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Zoratti E, Wood R, Pomés A, Da Silva Antunes R, Altman MC, Benson B, Wheatley LM, Cho K, Calatroni A, Little FF, Pongracic J, Makhija M, Khurana Hershey GK, Sherenian MG, Rivera-Spoljaric K, Stokes JR, Gill MA, Gruchalla RS, Chambliss J, Liu AH, Kattan M, Busse PJ, Bacharier LB, Sheehan W, Kim H, Glesner J, Gergen PJ, Togias A, Baucom JL, Visness CM, Sette A, Busse WW, Jackson DJ. A pediatric randomized, controlled trial of German cockroach subcutaneous immunotherapy. J Allergy Clin Immunol 2024; 154:735-744.e10. [PMID: 38718950 PMCID: PMC11380590 DOI: 10.1016/j.jaci.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/28/2024] [Accepted: 04/23/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Cockroach allergy contributes to morbidity among urban children with asthma. Few trials address the effect of subcutaneous immunotherapy (SCIT) with cockroach allergen among these at-risk children. OBJECTIVES We sought to determine whether nasal allergen challenge (NAC) responses to cockroach allergen would improve following 1 year of SCIT. METHODS Urban children with asthma, who were cockroach-sensitized and reactive on NAC, participated in a year-long randomized double-blind placebo-controlled SCIT trial using German cockroach extract. The primary endpoint was the change in mean Total Nasal Symptom Score (TNSS) during NAC after 12 months of SCIT. Changes in nasal transcriptomic responses during NAC, skin prick test wheal size, serum allergen-specific antibody production, and T-cell responses to cockroach allergen were assessed. RESULTS Changes in mean NAC TNSS did not differ between SCIT-assigned (n = 28) versus placebo-assigned (n = 29) participants (P = .63). Nasal transcriptomic responses correlated with TNSS, but a treatment effect was not observed. Cockroach serum-specific IgE decreased to a similar extent in both groups, while decreased cockroach skin prick test wheal size was greater among SCIT participants (P = .04). A 200-fold increase in cockroach serum-specific IgG4 was observed among subjects receiving SCIT (P < .001) but was unchanged in the placebo group. T-cell IL-4 responses following cockroach allergen stimulation decreased to a greater extent among SCIT versus placebo (P = .002), while no effect was observed for IL-10 or IFN-γ. CONCLUSIONS A year of SCIT failed to alter NAC TNSS and nasal transcriptome responses to cockroach allergen challenge despite systemic effects on allergen-specific skin tests, induction of serum-specific IgG4 serum production and down-modulation of allergen-stimulated T-cell responses.
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Affiliation(s)
- Edward Zoratti
- Division of Allergy and Immunology, Department of Medicine, Henry Ford Health, Detroit, Mich.
| | - Robert Wood
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | | | | | | | | | - Lisa M Wheatley
- National Institute of Allergy and Infectious Diseases, Rockville, Md
| | - Kate Cho
- Rho, Inc, Federal Research Operations, Durham, NC
| | | | - Frederic F Little
- Department of Medicine, Boston University School of Medicine, Boston, Mass
| | - J Pongracic
- Department of Pediatrics, Anne and Robert H. Lurie Children's Hospital, Chicago, Ill
| | - Melanie Makhija
- Department of Pediatrics, Anne and Robert H. Lurie Children's Hospital, Chicago, Ill
| | | | | | | | - Jeffrey R Stokes
- Department of Pediatrics, St Louis Children's Hospital, St Louis, Mo
| | - Michelle A Gill
- Department of Pediatrics, St Louis Children's Hospital, St Louis, Mo
| | - Rebecca S Gruchalla
- Department of Pediatrics, University of Texas Southwest Medical Center, Dallas, Tex
| | - Jeffrey Chambliss
- Department of Pediatrics, University of Texas Southwest Medical Center, Dallas, Tex
| | - Andrew H Liu
- Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colo
| | - Meyer Kattan
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Paula J Busse
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Leonard B Bacharier
- Department of Pediatrics, Monroe Carell Children's Hospital at Vanderbilt University, Nashville, Tenn
| | - William Sheehan
- Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Haejin Kim
- Division of Allergy and Immunology, Department of Medicine, Henry Ford Health, Detroit, Mich
| | | | - Peter J Gergen
- National Institute of Allergy and Infectious Diseases, Rockville, Md
| | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, Rockville, Md
| | | | | | | | - William W Busse
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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Ellis AK, Cook V, Keith PK, Mace SR, Moote W, O'Keefe A, Quirt J, Rosenfield L, Small P, Watson W. Focused allergic rhinitis practice parameter for Canada. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2024; 20:45. [PMID: 39118164 PMCID: PMC11311964 DOI: 10.1186/s13223-024-00899-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 05/21/2024] [Indexed: 08/10/2024]
Abstract
Allergic rhinitis (AR) is a prevalent disease in Canada that affects both children and adults. Several guidelines for the management of AR have been published by professional allergy societies worldwide. However, there are regional differences in the clinical management of AR, and regulatory approval of some AR pharmacotherapies varies among countries. Thus, six research questions specific to the treatment of AR in Canada were identified for this focused practice parameter. Reviews of the literature published since 2016 were conducted to obtain evidence-based support for the responses of the Work Group to each research question. In response to research question 1 "In patients with symptoms indicative of AR, is serum-specific IgE sufficient to identify candidates for immunotherapy or is a skin prick test mandatory?" the Work Group concluded that either sIgE testing or skin prick test are acceptable for diagnosing AR and guiding immunotherapy. In response to research question 2 "When taking into account the preferences of the patient and the prescriber (stakeholder engagement) should second-generation oral antihistamine (OAH) or intranasal corticosteroid (INCS) be first line?" the Work Group concluded that existing guidelines generally agree on the use of INCS as a first-line therapy used for AR, however, patient and provider preferences and considerations can easily shift the first choice to a second-generation OAH. In response to research question 3 "Is a combination intranasal antihistamine (INAH)/INCS formulation superior to INCS plus OAH? Do they become equivalent after prolonged use?" the Work Group concluded that that the combination INAH/INCS is superior to an INCS plus OAH. However, there was insufficient evidence to answer the second question. In response to research question 4 "Do leukotriene receptor antagonists (LTRA) have a greater benefit than OAH in AR for some symptoms to justify a therapeutic trial in those who cannot tolerate INCS?" the Work Group concluded that LTRAs have inferior, or at best equivalent, daytime or overall symptom control compared with OAH, but LTRAs may improve nighttime symptom control and provide benefits in patients with AR and concomitant asthma. In response to research question 5 "Should sublingual immunotherapy (SLIT) tablets be considered first-line immunotherapeutic options over subcutaneous immunotherapy (SCIT) based on the evidence of efficacy?" the Work Group concluded that the choice of SLIT or SCIT cannot be made on efficacy alone, and differences in other factors outweigh any differences in efficacy. In response to research question 6 "Based on efficacy data, should ALL patients seen by an allergist be offered SLIT or SCIT as a treatment option?" the Work Group concluded that the efficacy data suggests that SLIT or SCIT should be used broadly in patients with AR, but other clinical concerns also need to be taken into consideration.
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Affiliation(s)
- Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada.
| | - Victoria Cook
- Community Allergy Clinic, Victoria, BC, and Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Paul K Keith
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sean R Mace
- Mace Allergy and Clinical Immunology, Toronto, ON, Canada
| | | | - Andrew O'Keefe
- Department of Pediatrics, Memorial University, St. John's, NL, Canada
| | - Jaclyn Quirt
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lana Rosenfield
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Small
- Jewish General Hospital, Montreal, QC, Canada
| | - Wade Watson
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
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3
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Olivieri B, Günaydın FE, Corren J, Senna G, Durham SR. The combination of allergen immunotherapy and biologics for inhalant allergies: Exploring the synergy. Ann Allergy Asthma Immunol 2024:S1081-1206(24)00365-X. [PMID: 38897405 DOI: 10.1016/j.anai.2024.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 06/10/2024] [Accepted: 06/11/2024] [Indexed: 06/21/2024]
Abstract
The development of monoclonal antibodies that selectively target IgE and type 2 immunity has opened new possibilities in the treatment of allergies. Although they have been used mainly as single therapies found to have efficacy in the management of asthma and other T2-mediated diseases, there is a growing interest in using these monoclonal antibodies in combination with allergen immunotherapy (AIT). AIT has transformed the treatment of allergic diseases by aiming to modify the underlying immune response to allergens rather than just providing temporary symptom relief. Despite the proven efficacy and safety of AIT, unmet needs call for further research and innovation. Combination strategies involving biologics and AIT exhibit potential in improving short-term efficacy, reducing adverse events, and increasing immunologic tolerance. Anti-IgE emerges as the most promising therapeutic strategy, not only enhancing AIT's safety and tolerability but also providing additional evidence of efficacy compared with AIT alone. Anti-interleukin-4 receptor offers a reduction in adverse effects and an improved immunologic profile when combined with AIT; however, its impact on short-term efficacy seems limited. The combination of cat dander subcutaneous immunotherapy with anti-thymic stromal lymphopoietin was synergistic with enhanced efficacy and altered immune responses that persisted for 1 year after discontinuation compared with AIT alone. Long-term studies are needed to evaluate the sustained benefits and safety profiles of combination strategies.
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Affiliation(s)
- Bianca Olivieri
- Asthma, Allergy and Clinical Immunology Section, University Hospital of Verona, Verona, Italy
| | - Fatma Esra Günaydın
- Department of Immunology and Allergy Diseases, Ordu University Education and Training Hospital, Ordu, Turkey
| | - Jonathan Corren
- Division of Allergy and Clinical Immunology, Department of Medicine and Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gianenrico Senna
- Asthma, Allergy and Clinical Immunology Section, University Hospital of Verona, Verona, Italy; Department of Medicine, University of Verona, Verona, Italy
| | - Stephen R Durham
- Allergy and Clinical Immunology, Section Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
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Creticos PS, Gunaydin FE, Nolte H, Damask C, Durham SR. Allergen Immunotherapy: The Evidence Supporting the Efficacy and Safety of Subcutaneous Immunotherapy and Sublingual Forms of Immunotherapy for Allergic Rhinitis/Conjunctivitis and Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1415-1427. [PMID: 38685477 DOI: 10.1016/j.jaip.2024.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/23/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
Allergen immunotherapy (AIT) is a recognized key therapeutic modality for the treatment of allergic respiratory disease. Definitive studies have provided evidence-based data to demonstrate its effectiveness in allergic rhinitis and asthma due to the inhalation of proteinaceous allergic substances from specific seasonal pollens, dust mites, animal allergens, and certain mold spores. Over the ensuing decades, laboratory investigations have provided objective evidence to demonstrate immunologic changes, including production of protective IgG antibody, suppression of IgE antibody, upregulation of regulatory T cells, and induction of a state of immune tolerance to the offending allergen(s). Tangential to this work were carefully designed clinical studies that defined allergen dose and duration of treatment, established the importance of preparing extracts with standardized allergens (or well-defined extracts) based on major protein moieties, and used allergen provocation models to demonstrate efficacy superior to placebo. In the United States, the use of subcutaneous immunotherapy extracts for AIT was grandfathered in by the Food and Drug Administration based on expert literature review. In contrast, sublingual tablet immunotherapy underwent formal clinical development programs (phase I-III clinical trials) that provided the necessary clinical evidence for safety and efficacy that led to regulatory agency approvals for the treatment of allergic rhinitis in properly characterized patients with allergy. The allergy specialist's treatment options currently include traditional subcutaneous AIT and specific sublingual tablets approved for grass, ragweed, house dust mites, trees belonging to the birch-homologous group, and Japanese cedar. Tangential to this are sublingual drops that are increasingly being used off-label (albeit not approved by the Food and Drug Administration) in the United States. This article will review the evidence-based literature supporting the use of these forms of AIT, as well as focus on several current controversies and gaps in our knowledge base that have relevance for the appropriate selection of patients for treatment with specific AIT.
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Affiliation(s)
- Peter Socrates Creticos
- Johns Hopkins Division of Allergy & Clinical Immunology, Baltimore, Md; Creticos Research Group, Crownsville, MD.
| | - Fatma E Gunaydin
- Department of Immunology & Allergy, Ordu University Education & Research Hospital, Ordu, Türkiye
| | | | - Cecilia Damask
- Department of Otolaryngology, Central Florida College of Medicine, Orlando, Fla
| | - Stephen R Durham
- Allergy & Clinical Immunology, Division of Respiratory Science, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, United Kingdom
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Chełmińska M, Specjalski K, Jassem E, Polańska J, Kita K, Górska L, Didkowska J, Wojciechowska U, Nittner-Marszalska M, Kuna P, Kupczyk M, Kruszewski J, Zakrzewski A, Czarnobilska E, Stobiecki M, Krenke R, Dąbrowski A, Kwaśniewski A, Jarząb J, Bożek A, Bodzenta-Łukaszyk A, Łukaszyk M, Kowalski M, Smorawska-Sabanty E, Fal A, Przybyłowska K, Bartuzi Z, Pałgan K, Niedoszytko M. Venom Immunotherapy Does Not Affect Survival of Patients with Malignant Tumor in Poland. J Clin Med 2024; 13:3152. [PMID: 38892863 PMCID: PMC11173344 DOI: 10.3390/jcm13113152] [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: 05/04/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Allergen immunotherapy (AIT) is a well-established and efficient method of causative treatment for allergic rhinitis, asthma and insect venom allergy. Traditionally, a recent history of malignant neoplasm is regarded as a contraindication to AIT due to concerns that AIT might stimulate tumor growth. However, there are no data confirming that the silencing of the Th2 response affects prognosis in cancer. Objectives: The aim of this study was to investigate frequency of malignant tumors in patients undergoing AIT and the association between AIT and cancer-related mortality. Patients and Methods: A group of 2577 patients with insect venom allergy undergoing AIT in 10 Polish allergology centers was screened in the Polish National Cancer Registry. Data on cancer type, diagnosis time and patients' survival were collected and compared with the general population. Results: In the study group, 86 cases of malignancies were found in 85 patients (3.3% of the group). The most common were breast (19 cases), lung (9 cases), skin (8 cases), colon and prostate cancers (5 cases each). There were 21 cases diagnosed before AIT, 38 during and 27 after completing AIT. Laplace's crude incidence rate was 159.5/100,000/year (general population rate: 260/100,000/year). During follow-up, 13 deaths related to cancer were revealed (15% of patients with cancer). Laplace's cancer mortality rate was 37.3/100,000/year (general population rate: 136.8/100,000/year). Conclusions: Malignancy was found in patients undergoing immunotherapy less often than in the general population. Patients with cancer diagnosed during or after AIT did not show a lower survival rate, which suggests that AIT does not affect the prognosis.
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Affiliation(s)
- Marta Chełmińska
- Department of Allergology, Medical University of Gdańsk, 80-952 Gdańsk, Poland; (M.C.); (K.K.); (L.G.); (M.N.)
| | - Krzysztof Specjalski
- Department of Allergology, Medical University of Gdańsk, 80-952 Gdańsk, Poland; (M.C.); (K.K.); (L.G.); (M.N.)
| | - Ewa Jassem
- Department of Pneumonology, Medical University of Gdańsk, 80-952 Gdańsk, Poland;
| | - Joanna Polańska
- Department of Data Science and Engineering, Silesian University of Technology, 44-100 Gliwice, Poland;
| | - Karolina Kita
- Department of Allergology, Medical University of Gdańsk, 80-952 Gdańsk, Poland; (M.C.); (K.K.); (L.G.); (M.N.)
| | - Lucyna Górska
- Department of Allergology, Medical University of Gdańsk, 80-952 Gdańsk, Poland; (M.C.); (K.K.); (L.G.); (M.N.)
| | - Joanna Didkowska
- National Institute of Oncology, 00-001 Warsaw, Poland; (J.D.); (U.W.)
| | | | - Marita Nittner-Marszalska
- Department of Internal Diseases, Pneumonology and Allergology, Medical University of Wroclaw, 50-368 Wroclaw, Poland;
| | - Piotr Kuna
- Department of Internal Diseases, Asthma and Allergy, Medical University of Łódź, 90-419 Łódż, Poland; (P.K.); (M.K.)
| | - Maciej Kupczyk
- Department of Internal Diseases, Asthma and Allergy, Medical University of Łódź, 90-419 Łódż, Poland; (P.K.); (M.K.)
| | - Jerzy Kruszewski
- Department of Infectious Diseases and Allergology, Military Institute of Medicine, 04-141 Warsaw, Poland; (J.K.); (A.Z.)
| | - Aleksander Zakrzewski
- Department of Infectious Diseases and Allergology, Military Institute of Medicine, 04-141 Warsaw, Poland; (J.K.); (A.Z.)
| | - Ewa Czarnobilska
- Centre of Clinical and Environmental Allergology, Jagiellonian University, 31-503 Cracow, Poland; (E.C.); (M.S.)
| | - Marcin Stobiecki
- Centre of Clinical and Environmental Allergology, Jagiellonian University, 31-503 Cracow, Poland; (E.C.); (M.S.)
| | - Rafał Krenke
- Department of Internal Diseases, Pneumonology and Allergology, Medical University of Warsaw, 02-097 Warsaw, Poland; (R.K.); (A.D.)
| | - Andrzej Dąbrowski
- Department of Internal Diseases, Pneumonology and Allergology, Medical University of Warsaw, 02-097 Warsaw, Poland; (R.K.); (A.D.)
| | | | - Jerzy Jarząb
- Clinical Department of Internal Medicine, Dermatology and Allergology, Medical University of Silesia, 40-055 Zabrze, Poland; (J.J.); (A.B.)
| | - Andrzej Bożek
- Clinical Department of Internal Medicine, Dermatology and Allergology, Medical University of Silesia, 40-055 Zabrze, Poland; (J.J.); (A.B.)
| | - Anna Bodzenta-Łukaszyk
- Department of Allergology and Internal Diseases, University Hospital, 15-089 Białystok, Poland;
| | - Mateusz Łukaszyk
- I Department of Pulmonary Diseases and Tuberculosis, Medical University of Białystok, 15-089 Białystok, Poland;
| | - Marek Kowalski
- Department of Immunology, Reumatology and Allergy, Medical University of Łódź, 92-213 Łódź, Poland (E.S.-S.)
| | - Ewa Smorawska-Sabanty
- Department of Immunology, Reumatology and Allergy, Medical University of Łódź, 92-213 Łódź, Poland (E.S.-S.)
| | - Andrzej Fal
- Department of Allergology, Pulmonary Diseases and Internal Medicine, MSWiA Central Clinical Hospital, 02-507 Warsaw, Poland; (A.F.); (K.P.)
| | - Katarzyna Przybyłowska
- Department of Allergology, Pulmonary Diseases and Internal Medicine, MSWiA Central Clinical Hospital, 02-507 Warsaw, Poland; (A.F.); (K.P.)
| | - Zbigniew Bartuzi
- Department of Allergology, Clinical Immunology and Internal Diseases, Jan Biziel University Hospital, Nicolaus Copernicus University, 85-067 Bydgoszcz, Poland; (Z.B.); (K.P.)
| | - Krzysztof Pałgan
- Department of Allergology, Clinical Immunology and Internal Diseases, Jan Biziel University Hospital, Nicolaus Copernicus University, 85-067 Bydgoszcz, Poland; (Z.B.); (K.P.)
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdańsk, 80-952 Gdańsk, Poland; (M.C.); (K.K.); (L.G.); (M.N.)
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6
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Olivieri B, Gil AJ, Stoenchev K, Durham SR, Scadding G. Utility of silver birch and house dust mite extracts derived from licensed sublingual tablets for nasal allergen challenge. Clin Transl Allergy 2024; 14:e12360. [PMID: 38779783 PMCID: PMC11112400 DOI: 10.1002/clt2.12360] [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: 12/27/2023] [Revised: 04/16/2024] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Nasal allergen challenge (NAC) is used to investigate the effects of allergen exposure and assess treatment efficacy in allergic rhinitis (AR). This study aims to establish dose-responses to NAC using licensed silver birch (SB) pollen and house dust mite (HDM) sublingual tablets as sources of the allergen extracts in participants with AR. METHODS Sixteen volunteers with HDM-induced perennial AR and 15 volunteers with SB pollen-induced seasonal rhinitis underwent a graded up-dosing NAC with extracts derived from HDM allergen (Acarizax®) and SB (Itulazax®) tablets, respectively. Total nasal symptom score (TNSS, range 0-12) and peak nasal inspiratory flow (PNIF) were recorded before, at 10 min and at the end of the NAC. The dose of each allergen that provoked a TNSS of at least 7 ("provoking dose 7") in most allergic participants was identified. NACs using the "provoking dose 7" were performed on 5 non-allergic individuals to test for irritant effects. The "provoking dose 7" of HDM extract was used in a subgroup of two SB allergic, non-HDM allergic, volunteers, and vice versa for SB extract, to test for allergen specificity of the responses. RESULTS Most patients experienced a TNSS of at least 7/12 at a median concentration of 1500 AU/mL for both SB pollen and HDM. The average decline in PNIF at this dose was 63.15% for SB and 63.99% for HDM. NACs using the 1500 AU/mL concentrations were performed on 5 non-allergic individuals with no symptomatic or PNIF response. 1500 AU/mL of HDM extract produced no symptoms in SB allergics nor 1500 AU/mL SB extract in HDM allergics. CONCLUSION For both SB and HDM extracts, the optimal allergen dose for NAC to cause a moderate-severity response ("provoking dose 7/12") was 1500 AU/mL. Licensed sublingual allergen tablets provide a readily available and inexpensive source of SB and HDM extracts for use in future interventional studies in AR.
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Affiliation(s)
- Bianca Olivieri
- Asthma, Allergy and Clinical Immunology SectionUniversity Hospital of VeronaVeronaItaly
| | - Ana Jimenez Gil
- Department of AllergyRoyal Brompton & Harefield Hospitals NHS TrustLondonUK
- Allergy and Clinical ImmunologyNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Kostadin Stoenchev
- Department of AllergyRoyal Brompton & Harefield Hospitals NHS TrustLondonUK
| | - Stephen R. Durham
- Department of AllergyRoyal Brompton & Harefield Hospitals NHS TrustLondonUK
- Allergy and Clinical ImmunologyNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Guy Scadding
- Department of AllergyRoyal Brompton & Harefield Hospitals NHS TrustLondonUK
- Allergy and Clinical ImmunologyNational Heart and Lung InstituteImperial College LondonLondonUK
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7
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Gurgel RK, Baroody FM, Damask CC, Mims JW, Ishman SL, Baker DP, Contrera KJ, Farid FS, Fornadley JA, Gardner DD, Henry LR, Kim J, Levy JM, Reger CM, Ritz HJ, Stachler RJ, Valdez TA, Reyes J, Dhepyasuwan N. Clinical Practice Guideline: Immunotherapy for Inhalant Allergy. Otolaryngol Head Neck Surg 2024; 170 Suppl 1:S1-S42. [PMID: 38408152 DOI: 10.1002/ohn.648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care. PURPOSE The purpose of this clinical practice guideline (CPG) is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce the risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS The GDG made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitizations, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions (LRs) to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The GDG offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.
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Affiliation(s)
| | - Fuad M Baroody
- The University of Chicago Medicine, Chicago, Illinois, USA
| | | | - James Whit Mims
- Wake Forest Baptist Health, Winston Salem, North Carolina, USA
| | | | - Dole P Baker
- Anderson ENT & Facial Plastics, Anderson, South Carolina, USA
| | | | | | - John A Fornadley
- Associated Otolaryngologists of PA, Inc, Hershey, Pennsylvania, USA
| | | | | | - Jean Kim
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua M Levy
- National Institute on Deafness and Other Communication Disorders, Bethesda, Maryland, USA
| | - Christine M Reger
- Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | - Joe Reyes
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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8
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Nelson HS, Sowers T, Plunkett G, Nolte H, Rance K. The Art of Dosing for Subcutaneous Immunotherapy in North America. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:13-22. [PMID: 37385447 DOI: 10.1016/j.jaip.2023.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 05/18/2023] [Accepted: 06/13/2023] [Indexed: 07/01/2023]
Abstract
Subcutaneous immunotherapy (SCIT) is a long-established treatment option for allergic rhinoconjunctivitis. Proper dosing of the allergens is critical for the efficacy and safety of SCIT. Of the hundreds of liquid allergen extracts in the United States, effective and well-tolerated SCIT dosing has only been established for a small number. Thus, SCIT dosing remains largely empiric and continues to be, by necessity, an art. To highlight the complexity of SCIT dosing, this review summarizes the historical and current landscape of U.S. allergen extracts, differences among U.S. and European allergen extracts, allergen selection for SCIT, considerations for compounding of allergen extract mixtures, and recommended dosing. As of 2021, 18 standardized allergen extracts are available in the United States; all other extracts remain unstandardized without characterization of allergen content or potency. U.S. allergen extracts differ from European extracts in formulation and potency characterization. There is no standardized methodology for SCIT allergen selection, and interpretation of allergen sensitization is not straightforward. Compounding of SCIT mixtures requires consideration of potential dilution effects, allergen cross-reactivity, proteolytic activity, and additives. Probable effective dose ranges for SCIT are recommended in U.S. allergy immunotherapy practice parameters, although there are few studies using U.S. extracts supporting these doses as therapeutic. In contrast, optimized doses of sublingual immunotherapy tablets have been confirmed in North American phase 3 trials. The SCIT dosing for each patient remains an art that requires clinical experience and consideration of polysensitization, tolerability, compounding of allergen extract mixtures, and the range of recommended doses within the context of extract potency variability.
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Affiliation(s)
- Harold S Nelson
- Department of Medicine, National Jewish Health, Denver, Colo
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9
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Nelson HS. The Art of Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1-10. [PMID: 37898175 DOI: 10.1016/j.jaip.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 10/30/2023]
Abstract
Selection of a patient with rhinitis/conjunctivitis or asthma for allergy immunotherapy (AIT) requires several decisions. First, does the patient's sensitization, pattern of exposure to an allergen, and degree of exposure to that allergen reasonably suggest a causal relationship? Does the level and duration of symptoms warrant the cost and inconvenience of immunotherapy, or is the patient motivated by the disease-modifying potential of AIT? If AIT is selected, is the choice to be greater safety and convenience with sublingual immunotherapy (SLIT) tablets, but with treatment probably limited to 2 or 3 allergens, or for subcutaneous immunotherapy where multiple allergen therapy is the rule and efficacy may be somewhat greater, at least initially, or does the physician go off-label into the unknowns of liquid SLIT? Are there extracts of sufficient potency to achieve likely effective doses? How does the physician deal with large local or systemic reactions, with gaps in treatment, with pollen seasons, and the use of premedication or cautionary prescription of epinephrine autoinjectors? How can adherence to AIT be improved? These and other questions are addressed in this paper.
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Affiliation(s)
- Harold S Nelson
- Department of Medicine, Division of Allergy/Immunology, National Jewish Health, Denver, Colo.
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10
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Layhadi JA, Lalioti A, Palmer E, van Zelm MC, Wambre E, Shamji MH. Mechanisms and Predictive Biomarkers of Allergen Immunotherapy in the Clinic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:59-66. [PMID: 37996041 DOI: 10.1016/j.jaip.2023.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/15/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023]
Abstract
Allergen immunotherapy (AIT) remains to be the only disease-modifying treatment for IgE-mediated allergic diseases such as allergic rhinitis. It can provide long-term clinical benefits when given for 3 years or longer. Mechanisms of immune tolerance induction by AIT are underscored by the modulation of several compartments within the immune system. These include repair of disruption in epithelial barrier integrity, modulation of the innate immune compartment that includes regulatory dendritic cells and innate lymphoid cells, and adaptive immune compartments such as induction of regulatory T and B cells. Altogether, these are also associated with the dampening of allergen-specific TH2 and T follicular helper cell responses and subsequent generation of blocking antibodies. Although AIT is effective in modifying the immune response, there is a lack of validated and clinically relevant biomarkers that can be used to monitor desensitization, efficacy, and the likelihood of response, all of which can contribute to accelerating personalized medication and increasing patient care. Candidate biomarkers comprise humoral, cellular, metabolic, and in vivo biomarkers; however, these are primarily studied in small trials and require further validation. In this review, we evaluate the current candidates of biomarkers of AIT and how we can implement changes in future studies to help us identify clinically relevant biomarkers of safety, compliance, and efficacy.
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Affiliation(s)
- Janice A Layhadi
- Department of National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Anastasia Lalioti
- Department of National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Elizabeth Palmer
- Department of National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Menno C van Zelm
- Department of Immunology, Monash University and Alfred Health, Melbourne, Victoria, Australia; Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Erik Wambre
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mohamed H Shamji
- Department of National Heart and Lung Institute, Imperial College London, London, United Kingdom.
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11
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Sio YY, Victoria Nanong GA, Lim JA, Matta SA, Say YH, Teh KF, Wong YR, Rawanan Shah SM, Reginald K, Chew FT. Sensitization to oil palm pollen associates with risks and severity of allergic diseases. World Allergy Organ J 2024; 17:100853. [PMID: 38235258 PMCID: PMC10792632 DOI: 10.1016/j.waojou.2023.100853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/11/2023] [Accepted: 11/25/2023] [Indexed: 01/19/2024] Open
Abstract
Background Elaeis guineensis (Ela g, oil palm) pollen is one of the most predominant species of inhalant allergens in the tropical Southeast Asia region; however, its association with the manifestation of allergic diseases remains largely unexplored. This study aimed to determine the sensitization pattern of oil palm pollen and associate this with the risk and severity of allergic diseases. Methods Participants were recruited as a part of the Singapore and Malaysia cross-sectional genetic and epidemiological study (SMCSGES). Two independent cohorts were recruited: n = 564 serum samples were collected and serological assessment was performed against a panel of 16 crude inhalant allergens including house dust mite, pet, insect, pollen, and fungal allergens; n = 13 652 Singapore/Malaysia Chinese young adults were recruited and skin prick test was used to assess oil palm sensitization, which was tested for its association with the risk and severity of asthma, allergic rhinitis (AR), and atopic dermatitis (AD). Results The sensitization rate of oil palm pollen is 9.6% in the n = 564 Singapore/Malaysia cohort. In the n = 13 652 Singapore/Malaysia Chinese cohort, oil palm sensitization significantly associates with increased risks of asthma (p = 1.34x10-4), AR (p = 2.91x10-13), and AD (p = 6.95x10-7). Asthmatic patients with oil palm sensitization have increased risks of wheezing (p = 0.00995), nocturnal cough (p = 0.0122), and exacerbations (p = 0.00139) in the past 12 months. AR patients with oil palm sensitization also have an increased risk of developing moderate-to-severe symptoms (p = 0.00113). Conclusions We have identified significant associations of oil palm sensitization with increased risks, exacerbations, and the severity of symptoms of allergic diseases in the tropical Southeast Asian region (Singapore/Malaysia).
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Affiliation(s)
- Yang Yie Sio
- Department of Biological Sciences, National University of Singapore, Singapore
| | | | - Jie Ann Lim
- Department of Biological Sciences, National University of Singapore, Singapore
| | - Sri Anusha Matta
- Department of Biological Sciences, National University of Singapore, Singapore
| | - Yee-How Say
- Department of Biological Sciences, National University of Singapore, Singapore
- Department of Biomedical Science, Faculty of Science, Universiti Tunku Abdul Rahman (UTAR) Kampar Campus, Kampar, Perak, Malaysia
- Department of Biological Sciences, School of Medical and Life Sciences, Sunway University, Malaysia
| | - Keng Foo Teh
- Department of Biological Sciences, School of Medical and Life Sciences, Sunway University, Malaysia
| | - Yi Ru Wong
- Department of Biological Sciences, School of Medical and Life Sciences, Sunway University, Malaysia
| | - Smyrna Moti Rawanan Shah
- Department of Biological Sciences, School of Medical and Life Sciences, Sunway University, Malaysia
| | - Kavita Reginald
- Department of Biological Sciences, School of Medical and Life Sciences, Sunway University, Malaysia
| | - Fook Tim Chew
- Department of Biological Sciences, National University of Singapore, Singapore
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12
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Arshad H, Lack G, Durham SR, Penagos M, Larenas-Linnemann D, Halken S. Prevention Is Better than Cure: Impact of Allergen Immunotherapy on the Progression of Airway Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:45-56. [PMID: 37844847 DOI: 10.1016/j.jaip.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/01/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023]
Abstract
Allergen immunotherapy is highly effective for seasonal pollinosis. Three years of treatment results in long-term efficacy. This disease modification is accompanied by downregulation of allergen-specific Th2 responses and the induction of persistent specific IgG- and IgA-associated IgE-blocking activity. In children with seasonal rhinitis, both subcutaneous and sublingual pollen immunotherapy have been shown to reduce the development of asthma symptoms and asthma medication requirements. House dust mite tablet allergen immunotherapy has been shown to be effective for perennial mite-driven rhinitis in adults and children and may suppress asthma exacerbations, whereas its long-term efficacy has yet to be explored. The success of primary prevention of peanut allergy in childhood by introduction of peanut into the diet during infancy provides a strong rationale to explore whether primary prevention of inhalant allergies and asthma may also be possible. House dust mite allergy is a major risk factor for developing asthma. Preliminary data in at-risk children suggest that sublingual house dust mite immunotherapy initiated during infancy could reduce the onset of multiple allergen sensitizations and prevent the development of asthma at age 6 years. This possibility should now be explored in an adequately powered, prospectively randomized controlled trial.
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Affiliation(s)
- Hasan Arshad
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom; The David Hide Asthma and Allergy Centre, Isle of Wight, United Kingdom
| | - Gideon Lack
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Stephen R Durham
- Allergy and Clinical Immunology, Division of Respiratory Science, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, United Kingdom
| | - Martin Penagos
- Allergy and Clinical Immunology, Division of Respiratory Science, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, United Kingdom
| | - Désireé Larenas-Linnemann
- Médica Sur, Clinical Foundation and Hospital, Centro de Excelencia en Asma y Alergia, Mexico City, Mexico
| | - Susanne Halken
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.
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13
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Nakamura K, Kouzaki H, Murao T, Kawakita K, Arai H, Matsumoto K, Kubo Y, Tojima I, Shimizu S, Ogawa Y, Yuta A, Sakai R, Ohno H, Kido H, Shimizu T. Sublingual immunotherapy decreases the avidity of antigen-specific IgE in patients with Japanese cedar pollinosis. Allergy 2023; 78:3268-3271. [PMID: 37807665 DOI: 10.1111/all.15900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/06/2023] [Accepted: 09/13/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Keigo Nakamura
- Department of Otorhinolaryngology-Head and Neck Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Hideaki Kouzaki
- Department of Otorhinolaryngology-Head and Neck Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Takuya Murao
- Department of Otorhinolaryngology-Head and Neck Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Kento Kawakita
- Department of Otorhinolaryngology-Head and Neck Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Hiroyuki Arai
- Department of Otorhinolaryngology-Head and Neck Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Koji Matsumoto
- Department of Otorhinolaryngology-Head and Neck Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Yoshihito Kubo
- Department of Otorhinolaryngology-Head and Neck Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Ichiro Tojima
- Department of Otorhinolaryngology-Head and Neck Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Shino Shimizu
- Department of Otorhinolaryngology-Head and Neck Surgery, Shiga University of Medical Science, Otsu, Japan
| | | | - Atsushi Yuta
- Department of Otorhinolaryngology-Head and Neck Surgery, Shiga University of Medical Science, Otsu, Japan
- Yuta Clinic, Tsu, Japan
| | - Rika Sakai
- Division of Enzyme Chemistry, Institute for Enzyme Research, Tokushima University, Tokushima, Japan
| | - Hitoshi Ohno
- Division of Enzyme Chemistry, Institute for Enzyme Research, Tokushima University, Tokushima, Japan
| | - Hiroshi Kido
- Division of Enzyme Chemistry, Institute for Enzyme Research, Tokushima University, Tokushima, Japan
| | - Takeshi Shimizu
- Department of Otorhinolaryngology-Head and Neck Surgery, Shiga University of Medical Science, Otsu, Japan
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14
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Li S, Toriumi H, Takahashi D, Kamasaki T, Fujioka Y, Nagatoishi S, Li J, Liu Y, Hosokawa T, Tsumoto K, Ohba Y, Katayama Y, Murakami D, Hase K, Mori T. Safe and efficient oral allergy immunotherapy using one-pot-prepared mannan-coated allergen nanoparticles. Biomaterials 2023; 303:122381. [PMID: 37935073 DOI: 10.1016/j.biomaterials.2023.122381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/16/2023] [Accepted: 10/27/2023] [Indexed: 11/09/2023]
Abstract
Allergen immunotherapy (AIT) is the only curative treatment for allergic diseases. However, AIT has many disadvantages related to efficiency, safety, long-term duration, and patient compliance. Dendritic cells (DCs) have an important role in antigen-specific tolerance induction; thus, DC-targeting strategies to treat allergies such as glutaraldehyde crosslinked antigen to mannoprotein (MAN) have been established. However, glutaraldehyde crosslinking may reduce the antigen presentation efficiency of DCs. To overcome this, we developed a MAN-coated ovalbumin (OVA) nanoparticle (MDO), which uses intermolecular disulfide bond to crosslink OVA and MAN. MDO effectively targeted DCs resulting in tolerogenic DCs, and promoted higher antigen presentation efficiency by DCs compared with OVA or glutaraldehyde crosslinked nanoparticles. In vitro and in vivo experiments showed that DCs exposed to MDO induced Treg cells. Moreover, MDO had low reactivity with anti-OVA antibodies and did not induce anaphylaxis in allergic mice, demonstrating its high safety profile. In a mouse model of allergic asthma, MDO had significant preventative and therapeutic effects when administered orally or subcutaneously. Therefore, MDO represents a promising new approach for the efficient and safe treatment of allergies.
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Affiliation(s)
- Shunyi Li
- Graduate School of Systems Life Sciences, Kyushu University, Fukuoka, 819-0395, Japan
| | - Hiroki Toriumi
- Division of Biochemistry, Graduate School of Pharmaceutical Sciences, Keio University, Tokyo, 105-8512, Japan
| | - Daisuke Takahashi
- Division of Biochemistry, Faculty of Pharmacy and Graduate School of Pharmaceutical Sciences, Keio University, Tokyo, 105-8512, Japan
| | - Tomoko Kamasaki
- Department of Cell Physiology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, 060-8638, Japan
| | - Yoichiro Fujioka
- Department of Cell Physiology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, 060-8638, Japan
| | - Satoru Nagatoishi
- The Institute of Medical Science, The University of Tokyo, Tokyo, 108-8639, Japan; Department of Bioengineering, School of Engineering, The University of Tokyo, Tokyo, 113-8656, Japan
| | - Jinting Li
- Graduate School of Systems Life Sciences, Kyushu University, Fukuoka, 819-0395, Japan
| | - Yiwei Liu
- Department of Applied Chemistry, Faculty of Engineering, Kyushu University, Fukuoka, 819-0395, Japan
| | - Takanatsu Hosokawa
- Graduate School of Systems Life Sciences, Kyushu University, Fukuoka, 819-0395, Japan
| | - Kouhei Tsumoto
- The Institute of Medical Science, The University of Tokyo, Tokyo, 108-8639, Japan; Department of Bioengineering, School of Engineering, The University of Tokyo, Tokyo, 113-8656, Japan
| | - Yusuke Ohba
- Department of Cell Physiology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, 060-8638, Japan
| | - Yoshiki Katayama
- Graduate School of Systems Life Sciences, Kyushu University, Fukuoka, 819-0395, Japan; Department of Applied Chemistry, Faculty of Engineering, Kyushu University, Fukuoka, 819-0395, Japan; Center for Future Chemistry, Kyushu University, Fukuoka, 819-0395, Japan; International Research Center for Molecular Systems, Kyushu University, Fukuoka, 819-0395, Japan; Centre for Advanced Medicine Innovation, Kyushu University, Fukuoka, 812-8582, Japan; Department of Biomedical Engineering, Chung Yuan Christian University, Chung Li, 32023, Taiwan.
| | - Daisuke Murakami
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan.
| | - Koji Hase
- Division of Biochemistry, Faculty of Pharmacy and Graduate School of Pharmaceutical Sciences, Keio University, Tokyo, 105-8512, Japan; The Institute of Fermentation Sciences (IFeS), Faculty of Food and Agricultural Sciences, Fukushima University, Kanayagawa, Fukushima, 960-1296, Japan; International Research and Development Centre for Mucosal Vaccines, The Institute of Medical Science, The University of Tokyo (IMSUT), Tokyo, 108-8639, Japan.
| | - Takeshi Mori
- Graduate School of Systems Life Sciences, Kyushu University, Fukuoka, 819-0395, Japan; Department of Applied Chemistry, Faculty of Engineering, Kyushu University, Fukuoka, 819-0395, Japan; Center for Future Chemistry, Kyushu University, Fukuoka, 819-0395, Japan.
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15
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Altman MC, Segnitz RM, Larson D, Jayavelu ND, Smith MT, Patel S, Scadding GW, Qin T, Sanda S, Steveling E, Eifan AO, Penagos M, Jacobson MR, Parkin RV, Shamji MH, Togias A, Durham SR. Nasal and blood transcriptomic pathways underpinning the clinical response to grass pollen immunotherapy. J Allergy Clin Immunol 2023; 152:1247-1260. [PMID: 37460024 PMCID: PMC10788383 DOI: 10.1016/j.jaci.2023.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 05/19/2023] [Accepted: 06/01/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Allergen immunotherapy (AIT) is a well-established disease-modifying therapy for allergic rhinitis, yet the fundamental mechanisms underlying its clinical effect remain inadequately understood. Gauging Response in Allergic Rhinitis to Sublingual and Subcutaneous Immunotherapy was a randomized, double-blind, placebo-controlled trial of individuals allergic to timothy grass who received 2 years of placebo (n = 30), subcutaneous immunotherapy (SCIT) (n = 27), or sublingual immunotherapy (SLIT) (n = 27) and were then followed for 1 additional year. OBJECTIVE We used yearly biospecimens from the Gauging Response in Allergic Rhinitis to Sublingual and Subcutaneous Immunotherapy study to identify molecular mechanisms of response. METHODS We used longitudinal transcriptomic profiling of nasal brush and PBMC samples after allergen provocation to uncover airway and systemic expression pathways mediating responsiveness to AIT. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01335139, EudraCT Number: 2010-023536-16. RESULTS SCIT and SLIT demonstrated similar changes in gene module expression over time. In nasal samples, alterations included downregulation of pathways of mucus hypersecretion, leukocyte migration/activation, and endoplasmic reticulum stress (log2 fold changes -0.133 to -0.640, false discovery rates [FDRs] <0.05). We observed upregulation of modules related to epithelial development, junction formation, and lipid metabolism (log2 fold changes 0.104 to 0.393, FDRs <0.05). In PBMCs, modules related to cellular stress response and type 2 cytokine signaling were reduced by immunotherapy (log2 fold changes -0.611 to -0.828, FDRs <0.05). Expression of these modules was also significantly associated with both Total Nasal Symptom Score and peak nasal inspiratory flow, indicating important links between treatment, module expression, and allergen response. CONCLUSIONS Our results identify specific molecular responses of the nasal airway impacting barrier function, leukocyte migration activation, and mucus secretion that are affected by both SCIT and SLIT, offering potential targets to guide novel strategies for AIT.
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Affiliation(s)
- Matthew C Altman
- Systems Immunology Division, Benaroya Research Institute, Seattle; Division of Allergy and Infectious Disease, Department of Medicine, University of Washington, Seattle.
| | - R Max Segnitz
- Division of Allergy and Infectious Disease, Department of Medicine, University of Washington, Seattle
| | | | | | - Malisa T Smith
- Division of Allergy and Infectious Disease, Department of Medicine, University of Washington, Seattle
| | - Sana Patel
- Division of Allergy and Infectious Disease, Department of Medicine, University of Washington, Seattle
| | - Guy W Scadding
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, London
| | | | - Srinath Sanda
- Madison Clinic for Pediatric Diabetes, University of California San Francisco, San Francisco
| | - Esther Steveling
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, London
| | - Aarif O Eifan
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, London
| | - Martin Penagos
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, London
| | - Mikila R Jacobson
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, London
| | - Rebecca V Parkin
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, London
| | - Mohamed H Shamji
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, London
| | - Alkis Togias
- The National Institute of Allergy and Infectious Disease, Bethesda
| | - Stephen R Durham
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, London
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16
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Mahlab-Guri K, Mishayev D, Yakovlev M, Asher I, Sthoeger Z, Guri A, Elbirt D, Nemet S, Rosenberg-Bezalel S. Modification of allergen subcutaneous immunotherapy safety precautions and systemic allergic reaction rate reduction. Immunotherapy 2023; 15:1389-1400. [PMID: 37694383 DOI: 10.2217/imt-2023-0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
Background: Despite their life-threatening potential, medical team mistakes during subcutaneous immunotherapy are rarely discussed. Real data are missing, and a survey study estimated that dosing errors are responsible for 25% of systemic reactions during immunotherapy. To minimize errors, we modified our safety precautions and compared the rates of systemic allergic reactions before and after the change. Methods: Our retrospective comparative cohort study compared systemic allergic reaction rates during 2012-2015 and 2016-2019, after a second check of the injected allergen/s by another nurse/physician was added to the treatment protocol. Results: The rate of systemic allergic reaction per injection was reduced from 0.93 to 0.71%; p = 0.023. Conclusion: A second check prior to injection is beneficial and can reduce the allergic reaction rate during immunotherapy.
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Affiliation(s)
- Keren Mahlab-Guri
- Department of Allergy & Clinical Immunology, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - David Mishayev
- Faculty of Medicine, Hebrew University of Jerusalem, 9112102, Israel
| | - Marina Yakovlev
- Department of Medicine D, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, 7661041, Israel
| | - Ilan Asher
- Department of Allergy & Clinical Immunology, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Zev Sthoeger
- Department of Allergy & Clinical Immunology, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Alex Guri
- Department of Pediatrics, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, 7661041, Israel
| | - Daniel Elbirt
- Department of Allergy & Clinical Immunology, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Shay Nemet
- Department of Allergy & Clinical Immunology, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Shira Rosenberg-Bezalel
- Department of Allergy & Clinical Immunology, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
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17
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Suhrkamp I, Scheffold A, Heine G. T-cell subsets in allergy and tolerance induction. Eur J Immunol 2023; 53:e2249983. [PMID: 37489248 DOI: 10.1002/eji.202249983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 07/19/2023] [Accepted: 07/24/2023] [Indexed: 07/26/2023]
Abstract
Antigen-specific T lymphocytes are the central regulators of tolerance versus immune pathology against otherwise innocuous antigens and key targets of antigen-specific immune therapy. Recent advances in the understanding of T cells in tolerance and allergy resulted from improved technologies to directly characterize allergen-specific T cells by multiparameter flow cytometry or single-cell sequencing. This unravelled phenotypically and functionally distinct populations, such as Type 2a T helper cells (Th2a), follicular Th cells (Tfh), regulatory T cells (Treg), Type 1 regulatory T cells (Tr1), and follicular T regulatory cells. Here we will discuss the role of the different Th-cell subsets in the healthy state, during sensitization and development of allergy, and in tolerance induction by allergen immunotherapy (AIT). To date, the mechanisms of AIT as the only causal treatment of allergy are not completely understood. The analyses of allergen-specific T cells directly ex vivo during AIT support the concept of specific-Th2(a) cell deletion rather than an expansion of allergen-specific Tr1 or Treg cells as underlying mechanism.
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Affiliation(s)
- Ina Suhrkamp
- Department of Dermatology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Alexander Scheffold
- Institute of Immunology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Guido Heine
- Department of Dermatology, University Hospital Schleswig-Holstein, Kiel, Germany
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18
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De Carli M, Capezzali E, Tonon S, Frossi B. Mechanism and clinical evidence of immunotherapy in allergic rhinitis. FRONTIERS IN ALLERGY 2023; 4:1217388. [PMID: 37601646 PMCID: PMC10434251 DOI: 10.3389/falgy.2023.1217388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/21/2023] [Indexed: 08/22/2023] Open
Abstract
Allergic rhinitis is a common upper airway disease caused by hypersensitivity to various aeroallergens. It causes increased inflammation throughout the body and may be complicated by other otolaryngological pathologies such as chronic hyperplastic eosinophilic sinusitis, nasal polyposis, and serous otitis media. Allergic rhinitis is an IgE-mediated disease and immunotherapy can be a possible approach for patients to limit the use of antihistamines and corticosteroids. There is evidence that allergen immunotherapy can prevent the development of new sensitizations and reduce the risk of later development of asthma in patients with allergic rhinitis. However, some patients do not benefit from this approach and the efficacy of immunotherapy in reducing the severity and relapse of symptoms is still a matter of debate. This review highlights new aspects of allergic rhinitis with a particular focus on the impact of sexual dimorphism on the disease manifestation and efficacy to the allergen specific immunotherapy.
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Affiliation(s)
- Marco De Carli
- Second Unit of Internal Medicine, University Hospital of Udine, Udine, Italy
| | | | - Silvia Tonon
- Department of Medicine, University of Udine, Udine, Italy
| | - Barbara Frossi
- Department of Medicine, University of Udine, Udine, Italy
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19
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Sahiner UM, Giovannini M, Escribese MM, Paoletti G, Heffler E, Alvaro Lozano M, Barber D, Canonica GW, Pfaar O. Mechanisms of Allergen Immunotherapy and Potential Biomarkers for Clinical Evaluation. J Pers Med 2023; 13:jpm13050845. [PMID: 37241015 DOI: 10.3390/jpm13050845] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/28/2023] [Accepted: 05/03/2023] [Indexed: 05/28/2023] Open
Abstract
Allergen-immunotherapy (AIT) is an efficacious and disease-modifying treatment option for IgE-mediated diseases. Among these allergic rhinitis, insect venom allergy, food allergy, and allergic asthma are the most common candidates for AIT. AIT gives rise to clinical immunotolerance which may last for years after the treatment cessation. Mechanisms of AIT include suppression of allergic inflammation in target tissues and stimulation of the production of blocking antibodies, especially IgG4 and IgA. These mechanisms are followed by a reduction of underlying allergen-specific Th2 cell-driven responses to the allergens. Tolerance induction takes place through the desensitization of effector cells and stimulation of regulatory T cells that show their effects by mechanisms involving cell-cell cross-talk, but also other mechanisms, e.g., by the production of immunomodulatory cytokines such as, e.g., IL-10 and TGF-beta. From a personalized medical perspective, there is a need for clinical biomarkers of value in selecting responders and optimizing patient care during AIT. Also, a deeper understanding of underlying mechanistic processes will improve AIT's future outcomes. In this paper, the current knowledge of mechanisms in AIT is reviewed with a special focus on biomarkers of this therapy.
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Affiliation(s)
- Umit M Sahiner
- Pediatric Allergy Unit, Department of Pediatrics, Hacettepe University School of Medicine, Hacettepe University Childrens Hospital, 06230 Ankara, Turkey
| | - Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Maria M Escribese
- Departamento de Ciencias Médicas Básicas, Instituto de Medicina Molecular Aplicada (IMMA) Nemesio Díez, Facultad de Medicina, Universidad San PabloCEU, CEU Universities, 28668 Madrid, Spain
| | - Giovanni Paoletti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Enrico Heffler
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Montserrat Alvaro Lozano
- Pediatric Allergy and Clinical Immunology Service, Hospital Sant Joan de Déu, 08950 Barcelona, Spain
| | - Domingo Barber
- Departamento de Ciencias Médicas Básicas, Instituto de Medicina Molecular Aplicada (IMMA) Nemesio Díez, Facultad de Medicina, Universidad San PabloCEU, CEU Universities, 28668 Madrid, Spain
| | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Personalized Medicine, Asthma and Allergy, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, Philipps-Universität Marburg, University Hospital Marburg, 35039 Marburg, Germany
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20
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Jiang S, Xie S, Tang Q, Zhang H, Xie Z, Zhang J, Jiang W. Evaluation of Intralymphatic Immunotherapy in Allergic Rhinitis Patients: A Systematic Review and Meta-analysis. Mediators Inflamm 2023; 2023:9377518. [PMID: 37197570 PMCID: PMC10185423 DOI: 10.1155/2023/9377518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/22/2022] [Accepted: 03/18/2023] [Indexed: 05/19/2023] Open
Abstract
Background Intralymphatic immunotherapy (ILIT) is short-course administration of allergen-specific immunotherapy (AIT). This study is aimed at assessing the clinical efficacy and safety of ILIT in patients with allergic rhinitis (AR). Methods MEDLINE, PUBMED, and Cochrane Library were used to conduct electronic searches for clinical trials comparing ILIT and placebo in patients with AR. The final search took place on August 24, 2022. Cochrane Handbook for Systematic Reviews of Interventions was used to assess the risk of bias in the included studies. The outcomes included combined symptom and medication scores (CSMS), visual analog scale (VAS), allergic rhinoconjunctivitis quality of life (RQLQ), Skin-prick test (SPT), and adverse events (AEs). Data were synthesized as mean difference (MD)/standard mean difference (SMD) or risk difference (RD) and 95% confidence interval (CI). Results Thirteen studies (454 participants) were included in this study. The ILIT group had better clinical improvement on the CSMS (random effects model, SMD-0.85, 95% CI [-1.58, -0.11], P = 0.02) and RQLQ (fixed-effects model, MD-0.42, 95% CI [0.69, 0.15], P = 0.003) than the placebo group. The booster injection was beneficial for CSMS (P < 0.0001), and the 4-week injection interval was superior to the 2-week injection period for improving VAS (P < 0.0001). Local swelling or erythema was the main AE following injection (random effects model, RD 0.16, 95% CI [0.05, 0.27], P = 0.005). Discussion. For individuals with AR, ILIT is safe and effective. ILIT alleviates clinical symptoms and reduces pharmaceutical consumption without causing severe AEs. However, the validity of this study is compromised by the substantial heterogeneity and risk of bias in the included researches. RegistrationCRD42022355329.
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Affiliation(s)
- Sijie Jiang
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University, Changsha, China
- Hunan Province Key Laboratory of Otolaryngology Critical Diseases, Xiangya Hospital of Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, China
| | - Shaobing Xie
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University, Changsha, China
- Hunan Province Key Laboratory of Otolaryngology Critical Diseases, Xiangya Hospital of Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, China
| | - Qingping Tang
- Department of Rehabilitation, Brain Hospital of Hunan Province, Hunan University of Chinese Medicine, Changsha, China
| | - Hua Zhang
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University, Changsha, China
- Hunan Province Key Laboratory of Otolaryngology Critical Diseases, Xiangya Hospital of Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, China
| | - Zhihai Xie
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University, Changsha, China
- Hunan Province Key Laboratory of Otolaryngology Critical Diseases, Xiangya Hospital of Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, China
| | - Junyi Zhang
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University, Changsha, China
- Hunan Province Key Laboratory of Otolaryngology Critical Diseases, Xiangya Hospital of Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, China
| | - Weihong Jiang
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital of Central South University, Changsha, China
- Hunan Province Key Laboratory of Otolaryngology Critical Diseases, Xiangya Hospital of Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, China
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21
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Fiala S, Fleit HB. Clinical and experimental treatment of allergic asthma with an emphasis on allergen immunotherapy and its mechanisms. Clin Exp Immunol 2023; 212:14-28. [PMID: 36879430 PMCID: PMC10081111 DOI: 10.1093/cei/uxad031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 01/23/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Allergen immunotherapy (AIT) is currently the only form of treatment that modifies allergic asthma. Pharmacotherapy alone seeks to control the symptoms of allergic asthma, allergic rhinitis, and other atopic conditions. In contrast, AIT can induce long-term physiological modifications through the immune system. AIT enables individuals to live improved lives many years after treatment ends, where they are desensitized to the allergen(s) used or no longer have significant allergic reactions upon allergen provocation. The leading forms of treatment with AIT involve injections of allergen extracts with increasing doses via the subcutaneous route or drops/tablets via the sublingual route for several years. Since the initial attempts at this treatment as early as 1911 by Leonard Noon, the mechanisms by which AIT operates remain unclear. This literature-based review provides the primary care practitioner with a current understanding of the mechanisms of AIT, including its treatment safety, protocols, and long-term efficacy. The primary mechanisms underlying AIT include changes in immunoglobulin classes (IgA, IgE, and IgG), immunosuppressive regulatory T-cell induction, helper T cell type 2 to helper T cell type 1 cell/cytokine profile shifts, decreased early-phase reaction activity and mediators, and increased production of IL-10, IL-35, TGF-β, and IFN-γ. Using the databases PubMed and Embase, a selective literature search was conducted searching for English, full-text, reviews published between 2015 and 2022 using the keywords (with wildcards) "allerg*," "immunotherap*," "mechanis*," and "asthma." Among the cited references, additional references were identified using a manual search.
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Affiliation(s)
- Scott Fiala
- Department of Pathology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Howard B Fleit
- Department of Pathology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
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22
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Wise SK, Damask C, Roland LT, Ebert C, Levy JM, Lin S, Luong A, Rodriguez K, Sedaghat AR, Toskala E, Villwock J, Abdullah B, Akdis C, Alt JA, Ansotegui IJ, Azar A, Baroody F, Benninger MS, Bernstein J, Brook C, Campbell R, Casale T, Chaaban MR, Chew FT, Chambliss J, Cianferoni A, Custovic A, Davis EM, DelGaudio JM, Ellis AK, Flanagan C, Fokkens WJ, Franzese C, Greenhawt M, Gill A, Halderman A, Hohlfeld JM, Incorvaia C, Joe SA, Joshi S, Kuruvilla ME, Kim J, Klein AM, Krouse HJ, Kuan EC, Lang D, Larenas-Linnemann D, Laury AM, Lechner M, Lee SE, Lee VS, Loftus P, Marcus S, Marzouk H, Mattos J, McCoul E, Melen E, Mims JW, Mullol J, Nayak JV, Oppenheimer J, Orlandi RR, Phillips K, Platt M, Ramanathan M, Raymond M, Rhee CS, Reitsma S, Ryan M, Sastre J, Schlosser RJ, Schuman TA, Shaker MS, Sheikh A, Smith KA, Soyka MB, Takashima M, Tang M, Tantilipikorn P, Taw MB, Tversky J, Tyler MA, Veling MC, Wallace D, Wang DY, White A, Zhang L. International consensus statement on allergy and rhinology: Allergic rhinitis - 2023. Int Forum Allergy Rhinol 2023; 13:293-859. [PMID: 36878860 DOI: 10.1002/alr.23090] [Citation(s) in RCA: 101] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/11/2022] [Accepted: 09/13/2022] [Indexed: 03/08/2023]
Abstract
BACKGROUND In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document. METHODS ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work. RESULTS ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost. CONCLUSION The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.
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Affiliation(s)
- Sarah K Wise
- Otolaryngology-HNS, Emory University, Atlanta, Georgia, USA
| | - Cecelia Damask
- Otolaryngology-HNS, Private Practice, University of Central Florida, Lake Mary, Florida, USA
| | - Lauren T Roland
- Otolaryngology-HNS, Washington University, St. Louis, Missouri, USA
| | - Charles Ebert
- Otolaryngology-HNS, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Joshua M Levy
- Otolaryngology-HNS, Emory University, Atlanta, Georgia, USA
| | - Sandra Lin
- Otolaryngology-HNS, University of Wisconsin, Madison, Wisconsin, USA
| | - Amber Luong
- Otolaryngology-HNS, McGovern Medical School of the University of Texas, Houston, Texas, USA
| | - Kenneth Rodriguez
- Otolaryngology-HNS, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ahmad R Sedaghat
- Otolaryngology-HNS, University of Cincinnati, Cincinnati, Ohio, USA
| | - Elina Toskala
- Otolaryngology-HNS, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Baharudin Abdullah
- Otolaryngology-HNS, Universiti Sains Malaysia, Kubang, Kerian, Kelantan, Malaysia
| | - Cezmi Akdis
- Immunology, Infectious Diseases, Swiss Institute of Allergy and Asthma Research, Davos, Switzerland
| | - Jeremiah A Alt
- Otolaryngology-HNS, University of Utah, Salt Lake City, Utah, USA
| | | | - Antoine Azar
- Allergy/Immunology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Fuad Baroody
- Otolaryngology-HNS, University of Chicago, Chicago, Illinois, USA
| | | | | | - Christopher Brook
- Otolaryngology-HNS, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Raewyn Campbell
- Otolaryngology-HNS, Macquarie University, Sydney, NSW, Australia
| | - Thomas Casale
- Allergy/Immunology, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Mohamad R Chaaban
- Otolaryngology-HNS, Cleveland Clinic, Case Western Reserve University, Cleveland, Ohio, USA
| | - Fook Tim Chew
- Allergy/Immunology, Genetics, National University of Singapore, Singapore, Singapore
| | - Jeffrey Chambliss
- Allergy/Immunology, University of Texas Southwestern, Dallas, Texas, USA
| | - Antonella Cianferoni
- Allergy/Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | | | - Anne K Ellis
- Allergy/Immunology, Queens University, Kingston, ON, Canada
| | | | - Wytske J Fokkens
- Otorhinolaryngology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | | | - Matthew Greenhawt
- Allergy/Immunology, Pediatrics, University of Colorado, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Amarbir Gill
- Otolaryngology-HNS, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashleigh Halderman
- Otolaryngology-HNS, University of Texas Southwestern, Dallas, Texas, USA
| | - Jens M Hohlfeld
- Respiratory Medicine, Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, Hannover Medical School, German Center for Lung Research, Hannover, Germany
| | | | - Stephanie A Joe
- Otolaryngology-HNS, University of Illinois Chicago, Chicago, Illinois, USA
| | - Shyam Joshi
- Allergy/Immunology, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Jean Kim
- Otolaryngology-HNS, Johns Hopkins University, Baltimore, Maryland, USA
| | - Adam M Klein
- Otolaryngology-HNS, Emory University, Atlanta, Georgia, USA
| | - Helene J Krouse
- Otorhinolaryngology Nursing, University of Texas Rio Grande Valley, Edinburg, Texas, USA
| | - Edward C Kuan
- Otolaryngology-HNS, University of California Irvine, Orange, California, USA
| | - David Lang
- Allergy/Immunology, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Matt Lechner
- Otolaryngology-HNS, University College London, Barts Health NHS Trust, London, UK
| | - Stella E Lee
- Otolaryngology-HNS, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Victoria S Lee
- Otolaryngology-HNS, University of Illinois Chicago, Chicago, Illinois, USA
| | - Patricia Loftus
- Otolaryngology-HNS, University of California San Francisco, San Francisco, California, USA
| | - Sonya Marcus
- Otolaryngology-HNS, Stony Brook University, Stony Brook, New York, USA
| | - Haidy Marzouk
- Otolaryngology-HNS, State University of New York Upstate, Syracuse, New York, USA
| | - Jose Mattos
- Otolaryngology-HNS, University of Virginia, Charlottesville, Virginia, USA
| | - Edward McCoul
- Otolaryngology-HNS, Ochsner Clinic, New Orleans, Louisiana, USA
| | - Erik Melen
- Pediatric Allergy, Karolinska Institutet, Stockholm, Sweden
| | - James W Mims
- Otolaryngology-HNS, Wake Forest University, Winston Salem, North Carolina, USA
| | - Joaquim Mullol
- Otorhinolaryngology, Hospital Clinic Barcelona, Barcelona, Spain
| | - Jayakar V Nayak
- Otolaryngology-HNS, Stanford University, Palo Alto, California, USA
| | - John Oppenheimer
- Allergy/Immunology, Rutgers, State University of New Jersey, Newark, New Jersey, USA
| | | | - Katie Phillips
- Otolaryngology-HNS, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael Platt
- Otolaryngology-HNS, Boston University, Boston, Massachusetts, USA
| | | | | | - Chae-Seo Rhee
- Rhinology/Allergy, Seoul National University Hospital and College of Medicine, Seoul, Korea
| | - Sietze Reitsma
- Otolaryngology-HNS, University of Amsterdam, Amsterdam, Netherlands
| | - Matthew Ryan
- Otolaryngology-HNS, University of Texas Southwestern, Dallas, Texas, USA
| | - Joaquin Sastre
- Allergy, Fundacion Jiminez Diaz, University Autonoma de Madrid, Madrid, Spain
| | - Rodney J Schlosser
- Otolaryngology-HNS, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Theodore A Schuman
- Otolaryngology-HNS, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Marcus S Shaker
- Allergy/Immunology, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Aziz Sheikh
- Primary Care, University of Edinburgh, Edinburgh, Scotland
| | - Kristine A Smith
- Otolaryngology-HNS, University of Utah, Salt Lake City, Utah, USA
| | - Michael B Soyka
- Otolaryngology-HNS, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Masayoshi Takashima
- Otolaryngology-HNS, Houston Methodist Academic Institute, Houston, Texas, USA
| | - Monica Tang
- Allergy/Immunology, University of California San Francisco, San Francisco, California, USA
| | | | - Malcolm B Taw
- Integrative East-West Medicine, University of California Los Angeles, Westlake Village, California, USA
| | - Jody Tversky
- Allergy/Immunology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Matthew A Tyler
- Otolaryngology-HNS, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maria C Veling
- Otolaryngology-HNS, University of Texas Southwestern, Dallas, Texas, USA
| | - Dana Wallace
- Allergy/Immunology, Nova Southeastern University, Ft. Lauderdale, Florida, USA
| | - De Yun Wang
- Otolaryngology-HNS, National University of Singapore, Singapore, Singapore
| | - Andrew White
- Allergy/Immunology, Scripps Clinic, San Diego, California, USA
| | - Luo Zhang
- Otolaryngology-HNS, Beijing Tongren Hospital, Beijing, China
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23
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Pollock RF, Slættanes AK, Brandi H, Grand TS. A Cost-Utility Analysis of SQ ® Tree SLIT-Tablet versus Placebo in the Treatment of Birch Pollen Allergic Rhinitis from a Swedish Societal Perspective. CLINICOECONOMICS AND OUTCOMES RESEARCH 2023; 15:69-86. [PMID: 36761408 PMCID: PMC9904213 DOI: 10.2147/ceor.s377399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 12/07/2022] [Indexed: 02/05/2023] Open
Abstract
Background and Aims Allergic rhinitis (AR) is an immunoglobulin E antibody-mediated inflammatory condition that arises in response to inhaled allergens such as pollen. Pollens from trees in the birch homologous group are the most common allergenic tree pollens in Northern and Central Europe and North America. SQ® Tree SLIT-Tablet (ITULAZAX®) is a sublingual immunotherapy tablet indicated for moderate-to-severe AR and/or conjunctivitis induced by pollen from the birch homologous group. The present analysis evaluated the cost-utility of treating adults with AR with SQ Tree SLIT-Tablet versus placebo, both in combination with symptom-relieving medications, from a Swedish societal perspective. Methods A model was developed to evaluate changes in cost and quality of life associated with using SQ Tree SLIT-Tablet relative to placebo in an adult population of individuals with AR. The model captured costs associated with symptom-relieving medications, healthcare professional interactions, SQ Tree SLIT-Tablet, and indirect costs arising from absenteeism and reduced workplace productivity. The analysis was conducted over 10 years with costs captured in 2021 Swedish Krona (SEK) and future costs and effects discounted at 3% per annum. One-way and probabilistic sensitivity analyses were conducted. Results Treatment with SQ Tree SLIT-Tablet resulted in an improvement of 0.041 quality-adjusted life years (QALYs) over 10 years versus placebo. From a Swedish societal perspective, costs increased by SEK 9077 over the same period, resulting in an incremental cost-utility ratio of SEK 223,445 per QALY gained. One-way sensitivity analysis showed that the model was most sensitive to assumptions around the disease-modifying effect of SQ Tree SLIT-Tablet. Conclusion SQ Tree SLIT-Tablet improved quality of life in moderate-to-severe AR and/or conjunctivitis induced by pollen from the birch homologous group in Sweden, with only a modest increase in societal costs over a medium-term time horizon, representing good value for money at a willingness-to-pay threshold of SEK 700,000 per QALY.
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Affiliation(s)
| | - Andreas K Slættanes
- ALK-Abelló A/S, Hørsholm, Denmark,Correspondence: Andreas K Slættanes, ALK-Abelló A/S, Bøge Allé 1, Hørsholm, DK-2970, Denmark, Tel +45 53638813, Email
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24
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Corren J, Larson D, Altman MC, Segnitz RM, Avila PC, Greenberger PA, Baroody F, Moss MH, Nelson H, Burbank AJ, Hernandez ML, Peden D, Saini S, Tilles S, Hussain I, Whitehouse D, Qin T, Villarreal M, Sever M, Wheatley LM, Nepom GT, Sanda S. Effects of combination treatment with tezepelumab and allergen immunotherapy on nasal responses to allergen: A randomized controlled trial. J Allergy Clin Immunol 2023; 151:192-201. [PMID: 36223848 DOI: 10.1016/j.jaci.2022.08.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 07/28/2022] [Accepted: 08/04/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Thymic stromal lymphopoietin (TSLP) has been shown to play a central role in the initiation and persistence of allergic responses. OBJECTIVE We evaluated whether tezepelumab, a human monoclonal anti-TSLP antibody, improved the efficacy of subcutaneous allergen immunotherapy (SCIT) and promoted the development of tolerance in patients with allergic rhinitis. METHODS We conducted a double-blind parallel design trial in patients with cat allergy. A total of 121 patients were randomized to receive either intravenous tezepelumab plus subcutaneous cat SCIT, cat SCIT alone, tezepelumab alone, or placebo for 52 weeks, followed by 52 weeks of observation. Nasal allergen challenge (NAC), skin testing, and blood and nasal samples were obtained throughout the study. RESULTS At week 52, the NAC-induced total nasal symptom scores (TNSS) (calculated as area under the curve [AUC0-1h] and as peak score [Peak0-1h] during the first hour after NAC) were significantly reduced in patients receiving tezepelumab/SCIT compared to SCIT alone. At week 104, one year after stopping treatment, the primary end point TNSS AUC0-1h was not significantly different in the tezepelumab/SCIT group compared to SCIT alone, while TNSS Peak0-1h was significantly lower in those receiving combination treatment versus SCIT. Transcriptomic analysis of nasal epithelial samples demonstrated that treatment with the combination of SCIT/tezepelumab, but neither monotherapy, caused persistent downregulation of a gene network related to type 2 inflammation that was associated with improvement in NAC responses. CONCLUSIONS Inhibition of TSLP augments the efficacy of SCIT during therapy and may promote tolerance after a 1-year course of treatment. (ClinicalTrials.gov NCT02237196).
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Affiliation(s)
- Jonathan Corren
- Departments of Medicine and Pediatrics, David Geffen School of Medicine, University of California, Los Angeles.
| | | | - Matthew C Altman
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle; Benaroya Research Institute, Seattle
| | - R Max Segnitz
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle
| | - Pedro C Avila
- Division of Allergy-Immunology, Feinberg School of Medicine, Chicago
| | | | - Fuad Baroody
- University of Chicago Medicine and Comer Children's Hospital, Chicago
| | - Mark H Moss
- Section of Allergy, Pulmonary and Critical Care, University of Wisconsin Hospital and Clinics, Madison
| | - Harold Nelson
- Department of Medicine, Division of Allergy and Clinical Immunology, National Jewish Health, Denver
| | - Allison J Burbank
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - David Peden
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Sarbjit Saini
- Division of Allergy & Clinical Immunology, Johns Hopkins University, Baltimore
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25
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Abstract
PURPOSE OF REVIEW Intralymphatic immunotherapy (ILIT) is a promising novel method of immunotherapy, that is short and convenient, and may be very effective. Results have been varied, and efforts to unravel the real value of the treatment are ongoing. Methods used to assess the effect in clinical trials have been so varied that it is difficult to compare studies with each other. RECENT FINDINGS Some advances have been made; the importance of injecting into the lymph node has been illustrated, and treatment with a range of medicines has proven to be successful. In meta-analyses the treatment has been shown to have no serious side effects and to be an effective short term desensitizing agent. Now it remains to be shown that ILIT also has long-term effects of tolerance. Preliminary data suggest that there is a long-term effect. SUMMARY Injecting allergen directly into a lymph node strengthens the protective immune response. ILIT is safe and induces desensitization and very likely also induces tolerance. Compliance will improve compared with other treatment forms. If ILIT holds its promise, it will become an attractive option for patients with allergy.
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Rahman RS, Wesemann DR. Immunology of allergen immunotherapy. IMMUNOTHERAPY ADVANCES 2022; 2:ltac022. [PMID: 36530352 PMCID: PMC9749131 DOI: 10.1093/immadv/ltac022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/24/2022] [Indexed: 10/17/2023] Open
Abstract
Allergen immunotherapy (AIT) is the only disease-modifying therapy for allergic disease. Through repeated inoculations of low doses of allergen-either as whole proteins or peptides-patients can achieve a homeostatic balance between inflammatory effectors induced and/or associated with allergen contact, and mediators of immunologic non-responsiveness, potentially leading to sustained clinical improvements. AIT for airborne/respiratory tract allergens and insect venoms have traditionally been supplied subcutaneously, but other routes and modalities of administration can also be effective. Despite differences of allergen administration, there are some similarities of immunologic responses across platforms, with a general theme involving the restructuring and polarization of adaptive and innate immune effector cells. Here we review the immunology of AIT across various delivery platforms, including subcutaneous, sublingual, epicutaneous, intradermal, and intralymphatic approaches, emphasizing shared mechanisms associated with achieving immunologic non-responsiveness to allergen.
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Affiliation(s)
| | - Duane R Wesemann
- Department of Medicine, Division of Allergy and Clinical Immunology, Division of Genetics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Ragon Institute of MGH, MIT, and Harvard, Boston, MA, USA
- Broad Institute of MIT and Harvard, Boston, MA, USA
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Tan TJ, Delgado-Dolset MI, Escribese MM, Barber D, Layhadi JA, Shamji MH. Biomarkers of AIT: Models of prediction of efficacy. Allergol Select 2022; 6:267-275. [PMID: 36457722 PMCID: PMC9707369 DOI: 10.5414/alx02333e] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 09/20/2022] [Indexed: 08/24/2023] Open
Abstract
Allergic rhinitis is an IgE-mediated inflammation that remains a clinical challenge, affecting 40% of the UK population with a wide range of severity from nasal discomfort to life-threatening anaphylaxis. It can be managed by pharmacotherapeutics and in selected patients by allergen immunotherapy (AIT), which provides long-term clinical efficacy, especially during peak allergy season. However, there are no definitive biomarkers for AIT efficacy. Here, we aim to summarize the key adaptive, innate, humoral, and metabolic advances in biomarker identification in response to AIT. Mechanisms of efficacy consist of an immune deviation towards TH1-secreting IFN-γ, as well as an induction of IL10+ cTFR and TREG have been observed. TH2 cells undergo exhaustion after AIT due to chronic allergen exposure and correlates with the exhaustion markers PD-1, CTLA-4, TIGIT, and LAG3. IL10+ DCREG expressing C1Q and STAB are induced. KLRG1+ IL10+ ILC2 were shown to be induced in AIT in correlation with efficacy. BREG cells secreting IL-10, IL-35, and TGF-β are induced. Blocking antibodies IgG, IgA, and IgG4 are increased during AIT; whereas inflammatory metabolites, such as eicosanoids, are reduced. There are multiple promising biomarkers for AIT currently being evaluated. A panomic approach is essential to better understand cellular, molecular mechanisms and their correlation with clinical outcomes. Identification of predictive biomarkers of AIT efficacy will hugely impact current practice allowing physicians to select eligible patients that are likely to respond to treatment as well as improve patients' compliance to complete the course of treatment.
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Affiliation(s)
- Tiak Ju Tan
- Immunomodulation and Tolerance Group, Department of National Heart and Lung Institute, Imperial College London, London, UK, and
| | - María I. Delgado-Dolset
- Immunomodulation and Tolerance Group, Department of National Heart and Lung Institute, Imperial College London, London, UK, and
- Institute of Applied Molecular Medicine (IMMA), Department of Basic Medical Sciences, Facultad de Medicina, Universidad San Pablo-CEU, CEU Universities, Urbanización Montepríncipe, Boadilla del Monte, Madrid, Spain
| | - María M. Escribese
- Institute of Applied Molecular Medicine (IMMA), Department of Basic Medical Sciences, Facultad de Medicina, Universidad San Pablo-CEU, CEU Universities, Urbanización Montepríncipe, Boadilla del Monte, Madrid, Spain
| | - Domingo Barber
- Institute of Applied Molecular Medicine (IMMA), Department of Basic Medical Sciences, Facultad de Medicina, Universidad San Pablo-CEU, CEU Universities, Urbanización Montepríncipe, Boadilla del Monte, Madrid, Spain
| | - Janice A. Layhadi
- Immunomodulation and Tolerance Group, Department of National Heart and Lung Institute, Imperial College London, London, UK, and
| | - Mohamed H. Shamji
- Immunomodulation and Tolerance Group, Department of National Heart and Lung Institute, Imperial College London, London, UK, and
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28
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Matsuda M, Shimizu S, Kitatani K, Nabe T. Extracellular Vesicles Derived from Allergen Immunotherapy-Treated Mice Suppressed IL-5 Production from Group 2 Innate Lymphoid Cells. Pathogens 2022; 11:1373. [PMID: 36422624 PMCID: PMC9693437 DOI: 10.3390/pathogens11111373] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 07/28/2024] Open
Abstract
Allergen immunotherapy (AIT), such as subcutaneous immunotherapy (SCIT), is a treatment targeting the causes of allergic diseases. The roles of extracellular vesicles (EVs), bilayer lipid membrane blebs released from all types of cells, in AIT have not been clarified. To examine the roles of EVs in SCIT, it was analyzed whether (1) EVs are phenotypically changed by treatment with SCIT, and (2) EVs derived from SCIT treatment suppress the function of group 2 innate lymphoid cells (ILC2s), which are major cells contributing to type 2 allergic inflammation. As a result, (1) expression of CD9, a canonical EV marker, was highly up-regulated by SCIT in a murine model of asthma; and (2) IL-5 production from ILC2s in vitro was significantly decreased by the addition of serum EVs derived from SCIT-treated but not non-SCIT-treated mice. In conclusion, it was indicated that EVs were transformed by SCIT, changing to a suppressive phenotype of type 2 allergic inflammation.
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Affiliation(s)
| | | | | | - Takeshi Nabe
- Laboratory of Immunopharmacology, Faculty of Pharmaceutical Sciences, Setsunan University, 45-1 Nagaotoge cho, Hirakata 573-0101, Japan
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29
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Abstract
Allergen immunotherapy is a form of therapeutic vaccination for established IgE-mediated hypersensitivity to common allergen sources such as pollens, house dust mites and the venom of stinging insects. The classical protocol, introduced in 1911, involves repeated subcutaneous injection of increasing amounts of allergen extract, followed by maintenance injections over a period of 3 years, achieving a form of allergen-specific tolerance that provides clinical benefit for years after its discontinuation. More recently, administration through the sublingual route has emerged as an effective, safe alternative. Oral immunotherapy for peanut allergy induces effective ‘desensitization’ but not long-term tolerance. Research and clinical trials over the past few decades have elucidated the mechanisms underlying immunotherapy-induced tolerance, involving a reduction of allergen-specific T helper 2 (TH2) cells, an induction of regulatory T and B cells, and production of IgG and IgA ‘blocking’ antibodies. To better harness these mechanisms, novel strategies are being explored to achieve safer, effective, more convenient regimens and more durable long-term tolerance; these include alternative routes for current immunotherapy approaches, novel adjuvants, use of recombinant allergens (including hypoallergenic variants) and combination of allergens with immune modifiers or monoclonal antibodies targeting the TH2 cell pathway. Durham and Shamji review the history and future of allergen immunotherapy for established IgE-mediated hypersensitivity to common allergens. They describe the mechanisms of immunotherapy-induced tolerance and the new strategies being explored to achieve safer, more effective, long-term tolerance.
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López JF, Bel Imam M, Satitsuksanoa P, Lems S, Yang M, Hwang YK, Losol P, Choi JP, Kim SH, Chang YS, Akdis M, Akdis CA, van de Veen W. Mechanisms and biomarkers of successful allergen-specific immunotherapy. Asia Pac Allergy 2022; 12:e45. [PMID: 36452016 PMCID: PMC9669467 DOI: 10.5415/apallergy.2022.12.e45] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 10/30/2022] [Indexed: 11/22/2023] Open
Abstract
Allergen-specific immunotherapy (AIT) is considered the only curative treatment for allergic diseases mediated by immunoglobulin E (IgE). Currently, the route of administration depends both on the different types of causal allergens and on its effectiveness and safety profile. Several studies have reported the mechanisms and changes in humoral and cellular response underlying AIT; however, the full picture remains unknown. Knowledge of who can benefit from this type of treatment is urgently needed due to the patient safety risks and costs of AIT. In vivo or in vitro biomarkers have become a strategy to predict clinical outcomes in precision medicine. There are currently no standardized biomarkers that allow determining successful responses to AIT, however, some studies have found differences between responders and nonresponders. In addition, different candidates have been postulated that may have the potential to become biomarkers. In this review, we aim to summarize the findings to date related to biomarkers in different IgE-mediated allergic diseases (respiratory, food, and venom allergy) with the potential to define who will benefit from AIT.
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Affiliation(s)
- Juan-Felipe López
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Manal Bel Imam
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | | | - Sophieke Lems
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Minglin Yang
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Yu-Kyoung Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Purevsuren Losol
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University, Seoul, Korea
| | - Jun-Pyo Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University, Seoul, Korea
| | - Yoon-Seok Chang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University, Seoul, Korea
| | - Mübeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Willem van de Veen
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
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31
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Bergmann KC, Raab J, Krause L, Becker S, Kugler S, Zuberbier T, Roth-Walter F, Jensen-Jarolim E, Kramer MF, Graessel A. Langfristiger Nutzen der gezielten Mikronährstoff-Supplementierung mit der holoBLG-Lutschtablette bei Hausstaubmilbenallergikern. ALLERGO JOURNAL 2022. [DOI: 10.1007/s15007-022-5078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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32
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Hesse L, Oude Elberink J, van Oosterhout AJ, Nawijn MC. Allergen immunotherapy for allergic airway diseases: Use lessons from the past to design a brighter future. Pharmacol Ther 2022; 237:108115. [DOI: 10.1016/j.pharmthera.2022.108115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 12/23/2021] [Accepted: 01/11/2022] [Indexed: 10/19/2022]
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Matsuda M, Terada T, Kitatani K, Kawata R, Nabe T. Roles of type 1 regulatory T (Tr1) cells in allergen-specific immunotherapy. FRONTIERS IN ALLERGY 2022; 3:981126. [PMID: 35991310 PMCID: PMC9381954 DOI: 10.3389/falgy.2022.981126] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/20/2022] [Indexed: 12/03/2022] Open
Abstract
Allergen-specific immunotherapy (AIT) is the only causative treatment for allergic diseases by modification of the immune response to allergens. A key feature of AIT is to induce immunotolerance to allergens by generating antigen-specific regulatory T (Treg) cells in allergic patients. Type 1 regulatory T (Tr1) cells and forkhead box protein 3 (Foxp3)-expressing Treg cells are well known among Treg cell subsets. Foxp3 was identified as a master transcription factor of Treg cells, and its expression is necessary for their suppressive activity. In contrast to Foxp3+ Treg cells, the master transcription factor of Tr1 cells has not been elucidated. Nevertheless, Tr1 cells are generally considered as a distinct subset of Treg cells induced in the periphery during antigen exposure in tolerogenic conditions and can produce large amounts of anti-inflammatory cytokines such as interleukin-10 and transforming growth factor-β, followed by down-regulation of the function of effector immune cells independently of Foxp3 expression. Since the discovery of Tr1 cells more than 20 years ago, research on Tr1 cells has expanded our understanding of the mechanism of AIT. Although the direct precursors and true identity of these cells continues to be disputed, we and others have demonstrated that Tr1 cells are induced in the periphery by AIT, and the induced cells are re-activated by antigens, followed by suppression of allergic symptoms. In this review, we discuss the immune mechanisms for the induction of Tr1 cells by AIT and the immune-suppressive roles of Tr1 cells in AIT.
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Affiliation(s)
- Masaya Matsuda
- Laboratory of Immunopharmacology, Faculty of Pharmaceutical Sciences, Setsunan University, Hirakata, Japan
| | - Tetsuya Terada
- Department of Otolaryngology, Head & Neck Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Kazuyuki Kitatani
- Laboratory of Immunopharmacology, Faculty of Pharmaceutical Sciences, Setsunan University, Hirakata, Japan
| | - Ryo Kawata
- Department of Otolaryngology, Head & Neck Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Takeshi Nabe
- Laboratory of Immunopharmacology, Faculty of Pharmaceutical Sciences, Setsunan University, Hirakata, Japan
- Correspondence: Takeshi Nabe
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34
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Penagos M, Durham SR. Long-term efficacy of the sublingual and subcutaneous routes in allergen immunotherapy. Allergy Asthma Proc 2022; 43:292-298. [PMID: 35818157 DOI: 10.2500/aap.2022.43.220026] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Allergen immunotherapy is highly effective in selected patients with allergic rhinitis, allergic asthma, and Hymenoptera venom allergy. Unlike anti-allergic drugs, both subcutaneous and sublingual immunotherapies have been shown to modify the underlying cause of the disease, with proved long-term clinical benefits after treatment cessation. In this review, we analyzed 10 randomized, double-blind, placebo controlled clinical trials of allergen immunotherapy that included blinded follow-up for at least 1 year after treatment withdrawal. Three studies of pollen subcutaneous immunotherapy provided evidence that a sustained, tolerogenic effect of subcutaneous immunotherapy can be achieved after 3 years of treatment. Six trials of sublingual immunotherapy provided robust evidence for long-term clinical benefit and persistent immunologic changes after grass pollen, house-dust mite, or Japanese cedar immunotherapy, whereas a clinical trial of both sublingual and subcutaneous grass pollen immunotherapies showed that 2 years of immunotherapy were efficacious but insufficient to induce long-term tolerance. These studies strongly supported international guidelines that recommend at least 3 years of allergen immunotherapy of proven value to achieve disease modification and sustained clinical and immunologic tolerance.
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35
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Creticos PS. Subcutaneous allergen immunotherapy in the treatment of allergic respiratory disease. Allergy Asthma Proc 2022; 43:260-266. [PMID: 35818144 DOI: 10.2500/aap.2022.43.220033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Subcutaneous immunotherapy is recognized as a cornerstone in the management of allergic respiratory disease in patients who are properly characterized with allergy and with allergic rhinoconjunctivis and/or well-controlled asthma, and who are willing to adhere to the rigorous treatment program. A key tenet is that it affords the opportunity to effect long-term clinical remission through its disease-modifying properties. Furthermore, it has the potential to prevent the progression of allergic rhinitis to asthma, prevent new allergen sensitivities, and improve a patient's quality of life.
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36
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Tan TJ, Layhadi JA, Shamji MH. Mechanisms and biomarkers of subcutaneous immunotherapy and sublingual immunotherapy in allergen immunotherapy. Allergy Asthma Proc 2022; 43:254-259. [PMID: 35818151 DOI: 10.2500/aap.2022.43.220030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There are currently no biomarkers that can accurately predict clinical outcomes and segregate responders from nonresponders in allergen immunotherapy (AIT). Therefore, identifying a reliable predictive biomarker is essential to enable clinicians to tailor personalized therapy. New developments in AIT biomarkers are currently being explored, and it would be important to identify key areas of development and their feasibility for use in the clinic. Biomarkers can be categorized broadly into seven domains: (i) Immunoglobulin E (IgE), (ii) IgG and IgA responses, (iii) IgE -facilitated allergen binding/blocking factor, (iv) basophil activation, (v) cytokines and chemokines, (vi) cellular markers, and (vii) in vivo biomarkers. Despite their potential, most biomarkers remain infeasible to be translated to the clinical setting due to requirements of complex instruments such as flow cytometry. The identification of suitable biomarkers remains key in predicting outcomes of AIT and requires more research. Additional exploration into integrative biomarkers may be required.
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37
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Abstract
Sublingual immunotherapy (SLIT)-tablets represent a new allergen immunotherapy option for clinicians. In North America, there are five SLIT-tablets approved for the treatment of allergic rhinoconjunctivitis (ARC). No SLIT-drops products are currently approved in the United States or Canada. This work reviewed the efficacy of the timothy grass SLIT-tablet, five-grass SLIT-tablet, ragweed SLIT-tablet, house-dust mite SLIT-tablet, and tree SLIT-tablet in patients with ARC. All the SLIT-tablets showed consistent clinical efficacy for the treatment of ARC in large, double-blind, placebo-controlled trials, including for both patients who were monosensitized and those who were polysensitized. Treatment with house-dust mite SLIT-tablet has shown efficacy in patients who are pollen sensitized during their respective pollen seasons. In contrast to SLIT-tablets, efficacy studies of SLIT-drops show high heterogeneity of treatment effect. Although data are scarce, data that compared the efficacy of SLIT-tablets versus ARC pharmacotherapy generally indicated that SLIT-tablets had a greater benefit than pharmacotherapy when compared with placebo, particularly for perennial ARC. When compared with subcutaneous immunotherapy, analysis of these data indicated that SLIT-tablets had a benefit over subcutaneous immunotherapy in regard to safety but somewhat less benefit in regard to efficacy. The safety of SLIT-tablets has been well documented, and a U.S. Food and Drug Administration class label with safety considerations is present in the prescribing information for all SLIT-tablets. No new safety signals have been observed after reinitiating SLIT-tablets after a short treatment interruption.
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Affiliation(s)
- Lawrence DuBuske
- From the Department of Internal Medicine, George Washington University Hospital, Washington, D.C.; and
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38
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Abstract
INTRODUCTION The numerous links between allergic rhinitis and asthma have been extensively explored in the last two decades, gaining great concern within the scientific community. These two conditions frequently coexist in the same patient and share numerous pathogenetic and pathophysiological mechanisms. AREAS COVERED We reviewed major pathophysiological, epidemiological, and clinical links between allergic rhinitis and asthma. We also provided a comprehensive discussion of allergic rhinitis treatment according to current guidelines, with a particular focus on the relevance of allergic rhinitis therapies in patients with comorbid asthma. EXPERT OPINION We believe that there are several unmet needs for our patients, however, there are promising advances forecasted for the future. Although allergic rhinitis is a recognized risk factor for asthma, a proper asthma detection and prevention plan in allergic rhinitis patients is not available. Allergen immunotherapy (AIT) represents a promising preventive strategy and may deserve an earlier positioning in allergic rhinitis management. A multidisciplinary approach should characterize the journey of patients with respiratory allergies, with an adequate referral to specialized Allergy/Asthma centers. Molecular Allergy Diagnosis may provide support for optimal AIT use. Finally, a possible evolution of biological treatment can be envisaged, mainly if biosimilars decrease such therapies' costs.
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Tang X, Rabin RL, Yan LK. A three-stage design for allergen immunotherapy trials. Allergy 2022; 77:1835-1842. [PMID: 34599605 DOI: 10.1111/all.15117] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 05/17/2021] [Accepted: 09/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical trials of allergen immunotherapy (AIT) may require up to 5 years to complete. These lengthy trials may be complicated by high and potentially differential dropouts, especially among participants who perceive that they are receiving placebo. We propose a three-stage design in which the placebo group in Stage 1 crosses over to receive active treatment in Stage 2. In Stage 3, AIT is discontinued to determine whether benefit is maintained post-treatment. We apply inferential statistics to support the three-stage design for clinical trials to determine clinical efficacy, treatment response over time, and sustained response to AIT. METHODS The proposed framework constitutes a series of hypothesis tests for comparing treatment responses at the end of each stage. A simulation study was performed to illustrate the statistical properties under varying statistical missing mechanisms and effect sizes. RESULTS The statistical properties in terms of bias and statistical power were consistent with what are expected from conventional analyses. Specifically, the extent of bias depended on the missing mechanism and magnitude. The statistical powers were largely driven by effect and sample sizes as well as prespecified success margins. As an illustration, assuming relative treatment differences of 25% and stagewise dropout rate of 15%, a sample size of 200 per group may achieve 93% power to demonstrate a treatment effect and 60% power to demonstrate a maintained response post-treatment. CONCLUSIONS Inferential statistics support our proposed study design for evaluating benefits of AIT over time and inform clinical understanding and decisions.
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Affiliation(s)
- Xinyu Tang
- Office of Biostatistics and Epidemiology Center for Biologics Evaluation and Research (CBER) U.S. Food and Drug Administration (FDA) Silver Spring Maryland USA
| | - Ronald L. Rabin
- Office of Vaccines Research and Review CBER FDA Silver Spring Maryland USA
| | - Lihan K. Yan
- Office of Biostatistics and Epidemiology Center for Biologics Evaluation and Research (CBER) U.S. Food and Drug Administration (FDA) Silver Spring Maryland USA
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40
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Yadav S, Singh S, Mandal P, Tripathi A. Immunotherapies in the treatment of immunoglobulin E‑mediated allergy: Challenges and scope for innovation (Review). Int J Mol Med 2022; 50:95. [PMID: 35616144 DOI: 10.3892/ijmm.2022.5151] [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: 12/24/2021] [Accepted: 02/28/2022] [Indexed: 11/05/2022] Open
Abstract
Immunoglobulin E (IgE)‑mediated allergy or hypersensitivity reactions are generally defined as an unwanted severe symptomatic immunological reaction that occurs due to shattered or untrained peripheral tolerance of the immune system. Allergen‑specific immunotherapy (AIT) is the only therapeutic strategy that can provide a longer‑lasting symptomatic and clinical break from medications in IgE‑mediated allergy. Immunotherapies against allergic diseases comprise a successive increasing dose of allergen, which helps in developing the immune tolerance against the allergen. AITs exerttheirspecial effectiveness directly or indirectly by modulating the regulator and effector components of the immune system. The number of success stories of AIT is still limited and it canoccasionallyhave a severe treatment‑associated adverse effect on patients. Therefore, the formulation used for AIT should be appropriate and effective. The present review describes the chronological evolution of AIT, and provides a comparative account of the merits and demerits of different AITs by keeping in focus the critical guiding factors, such as sustained allergen tolerance, duration of AIT, probability of mild to severe allergic reactions and dose of allergen required to effectuate an effective AIT. The mechanisms by which regulatory T cells suppress allergen‑specific effector T cells and how loss of natural tolerance against innocuous proteins induces allergy are reviewed. The present review highlights the major AIT bottlenecks and the importantregulatory requirements for standardized AIT formulations. Furthermore, the present reviewcalls attention to the problem of 'polyallergy', which is still a major challenge for AIT and the emerging concept of 'component‑resolved diagnosis' (CRD) to address the issue. Finally, a prospective strategy for upgrading CRD to the next dimension is provided, and a potential technology for delivering thoroughly standardized AIT with minimal risk is discussed.
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Affiliation(s)
- Sarika Yadav
- Systems Toxicology and Health Risk Assessment Group, CSIR‑Indian Institute of Toxicology Research, Lucknow, Uttar Pradesh 226001, India
| | - Saurabh Singh
- Systems Toxicology and Health Risk Assessment Group, CSIR‑Indian Institute of Toxicology Research, Lucknow, Uttar Pradesh 226001, India
| | - Payal Mandal
- Food, Drugs and Chemical Toxicology Group, CSIR‑Indian Institute of Toxicology Research, Lucknow, Uttar Pradesh 226001, India
| | - Anurag Tripathi
- Systems Toxicology and Health Risk Assessment Group, CSIR‑Indian Institute of Toxicology Research, Lucknow, Uttar Pradesh 226001, India
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41
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Hsiao KC, Ponsonby AL, Ashley S, Lee CYY, Jindal L, Tang MLK. Longitudinal antibody responses to peanut following probiotic and peanut oral immunotherapy (PPOIT) in children with peanut allergy. Clin Exp Allergy 2022; 52:735-746. [PMID: 35403286 DOI: 10.1111/cea.14146] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 04/02/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Probiotic and Peanut Oral Immunotherapy (PPOIT) is effective at inducing sustained unresponsiveness (SU) at end-of-treatment and this effect persists up to four years post-treatment, referred to as persistent SU. We sought to evaluate (i) how PPOIT altered peanut-specific humoral immune indices, and (ii) how such longitudinal indices relate to persistent SU. METHODS Longitudinal serum/plasma levels of whole peanut- and peanut component- (Ara-h1, -h2, -h3, -h8, -h9) specific-IgE (sIgE) and specific-IgG4 (sIgG4) antibodies were measured by ImmunoCAP and salivary peanut-specific-IgA (sIgA) by ELISA in children (n=62) enrolled in the PPOIT-001 randomised trial from baseline (T0) to 4-years post-treatment (T5). Multivariate regression analyses of log-transformed values were used for point-in-time between group comparisons. Generalised estimating equations (GEE) were used for longitudinal comparisons between groups. RESULTS PPOIT was associated with changes in sIgE and sIgG4 over time. sIgE levels were significantly reduced post-treatment [T5, PPOIT v.s. Placebo ratio of geometric mean (GM): Ara-h1 0.07, p=0.008; Ara-h2 0.08, p=0.007; Ara-h3 0.15, p=0.021]. sIgG4 levels were significantly increased by end-of-treatment (T1, PPOIT v.s. Placebo ratio of GM: Ara-h1 3.77, p=0.011; Ara-h2 17.97, p<0.001; Ara-h3 10.42, p<0.001) but levels in PPOIT group decreased once treatment was stopped and returned to levels comparable with Placebo group by T5. Similarly, salivary peanut sIgA increased during treatment, as early as 4 months of treatment (PPOIT v.s. Placebo, ratio of GM: 2.04, p=0.014), then reduced post-treatment. CONCLUSION PPOIT was associated with broad reduction in peanut specific humoral responses which may mediate the clinical effects of SU that persists to 4-years post-treatment.
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Affiliation(s)
- Kuang-Chih Hsiao
- Department of Immunology, Starship Children's Hospital, Auckland, New Zealand
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
- Allergy Immunology Research, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Anne-Louise Ponsonby
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Sarah Ashley
- Allergy Immunology Research, Murdoch Childrens Research Institute, Melbourne, Australia
| | | | | | - Mimi L K Tang
- Allergy Immunology Research, Murdoch Childrens Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
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Bioinformatic Analysis and Cellular Assays Identify Substance P Influencing Th17/Treg Differentiation via the MyD88 Pathway as a Potential Contributor to the Progression of Asthma and Allergic Rhinitis. DISEASE MARKERS 2022; 2022:3843954. [PMID: 35190755 PMCID: PMC8858040 DOI: 10.1155/2022/3843954] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/24/2021] [Accepted: 12/31/2021] [Indexed: 12/22/2022]
Abstract
Objective This study is aimed at investigating the role of substance P (SP) in the development of asthma. Methods The Gene Expression Omnibus (GEO) database was used to characterize SP expression in allergic rhinitis (AR) and asthma. Peripheral blood was collected from patients with asthma or AR. The expression of relevant cytokines and neuropeptides was measured. Enzyme-linked immunosorbent assay (ELISA) was also performed. The mast cell line LAD2 and the lung bronchial epithelial cell line BEAS-2B were treated with different concentrations of SP concentration. Then, the qRT-PCR method was used to determine the mRNA expression. Furthermore, p38 and p65 and their associated phosphorylated proteins (p-p38 and p-p65) were further validated by western blotting. Result Clinical and GSE75011 data analysis suggested that MyD88 expression was upregulated in AR and asthma. Through the gene set variation analysis (GSVA), MyD88-related pathways were noticed and further investigated. ELISA results suggested that the SP expression was significantly increased in AR and asthma and IL-10 expression was decreased, whereas the expression of IL-6, IL-17A, IL-23, and TGF-β expressions increased. The mast cell line LAD2 was treated with different SP concentrations, and ELISA results showed that the expression of IL-6, IL-17A, IL-23, and TGF-β in the cell supernatant gradually increased with increasing SP concentrations, whereas that of IL-10 decreased. The lung bronchial epithelial cell line BEAS-2B was treated with different SP concentrations, and the expression of myeloid differentiation factor 88 (MyD88) and its related proteins was elevated. The expression of p38 and p-p38 proteins was elevated after SP treatment, and their expression levels elevated as SP concentrations increased. Finally, MyD88 expression at the single-cell level was also demonstrated. Conclusion SP may affect the cytokine expression through the MyD88 pathway, thereby influencing Th17/Treg differentiation and eventually participating in the pathological process of asthma and AR. There are many pathological similarities between allergic rhinitis (AR) and bronchial asthma. In the present study, SP was found to possibly activate downstream inflammatory signaling pathways via MyD88, thereby affecting Th17/Treg differentiation and ultimately participating in the pathological process of asthma and AR.
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Ezhuthachan ID, Banks TA, Cerise JE, Wong SC, Ponda P. Allergen Immunotherapy Extract Shortages and Their Effects on Clinical Care: A Work Group Report of the AAAAI Immunotherapy, Allergen Standardization, and Allergy Diagnostics Committee. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:444-452. [PMID: 34840110 DOI: 10.1016/j.jaip.2021.10.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/10/2021] [Accepted: 10/13/2021] [Indexed: 06/13/2023]
Abstract
Allergen immunotherapy (AIT) is the only disease-modifying therapy indicated for treatment of allergic asthma, rhinitis, conjunctivitis, and Hymenoptera hypersensitivity. Manufacturing of the extracts used in AIT involve multistep complex processes as well as regulatory oversight. Furthermore, some source materials are vulnerable to unexpected events of nature. Given these circumstances, allergen extract supply can be disrupted with a potential to adversely impact patient care. A group of members from the American Academy of Allergy, Asthma, and Immunology (AAAAI) Immunotherapy, Allergy Standardization and Allergy Diagnostic Committee formed a workgroup to assess the frequency and effects of allergen extract shortages and associated factors. This workgroup developed a survey that was distributed to a random 20% of the AAAAI membership. In addition, the group also performed a review of the scientific literature on allergen extract supply and shortage. Based on the findings of the survey study and literature review, the workgroup reports frequency and extent of shortages, potential ways to improve communication with suppliers, and need for further guidance in patient care during times of shortage.
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Affiliation(s)
- Idil Daloglu Ezhuthachan
- Division of Allergy and Immunology, Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY.
| | - Taylor A Banks
- Allergy/Immunology Division, Naval Medical Center Portsmouth, Portsmouth, Va
| | - Jane E Cerise
- Biostatistics Unit, Feinstein Institute for Medical Research, Manhasset, NY
| | - Stephen C Wong
- Allergy/Immunology Division, Carl R. Darnall Army Medical Center, Fort Hood, Tex
| | - Punita Ponda
- Division of Allergy and Immunology, Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
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Pfaar O, Bousquet J, Durham SR, Kleine‐Tebbe J, Larché M, Roberts G, Shamji MH, Gerth van Wijk R. One hundred and ten years of Allergen Immunotherapy: A journey from empiric observation to evidence. Allergy 2022; 77:454-468. [PMID: 34315190 DOI: 10.1111/all.15023] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/24/2021] [Indexed: 12/12/2022]
Abstract
One hundred and ten years after Noon's first clinical report of the subcutaneous application of allergen extracts, allergen immunotherapy (AIT) has evolved as the most important pillar of the treatment of allergic patients. It is the only disease-modifying treatment option available and the evidence for its clinical efficacy and safety is broad and undisputed. Throughout recent decades, more insights into the underlying mechanisms, in particular the modulation of innate and adaptive immune responses, have been described. AIT is acknowledged by worldwide regulatory authorities, and following the regulatory guidelines for product development, AIT products are subject to a rigorous evaluation before obtaining market authorization. Knowledge and practice are anchored in international guidelines, such as the recently published series of the European Academy of Allergy and Clinical Immunology (EAACI). Innovative approaches continue to be further developed with the focus on clinical improvement by, for example, the usage of adjuvants, peptides, recombinants, modification of allergens, new routes of administration, and the concomitant use of biologicals. In addition, real-life data provide complementary and valuable information on the effectiveness and tolerability of this treatment option in the clinical routine. New mobile health technologies and big-data approaches will improve daily treatment convenience, adherence, and efficacy of AIT. However, the current coronavirus disease 2019 (COVID-19) pandemic has also had some implications for the feasibility and practicability of AIT. Taken together, AIT as the only disease-modifying therapy in allergic diseases has been broadly investigated over the past 110 years laying the path for innovations and further improvement.
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Affiliation(s)
- Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital Marburg, Philipps‐Universität Marburg Marburg Germany
| | - Jean Bousquet
- Department of Dermatology and Allergy Charité, Universitätsmedizin Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health, Comprehensive Allergy Center Berlin Germany
- University Hospital Montpellier Montpellier France
| | - Stephen R. Durham
- Allergy and Clinical Immunology Asthma UK Centre in Allergic Mechanisms of Asthma Imperial College NIHR Biomedical Research Centre, National Heart and Lung Institute London UK
| | - Jörg Kleine‐Tebbe
- Allergy & Asthma Center Westend, Outpatient and Clinical Research Center Berlin Germany
| | - Mark Larché
- Department of Medicine McMaster University Hamilton ON Canada
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare Hamilton ON Canada
| | - Graham Roberts
- Faculty of Medicine University of Southampton Southampton UK
- The David Hide Asthma and Allergy Research Centre St Mary's Hospital Isle of Wight UK
- NIHR Southampton Biomedical Research Centre University Hospital Southampton NHS Foundation Trust Southampton UK
| | - Mohamed H. Shamji
- Allergy and Clinical Immunology Asthma UK Centre in Allergic Mechanisms of Asthma Imperial College NIHR Biomedical Research Centre, National Heart and Lung Institute London UK
| | - Roy Gerth van Wijk
- Section of Allergology and Clinical Immunology Department of Internal Medicine Erasmus Medical Center Rotterdam The Netherlands
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Kim SM, Kim JA, Kim HS, Yoon JS, Kim HH, Chun YH. Development of a house dust mite-induced mouse model for allergen-specific immunotherapy in allergic rhinitis. ALLERGY ASTHMA & RESPIRATORY DISEASE 2022. [DOI: 10.4168/aard.2022.10.4.195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Seok Min Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji An Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hwan Soo Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Seo Yoon
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Hee Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoon Hong Chun
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Penagos M, Durham SR. Allergen immunotherapy for long-term tolerance and prevention. J Allergy Clin Immunol 2022; 149:802-811. [DOI: 10.1016/j.jaci.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/12/2022] [Accepted: 01/14/2022] [Indexed: 10/19/2022]
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Shamji MH, Sharif H, Layhadi JA, Zhu R, Kishore U, Renz H. Diverse Immune Mechanisms of Allergen Immunotherapy for allergic rhinitis with and without asthma. J Allergy Clin Immunol 2022; 149:791-801. [DOI: 10.1016/j.jaci.2022.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/21/2022] [Accepted: 01/21/2022] [Indexed: 10/19/2022]
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Choi BY, Han M, Kwak JW, Kim TH. Genetics and Epigenetics in Allergic Rhinitis. Genes (Basel) 2021; 12:2004. [PMID: 34946955 PMCID: PMC8700872 DOI: 10.3390/genes12122004] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
The pathogenesis of allergic rhinitis is associated with genetic, environmental, and epigenetic factors. Genotyping of single nucleotide polymorphisms (SNPs) is an advanced technique in the field of molecular genetics that is closely correlated with genome-wide association studies (GWASs) in large population groups with allergic diseases. Many recent studies have paid attention to the role of epigenetics, including alteration of DNA methylation, histone acetylation, and miRNA levels in the pathogenesis of allergic rhinitis. In this review article, genetics and epigenetics of allergic rhinitis, including information regarding functions and significance of previously known and newly-discovered genes, are summarized. Directions for future genetic and epigenetic studies of allergic rhinitis are also proposed.
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Affiliation(s)
| | | | | | - Tae Hoon Kim
- Department of Otorhinolaryngology-Head & Neck Surgery, College of Medicine, Korea University, Seoul 02841, Korea; (B.Y.C.); (M.H.); (J.W.K.)
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Dramburg S, Perna S, Di Fraia M, Tripodi S, Arasi S, Castelli S, Villalta D, Buzzulini F, Sfika I, Villella V, Potapova E, Brighetti MA, Travaglini A, Verardo PL, Pelosi S, Matricardi PM. Heterogeneous validity of daily data on symptoms of seasonal allergic rhinitis recorded by patients using the e-diary AllergyMonitor®. Clin Transl Allergy 2021; 11:e12084. [PMID: 34950450 PMCID: PMC8674539 DOI: 10.1002/clt2.12084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patient-generated symptom and medication scores are essential for diagnostic and therapeutic decisions in seasonal allergic rhinitis (SAR). Previous studies have shown solid consistencies between different scores at population level in real-life data and trials. For clinicians, the evaluation of individual data quality over time is essential to decide whether to rely on these data in clinical decision-making. OBJECTIVE To analyze the consistency of different symptom (SS) and symptom medication scores (SMSs) at individual level in two study cohorts with different characteristics and explore individual patient trajectories over time. METHODS Within the pilot phase of the @IT.2020 project on diagnostic synergy of mobile health and molecular IgE assessment in patients with SAR, we analyzed data of 101 children and 93 adults with SAR and instructed them to record their symptoms and medication intake daily via the mobile app AllergyMonitor®. We then assessed the correlation between different SMS and a visual analogue scale (VAS) on the impact of allergy symptoms on daily life at population and individual level. RESULTS At population level, the Rhinoconjunctivitis total symptom score (RTSS) correlated better with VAS than the combined symptom and medication score (CSMS). At individual level, consistency among RTSS and VAS was highly heterogeneous and unrelated to disease severity or adherence to recording. Similar heterogeneity was observed for CSMS and VAS. CONCLUSIONS The correlation of clinical information provided by different disease severity scores based on data collected via electronic diaries (e-diaries), is sufficient at population level, but broadly heterogeneous for individual patients. Consistency of the recorded data must be examined for each patient before remotely collected information is used for clinical decision making.
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Affiliation(s)
- Stephanie Dramburg
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care MedicineCharité‐Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Serena Perna
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care MedicineCharité‐Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Marco Di Fraia
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care MedicineCharité‐Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Salvatore Tripodi
- Pediatric Allergology UnitSandro Pertini HospitalRomeItaly
- Allergology ServicePoliclinico CasilinoRomeItaly
| | - Stefania Arasi
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care MedicineCharité‐Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Translational Research in Pediatric Specialities AreaDivision of AllergyBambino Gesù Children's HospitalIRCCSRomeItaly
- Pediatric Allergology UnitDepartment of Pediatric MedicineBambino Gesù Children´s Research Hospital (IRCCS)RomeItaly
| | - Sveva Castelli
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care MedicineCharité‐Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Danilo Villalta
- Department of Immunology‐Allergy“S.Maria degli Angeli” HospitalPordenoneItaly
| | - Francesca Buzzulini
- Department of Immunology‐Allergy“S.Maria degli Angeli” HospitalPordenoneItaly
| | - Ifigenia Sfika
- Pediatric Allergology UnitSandro Pertini HospitalRomeItaly
| | | | - Ekaterina Potapova
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care MedicineCharité‐Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | | | | | | | | | - Paolo Maria Matricardi
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care MedicineCharité‐Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
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Shamji MH, Valenta R, Jardetzky T, Verhasselt V, Durham SR, Würtzen PA, van Neerven RJ. The role of allergen-specific IgE, IgG and IgA in allergic disease. Allergy 2021; 76:3627-3641. [PMID: 33999439 PMCID: PMC8601105 DOI: 10.1111/all.14908] [Citation(s) in RCA: 110] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/03/2021] [Accepted: 05/10/2021] [Indexed: 12/28/2022]
Abstract
Immunoglobulin E (IgE)‐mediated allergy is the most common hypersensitivity disease affecting more than 30% of the population. Exposure to even minute quantities of allergens can lead to the production of IgE antibodies in atopic individuals. This is termed allergic sensitization, which occurs mainly in early childhood. Allergen‐specific IgE then binds to the high (FcεRI) and low‐affinity receptors (FcεRII, also called CD23) for IgE on effector cells and antigen‐presenting cells. Subsequent and repeated allergen exposure increases allergen‐specific IgE levels and, by receptor cross‐linking, triggers immediate release of inflammatory mediators from mast cells and basophils whereas IgE‐facilitated allergen presentation perpetuates T cell–mediated allergic inflammation. Due to engagement of receptors which are highly selective for IgE, even tiny amounts of allergens can induce massive inflammation. Naturally occurring allergen‐specific IgG and IgA antibodies usually recognize different epitopes on allergens compared with IgE and do not efficiently interfere with allergen‐induced inflammation. However, IgG and IgA antibodies to these important IgE epitopes can be induced by allergen‐specific immunotherapy or by passive immunization. These will lead to competition with IgE for binding with the allergen and prevent allergic responses. Similarly, anti‐IgE treatment does the same by preventing IgE from binding to its receptor on mast cells and basophils. Here, we review the complex interplay of allergen‐specific IgE, IgG and IgA and the corresponding cell receptors in allergic diseases and its relevance for diagnosis, treatment and prevention of allergy.
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Affiliation(s)
| | - Rudolf Valenta
- Department of Pathophysiology and Allergy Research Medical University of Vienna Vienna Austria
- Laboratory of Immunopathology Department of Clinical Immunology and Allergology Sechenov First Moscow State Medical University Moscow Russia
- NRC Institute of Immunology FMBA of Russia Moscow Russia
- Karl Landsteiner University of Health Sciences Krems Austria
| | | | - Valerie Verhasselt
- School of Molecular Sciences University of Western Australia Perth WA Australia
| | | | | | - R.J. Joost van Neerven
- Wageningen University & Research Wageningen The Netherlands
- FrieslandCampina Amersfoort The Netherlands
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