, Rheumatology & Allergy, Medical University of Lodz, 251 Pomorska Str, 92-213 Lodz, Poland
| | - Ignacio Ansotegui
- Department of Allergy and Immunology, Hospital Quiron Bizkaia, Bilbao, Spain
| | - Werner Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Mona Al-Ahmad
- Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Mubeccel Akdis
- Swiss institute of Allergy & Asthma research, Davos, Switzerland
| | - Barbara K. Ballmer-Weber
- Allergy Unit, Dermatology Clinic, University Hospital Zürich, University Zürich, Zürich, Switzerland
| | - Kirsten Beyer
- Kirsten Beyer, Charité Universitätsmedizin Berlin, Klinik für Pädiatrie m.S. Pneumologie und Immunologie, Berlin, Germany
| | - Miguel Blanca
- Hospital Reg. Univ. Carlos Haya, Allergy Serv, Malaga, Spain
| | - Simon Brown
- Royal Perth Hospital, Department of Emergency Medicine, Perth, WA Australia
| | - Chaweewan Bunnag
- Department of Otolaryngology, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Mariana Castells
- Brigham & Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Hiok Hee Chng
- Department of Rheumatology, Allergy & Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Frederic De Blay
- Hôpitaux Universitaires de Strasbourg, Chest Diseases Department, Strasbourg, France
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergology and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa Japan
| | - Stanley Fineman
- Emory University School of Medicine, Atlanta Allergy & Asthma, Atlanta, Georgia
| | | | - Tari Haahtela
- Helsinki University Central Hospital, Helsinki, Finland
| | | | | | - Bee Wah Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joanna Makowska
- CSK, Department of Allergy & Clinical Immunology, Lodz, Poland
| | | | - Joaquim Mullol
- Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic, Clinical & Experimental Respiratory Immunoallergy, IDIBAPS, and CIBERES, Barcelona, Spain
| | - John Oppenheimer
- UMDNJ – Rutgers Medical School, c/o Pulmonary and Allergy Associates, Summit, New Jersey, USA
| | - Hae-Sim Park
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, South Korea
| | | | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital IST, University of Genoa, Genoa, Italy
| | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Harald Renz
- Universitatsklinikum GI & MR GmbH, Institut fur Laboratoriumsmedizin & Path, Standort Marburg, Marburg, Germany
| | - Franziska Rueff
- Klinikum der Ludwig-Maximilians-Universitat, Klinik & Poliklinik fur Dermatologie & Allergologie, Munchen, Germany
| | - Mario Sanchez-Borges
- Allergy and Clinical Immunology Department, Centro Medico-Docente La Trinidadad, Caracas, Venezuela
| | - Joaquin Sastre
- Allergy Department, Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, CIBER de Enfermedades Respiratorias (CIBERES), Institute Carlos III, Madrid, Spain
| | | | - Scott Sicherer
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | | | - Vera van Kempen
- Institute for Prevention and Occupational Medicine, German Social Accident Insurance, Ruhr-University Bochum (IPA), Bochum, Germany
| | - Barbara Bohle
- Division of Experimental Allergology, Department of Pathophysiology, Allergy Research Center of Pathophysiology, Infectiology & Immunology, Medical University of Vienna, Vienna, Austria
| | - G Walter Canonica
- Allergy & Respiratory Disease Clinic, DIMI – Department Int Med, University of Genoa, IRCCS AOU, San Martino – IST, Genoa, Italy
| | - Luis Caraballo
- Immunology Department, Universidad De Cartagena, Cartagena, Colombia
| | | | - Komei Ito
- Department of Allergy, Aichi Children’s Health and Medical Center, Aichi, Japan
| | - Erika Jensen-Jarolim
- Messerli Research Institute, Medical University Vienna, University Vienna, Vienna, Austria
| | - Mark Larche
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
| | | | - Lars K. Poulsen
- Gentofte University Hospital, Lab for Allergology, Allergy Clinic, Hellerup, Denmark
| | | | - Torsten Zuberbier
- Campus Charite Mitte, Klinik fur Dermatologie & Allergologie, Berlin, Germany
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Demoly P, Okamoto Y, Yang WH, Devillier P, Bergmann KC. 300 IR HDM tablet: a sublingual immunotherapy tablet for the treatment of house dust mite-associated allergic rhinitis. Expert Rev Clin Immunol 2016; 12:1141-1151. [PMID: 27632814 DOI: 10.1080/1744666x.2016.1237288] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The once-daily 300 index of reactivity (IR) house dust mite (HDM) tablet (Actair®; Stallergenes Greer, Antony, France/Shionogi & Co. Ltd., Osaka, Japan) is the first sublingual immunotherapy (SLIT) tablet to be approved for the treatment of HDM-induced allergic rhinitis. Areas covered: This drug profile reviews the current body of evidence on the efficacy, safety and tolerability of the 300 IR HDM tablet, its pharmacodynamics, and its role in clinical practice. Expert commentary: Data from its clinical development program demonstrate favorable efficacy and safety in adults and adolescents with HDM-induced allergic rhinitis, irrespective of mono- or polysensitization status, or the presence of comorbid mild asthma. The 300 IR HDM tablet is effective from as early as 2 months after treatment initiation, providing allergic symptom control and a reduction in the need for symptomatic medication, while improving health-related quality of life. Clinical efficacy is maintained for 1 year after treatment is stopped.
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Affiliation(s)
- Pascal Demoly
- a Department of Pulmonology - Division of Allergy , Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier and Sorbonne Universités , UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, Paris , France
| | - Yoshitaka Okamoto
- b Department of Otorhinolaryngology-Head and Neck Surgery, Graduate School of Medicine , Chiba University , Chiba , Japan
| | - William H Yang
- c Ottawa Allergy Research Corporation , University of Ottawa Medical School , Ottawa , Canada
| | - Philippe Devillier
- d UPRES EA 220, Université de Versailles Saint-Quentin , Department of Airway Diseases, Foch Hospital , Suresnes , France
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Kappen JH, Durham SR, Veen HI', Shamji MH. Applications and mechanisms of immunotherapy in allergic rhinitis and asthma. Ther Adv Respir Dis 2016; 11:73-86. [PMID: 27678500 DOI: 10.1177/1753465816669662] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Clinical and immunologic tolerance are hallmarks of successful allergen immunotherapy (AIT). Clinical benefits such as reduced symptoms, pharmacotherapy intake and improvement of quality of life persist following cessation of treatment. Successful AIT is associated with suppression of allergic inflammatory cells such as mast cells, eosinophils and basophils in target organs. Furthermore, AIT down-regulates type 2 innate lymphoid cells and allergen-specific type 2 T-helper (Th2) cells. The immunologic tolerant state following AIT is associated with the induction of distinct phenotypes of regulatory T-cells (T-regs) including interleukin (IL)-10-, IL-35- and transforming growth factor (TGF)-β- producing T-regs and FoxP3+ T-regs. B-cell responses, including the induction of IL-10+ regulatory B-cells (B-regs) and the production of IgG4-associated blocking antibodies are also induced following successful AIT. These events are associated with the suppression of antigen-specific Th2 responses and delayed immune deviation in favour of Th1 type responses. Insight into the mechanisms of AIT has allowed identification of novel biomarkers with potential to predict the clinical response to AIT and also novel therapeutic strategies for more effective and safer AIT.
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Affiliation(s)
- Jasper H Kappen
- Department of Pulmonology, STZ centre of excellence for Asthma & COPD, Franciscus Gasthuis & Vlietland, Kleiweg 500, 3045 PM, Rotterdam, The Netherlands
| | - Stephen R Durham
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Hans In 't Veen
- Department of Pulmonology, STZ centre of excellence for Asthma & COPD, Franciscus Gasthuis & Vlietland, Kleiweg 500, 3045 PM, Rotterdam, The Netherlands
| | - Mohamed H Shamji
- Allergy and Clinical Immunology, Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, Sir Alexander Fleming Building, South Kensington Campus, London SW7 2AZ, UK
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Ferrando M, Bagnasco D, Passalacqua G, Varricchi G, Canonica GW. MK-8237: a house dust mite vaccine for treating allergic rhinitis, asthma and atopic dermatitis. Expert Opin Biol Ther 2016; 16:1435-1441. [PMID: 27620194 DOI: 10.1080/14712598.2016.1234601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Since its introduction in clinical practice one century ago for the treatment of respiratory allergic diseases, allergen-specific immunotherapy (AIT) has exhibited a relevant clinical efficacy that was subsequently confirmed in controlled trials. Thus, AIT has been accepted worldwide, as testified by guidelines and international documents. AIT is considered pivotal in the management of allergic rhinitis with or without conjunctivitis and with or without asthma. These conditions, in addition to hymenoptera venom allergy, currently are the accepted indications. The use of AIT in house-dust mite allergy still remains debated, especially due to the methodological problems in assessing this form of respiratory allergy. The more recent experimental data on MK-8237 sublingual tablets provided evidence that AIT, in the sublingual form, is effective in dust mite allergy. AREAS COVERED At present, the evidence of the efficacy of AIT in conditions other than respiratory allergy are not conclusive, but encouraging results have been obtained in food allergy and atopic dermatitis. Herein, the authors discuss the data for these indications. EXPERT OPINION Not all patients respond to AIT in the same way. Accordingly, AIT represents a promising path to precision medicine and hopefully will be able to reduce this burden of non-responding patients.
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Affiliation(s)
- Matteo Ferrando
- a Allergy & Respiratory Diseases, DIMI Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino-IST , Genoa , Italy
| | - Diego Bagnasco
- a Allergy & Respiratory Diseases, DIMI Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino-IST , Genoa , Italy
| | - Giovanni Passalacqua
- a Allergy & Respiratory Diseases, DIMI Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino-IST , Genoa , Italy
| | - Gilda Varricchi
- b Department of Translational Medical Sciences, Division of Clinical Immunology and Allergy , University of Naples Federico II , Naples , Italy
| | - Giorgio Walter Canonica
- a Allergy & Respiratory Diseases, DIMI Department of Internal Medicine , University of Genoa, IRCCS AOU San Martino-IST , Genoa , Italy
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Nelson HS, Makatsori M, Calderon MA. Subcutaneous Immunotherapy and Sublingual Immunotherapy: Comparative Efficacy, Current and Potential Indications, and Warnings--United States Versus Europe. Immunol Allergy Clin North Am 2016; 36:13-24. [PMID: 26617224 DOI: 10.1016/j.iac.2015.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Subcutaneous immunotherapy and sublingual immunotherapy are effective for allergic rhinitis and allergic asthma and with some support for use in selected patients with atopic dermatitis. The sequence of immunologic responses is the same, irrespective of the route of administration, and similar disease modification has been demonstrated. However, there are differences between the two approaches. The most important is the greatly reduced likelihood of sublingual immunotherapy producing systemic reactions. There are major drawbacks for sublingual immunotherapy in regard to dosing. Finally, there is the question of relative clinical efficacy, with the currently available data favoring subcutaneous immunotherapy.
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Affiliation(s)
- Harold S Nelson
- National Jewish Health and University of Colorado Denver School of Medicine, 1400 Jackson Street, Denver, CO 80206, USA.
| | - Melina Makatsori
- Section of Allergy and Clinical Immunology, Royal Brompton and Harefield Hospital NHS Trust, National Heart and Lung Institute, Imperial College London, Dovehouse Street, London SW3 6LY, UK
| | - Moises A Calderon
- Section of Allergy and Clinical Immunology, Royal Brompton and Harefield Hospital NHS Trust, National Heart and Lung Institute, Imperial College London, Dovehouse Street, London SW3 6LY, UK; Department of Internal Medicine and Allergy, Faculty of Medicine, University of Costa Rica, San Jose, Costa Rica, USA
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240
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Arasi S, Pajno GB, Lau S, Matricardi PM. Local allergic rhinitis: A critical reappraisal from a paediatric perspective. Pediatr Allergy Immunol 2016; 27:569-73. [PMID: 27098888 DOI: 10.1111/pai.12577] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2016] [Indexed: 12/13/2022]
Abstract
The so-called local allergic rhinitis (LAR) has been proposed as a phenotype of rhinitis with Th2-driven prominent local allergic inflammation, nasal synthesis of specific IgE and a positive response to a nasal allergen provocation test, in the absence of 'systemic' atopy (negative skin prick test and serum allergen-specific IgE antibodies). To date, available data on LAR are mostly focused on adults. The purpose of this 'Rostrum' was to critically discuss data and implications of the 'LAR concept' in paediatrics. In the natural history of rhinitis due to IgE-mediated reactions triggered by exposure to allergens, a 'LAR' can be either the initial, transient stage of classical allergic rhinitis or a stable phenotype never evolving to 'systemic' IgE sensitization. Given the present difficulties in performing routinely nasal allergen provocation test in children, the development of sensitive and specific tests to detect IgE in the child's nasal secretions is a research priority. We suggest also the hypothetical role of allergen immunoprophylaxis or immunotherapy in LAR. Last, the term 'local allergic rhinitis' may be inappropriate, as rhinitis is always 'local', while IgE sensitization can be either 'local' or 'systemic'.
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Affiliation(s)
- Stefania Arasi
- Allergy Unit, Department of Pediatrics, University of Messina, Messina, Italy.,Molecular Allergology and Immunomodulation, Department of Pediatric Pneumology and Immunology, Charité Medical University, Berlin, Germany
| | | | - Susanne Lau
- Department of Paediatric Pneumology and Immunology, Charité Medical University, Berlin, Germany
| | - Paolo Maria Matricardi
- Molecular Allergology and Immunomodulation, Department of Pediatric Pneumology and Immunology, Charité Medical University, Berlin, Germany
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241
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Patient selection for subcutaneous versus sublingual immunotherapy. Curr Opin Allergy Clin Immunol 2016; 15:588-95. [PMID: 26485098 DOI: 10.1097/aci.0000000000000219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW With the Food and Drug Administration's approval of sublingual allergen-specific immunotherapy (SL-AIT) tablets for grass and ragweed pollen, SL-AIT is progressively gathering importance not only in Europe, but also in the United States and other parts of the world. We reviewed issues related to the selection of patients for the sublingual or the subcutaneous route for allergic patients, based on what has been published since January 2014 on subcutaneous-versus-SL-AIT efficacy, safety and other issues. (Figure is included in full-text article.) RECENT FINDINGS As patient's adherence seems one of the major problems in real-life AIT, investigators have sought how to enhance AIT simplicity by changing the route to home-administrated SL-AIT, and by shortening the subcutaneous-allergen-specific immunotherapy (SC-AIT) build-up or maintenance phase. The latter was safe with several hypoallergenic extracts. As for SL-AIT, double blind placebo-controlled large trials in patients with allergic rhinitis and asthma have shown the efficacy and safety of ragweed pollen and house dust mite SLIT tablets and highly concentrated liquid formulations, primarily in adults. A large trial with SLIT in 3-year-old children was effective. SUMMARY With the improvement of SL-AIT efficacy, the selection of SC-versus-SL-AIT will probably increasingly be based not on efficacy, but on practical aspects, without losing sight of which SL-AIT products have proven efficacy.
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242
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Local Side Effects of Sublingual and Oral Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:13-21. [PMID: 27527548 DOI: 10.1016/j.jaip.2016.06.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/09/2016] [Accepted: 06/14/2016] [Indexed: 01/23/2023]
Abstract
Sublingual immunotherapy (SLIT) is increasingly used worldwide, and several products have been recently registered as drugs for respiratory allergy by the European Medicine Agency and the Food and Drug Administration. Concerning inhalant allergens, the safety of SLIT is overall superior to that of subcutaneous immunotherapy in terms of systemic adverse events. No fatality has been ever reported, and episodes of anaphylaxis were described only exceptionally. Looking at the historical and recent trials, most (>90%) adverse events are "local" and confined to the site of administration. For this reason, a specific grading system has been developed by the World Allergy Organization to classify and describe local adverse events. There is an increasing amount of literature concerning oral desensitization for food allergens, referred to as oral immunotherapy. Also, in this case, local side effects are predominant, although systemic adverse events are more frequent than with inhalant allergens. We review herein the description of local side effects due to SLIT, with a special focus on large trials having a declared sample size calculation. The use of the Medical Dictionary for Regulatory Activities nomenclature for adverse events is mentioned in this context, as recommended by regulatory agencies. It is expected that a uniform classification/grading of local adverse events will improve and harmonize the surveillance and reporting on the safety of SLIT.
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243
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Lin CH, Alandijani S, Lockey RF. Subcutaneous versus sublingual immunotherapy. Expert Rev Clin Immunol 2016; 12:801-3. [DOI: 10.1080/1744666x.2016.1196137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Chen Hsing Lin
- Division of Allergy & Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
- James A. Haley Veterans’ Hospital, Tampa, FL, USA
| | - Sultan Alandijani
- Division of Allergy & Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
- James A. Haley Veterans’ Hospital, Tampa, FL, USA
| | - Richard F. Lockey
- Division of Allergy & Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
- James A. Haley Veterans’ Hospital, Tampa, FL, USA
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244
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Yukselen A. Allergen-specific immunotherapy in pediatric allergic asthma. Asia Pac Allergy 2016; 6:139-48. [PMID: 27489785 PMCID: PMC4967613 DOI: 10.5415/apallergy.2016.6.3.139] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 06/10/2016] [Indexed: 12/12/2022] Open
Abstract
Allergen-specific immunotherapy (AIT) is the only curative way that can change the immunologic response to allergens and thus can modify the natural progression of allergic diseases. There are some important criteria which contributes significantly on efficacy of AIT, such as the allergen extract used for treatment, the dose and protocol, patient selection in addition to the severity and control of asthma. The initiation of AIT in allergic asthma should be considered in intermittent, mild and moderate cases which coexisting with other allergic diseases such as allergic rhinitis, and in case of unacceptable adverse effects of medications. Two important impact of AIT; steroid sparing effect and preventing from progression to asthma should be taken into account in pediatric asthma when making a decision on starting of AIT. Uncontrolled asthma remains a significant risk factor for adverse events and asthma should be controlled both before and during administration of AIT. The evidence concerning the efficacy of subcutaneous (SCIT) and sublingual immunotherapy (SLIT) for treatment of pediatric asthma suggested that SCIT decreases asthma symptoms and medication scores, whereas SLIT can ameliorate asthma symptoms. Although the effectiveness of SCIT has been shown for both seasonal and perennial allergens, the data for SLIT is less convincing for perennial allergies in pediatric asthma.
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Affiliation(s)
- Ayfer Yukselen
- Division of Pediatric Allergy & Immunology, Department of Pediatrics, Baskent University Istanbul Hospital, Istanbul 34662, Turkey
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245
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Lemberg ML, Eberle P, Shah-Hosseini K. Importance of Quality of Life for Adherence to Sublingual Immunotherapy. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5186765. [PMID: 27504453 PMCID: PMC4967702 DOI: 10.1155/2016/5186765] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/18/2016] [Accepted: 06/23/2016] [Indexed: 11/22/2022]
Abstract
Background. Nonperception of efficacy ranks among the most commonly cited causes for nonadherence to sublingual immunotherapy (SLIT). Quality of life (QoL) in patients is a determining factor influencing adherence. We investigated QoL and adherence separately in SLIT patients at one pediatric practice in Germany. Methods. We conducted a noninterventional, cross-sectional, retrospective, quality-of-life survey among pediatric patients treated with SLIT. QoL was assessed using the generic SF-12 health survey in German. The items contained in the SF-12 health survey are weighted, added up, and converted to obtain a physical component score (PCS) and a mental component score (MCS). Each component score ranges from 0 to 100; the higher the score, the better the QoL perceived. Results. 201 surveyed patients who had undergone SLIT showed PCS-12 of 49.3 (± 7.0) and MCS-12 of 52.6 (± 7.2). These figures correlate strongly with those reported for the German general population (n = 2453): PCS-12 of 49.6 (± 8.7) and MCS-12 of 52.3 (± 8.0). 70.2% (73) of 104 patients were adherent at this practice. Conclusions. QoL in the SLIT patients surveyed here appears as good as that of the general population. Adherence to SLIT at this practice was remarkably better than that reported elsewhere.
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Affiliation(s)
- Marie-Luise Lemberg
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Lindenburger Allee 42, 50931 Cologne, Germany
| | - Peter Eberle
- Pediatric Practice for Pneumology/Allergology, Wilhelmshöher Allee 109, 34121 Kassel, Germany
| | - Kija Shah-Hosseini
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Lindenburger Allee 42, 50931 Cologne, Germany
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Canonica GW, Virchow JC, Zieglmayer P, Ljørring C, Smith IM, Mosbech H. Efficacy and safety of SQ house dust mite (HDM) SLIT-tablet treatment of HDM allergic asthma. Expert Rev Clin Immunol 2016; 12:805-15. [PMID: 27322777 DOI: 10.1080/1744666x.2016.1200467] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION In the treatment of house dust mite (HDM) respiratory allergic disease, allergy immunotherapy constitutes an add-on treatment option targeting the underlying immunological mechanisms of allergic disease. However, for the treatment of HDM allergic asthma, the use of subcutaneous allergy immunotherapy (SCIT) has been limited by the risk of systemic adverse events. Thus, sublingually administered allergy immunotherapy (SLIT) has been investigated as a treatment option with an improved tolerability profile that allows for safer treatment of patients with HDM allergic asthma. AREAS COVERED In this Drug Profile, we provide a review of the clinical data behind the SQ HDM SLIT-tablet, which was recently approved for the treatment of HDM allergic asthma and allergic rhinitis by regulatory authorities in several European countries. Expert commentary: The SQ HDM SLIT-tablet is the first allergy immunotherapy to be tested prospectively in patients with asthma, and to favorably modify patient relevant end points such as requirement for inhaled corticosteroid (ICS) or the time to first asthma exacerbation upon ICS reduction, suggesting that SQ HDM SLIT-tablet treatment may contribute to improving overall asthma control.
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Affiliation(s)
| | | | - Petra Zieglmayer
- c Allergy Center Vienna West , Vienna Challenge Chamber , Vienna , Austria
| | | | | | - Holger Mosbech
- e Allergy Clinic , Copenhagen University Hospital Gentofte , Hellerup , Denmark
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247
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Miceli Sopo S, Battista A, Greco M, Monaco S. Grass pollen sublingual immunotherapy and paediatric allergic rhinitis: A patient-oriented decision. Allergol Immunopathol (Madr) 2016; 44:382-6. [PMID: 26321601 DOI: 10.1016/j.aller.2015.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 05/22/2015] [Indexed: 10/23/2022]
Abstract
Guidelines and systematic review report that allergen immunotherapy (AIT) is, in general, effective in the treatment of allergic rhinitis. However, experts suggest not generalising the results of different clinical studies: for example, it would not be advisable to translate the results found in an adult population to a paediatric population or the results on the efficacy of AIT against a specific allergen to the AIT against a different allergen. Moreover, according to Evidence Based Medicine (EBM), clinical decisions are individualised and should derive from the "integration of best research evidence with clinical expertise and patient values". Taking into account the high specificity of the AIT and EBM principles, we tried to answer the question on how advisable it is to prescribe the AIT for the management of grass allergic rhinitis in children. To do this, we revised the scientific literature in order to solve a specific case scenario.
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248
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Scholz FM, Burrows AK, Muse R. First report of angio-oedema subsequent to the administration of allergen specific sublingual immunotherapy for the management of equine hypersensitivity dermatitis. Vet Dermatol 2016; 27:439-e115. [PMID: 27350603 DOI: 10.1111/vde.12349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sublingual immunotherapy (SLIT) offers an alternative mode of allergen delivery to subcutaneous immunotherapy (SCIT) with the aim of inducing immunological tolerance. Currently, there are no published reports regarding the efficacy or safety of SLIT in horses. HYPOTHESIS/OBJECTIVE To describe the first case of several adverse events occurring in a horse subsequent to the repeat administration of SLIT. ANIMAL A seven-year-old, warmblood mare with a confirmed diagnosis of equine hypersensitivity dermatitis (EHD). METHODS AND RESULTS Immunotherapy was recommended for management of EHD. Due to the temperament of the horse, the owner elected to proceed with SLIT. Thirty six hours after commencing SLIT, the mare developed scleral oedema, moderate dyspnoea and abdominal discomfort. SLIT was withdrawn for 10 days and re instituted using a ten-fold dilution of the original vaccine. Localized oedema and swelling of the tongue developed within 12 h of administration. At this juncture, SLIT was withdrawn. The horse was rechallenged with the SLIT allergen vehicle, 50% glycerine and no adverse reactions occurred. SCIT was commenced using the same allergens and no adverse events occurred with repeated administration. CONCLUSIONS AND CLINICAL IMPORTANCE To the best of the authors' knowledge, this is the first reported case of adverse reactions developing subsequent to the administration of SLIT for the management of EHD.
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Affiliation(s)
- Fiona M Scholz
- Animal Dermatology Clinic, Murdoch University Veterinary Hospital, 90 South Street, Murdoch, WA, 6150, Australia.
| | - Amanda K Burrows
- Animal Dermatology Clinic, Murdoch University Veterinary Hospital, 90 South Street, Murdoch, WA, 6150, Australia
| | - Russell Muse
- Animal Dermatology Clinic, Murdoch University Veterinary Hospital, 90 South Street, Murdoch, WA, 6150, Australia
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249
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Larsson O, Hellkvist L, Peterson-Westin U, Cardell LO. Novel strategies for the treatment of grass pollen-induced allergic rhinitis. Expert Opin Biol Ther 2016; 16:1143-50. [PMID: 27269991 DOI: 10.1080/14712598.2016.1190829] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Allergic rhinitis (AR) affects over 20% of the population of Europe and the United States. Allergen immunotherapy (AIT) is currently the only form of treatment that affects symptoms and modifies the progression of disease. Established forms of AIT include subcutaneous (SCIT) and sublingual (SLIT) immunotherapy and are widely effective, yet only 2-9% of eligible patients undergo therapy, likely due to the long duration of treatment. As a result, novel, faster forms of AIT are currently under development. AREAS COVERED This article provides an overview of AR and summarises the efficacy and mechanisms of established forms of AIT, highlighting the current drawbacks. We discuss novel strategies of AIT that have been developed in an attempt to tackle these limitations, including epicutaneous, intradermal and intralymphatic immunotherapy (ILIT), focusing on ILIT, the treatment that has been most comprehensively assessed. EXPERT OPINION Current strategies to treat AR suffer from a poor safety profile and, importantly, lack of adherence. ILIT is a faster and safer form of AIT, with a treatment regime of only 12 weeks. Further validation is required, but ILIT, with its short and comparatively inexpensive protocol, has the potential to offer disease-modifying therapy to a larger number of patients.
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Affiliation(s)
- Olivia Larsson
- a Division of ENT Diseases, Department of Clinical Sciences, Intervention and Technology , Karolinska Institutet , Stockholm , Sweden
| | - Laila Hellkvist
- a Division of ENT Diseases, Department of Clinical Sciences, Intervention and Technology , Karolinska Institutet , Stockholm , Sweden
| | - Ulla Peterson-Westin
- b Laboratory of Clinical Experimental Allergy Research, Department of Otorhinolaryngology Malmö , Lund University, Skåne University Hospital , Malmö , Sweden
| | - Lars Olaf Cardell
- a Division of ENT Diseases, Department of Clinical Sciences, Intervention and Technology , Karolinska Institutet , Stockholm , Sweden.,c Department of ENT Diseases , Karolinska University Hospital , Stockholm , Sweden
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Passalacqua G, Sastre J, Pfaar O, Wahn U, Demoly P. Comparison of allergenic extracts from different origins: the value of the FDA's bioequivalent allergy unit (BAU). Expert Rev Clin Immunol 2016; 12:733-9. [PMID: 27215895 DOI: 10.1080/1744666x.2016.1187561] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Allergy immunotherapy (AIT) is the only disease-modifying intervention for the treatment of allergic diseases. The clinical effectiveness of AIT is clearly dose-dependent, so it is important that clinicians can assess and compare the potency of the various products available. However, this is not possible in practice, because manufacturers use different methods to determine potency. Therefore, a clear need exists for adoption of a 'gold-standard' measure of allergenicity. The bioequivalent allergy unit (BAU) is thus far the only allergen unit approved by a regulatory agency (the US Food and Drug Administration), with European regulatory authorities yet to adopt a common unit. AREAS COVERED Using PubMed, we performed a review of the literature on measures of allergen extract potency, use of the BAU, and BAU assessment for grass pollen tablets. Expert commentary: There is an obvious benefit to allergists and patients for having a single, comparable unit across products, and we strongly support the adoption of a single, 'gold-standard' unit of measurement for all products. Use of the BAU allows a clear comparison of the potency of allergen products from different manufacturers, and enables better understanding of the potential reasons for any differences in administration and dosing protocols between these products.
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Affiliation(s)
- Giovanni Passalacqua
- a Allergy and Respiratory Diseases, IRCCS San Martino-IST , University of Genoa , Genoa , Italy
| | - Joaquín Sastre
- b Allergy Division, Fundación Jimenez Díaz, CIBER of Respiratory Diseases, Institute Carlos III , Universidad Autónoma de Madrid , Madrid , Spain
| | - Oliver Pfaar
- c Center for Rhinology and Allergology , Wiesbaden , Germany.,d Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty Mannheim , Universitätsmedizin Mannheim, Heidelberg University , Mannheim , Germany
| | - Ulrich Wahn
- e Department of Paediatric Pulmonology and Immunology, Charité Virchow-Klinikum , Humboldt University , Berlin , Germany
| | - Pascal Demoly
- f Department of Pulmonology, Division of Allergy , Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier and Sorbonne Universities , UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, Paris , France
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