Factors affecting time required to reach maintenance dose during subcutaneous immunotherapy

Compliance With Subcutaneous Immunotherapy Appointments in an Urban Tertiary Care Setting

INTRODUCTION

Subcutaneous immunotherapy (SCIT) is an effective treatment for allergic disease such as allergic rhinitis and asthma. Reported adherence rates to SCIT have been low, ranging between 50% and 89%. This study sought to evaluate compliance to SCIT in an urban "safety net," tertiary care center, and to evaluate for disparities in compliance based upon insurance and socioeconomic status.

METHODS

A retrospective chart review of SCIT patients between 2003 and 2016 was performed. Demographic data, insurance carriers, and comorbidities were collected. Compliance was evaluated on treatment adherence (percentage of injections administered/scheduled appointments). Statistical analysis was performed using R statistical software. Linear regression analysis was performed to compare compliance to the variables, asthma, duration of therapy, payor, and age. Analysis of variance was used to compare mean compliance between payor groups.

RESULTS

Two hundred five patients met our inclusion criteria and 28 were excluded. Insurance composition was Medicaid (67, 33%), Medicare (18, 9%), Health Safety Net (HSN) in Massachusetts (33, 16%), and commercial payors (82, 42%). Linear regression demonstrated that age, duration of therapy, and asthma status were not related to the percentage of missed doses ( P > .05). Payor status was statistically predictive of missed doses ( P = .02). When comparing average percentage of missed immunotherapy shots, Medicaid patients missed the most 34.2%, followed by Medicare 24.4%, commercial insurance 19.9%, and HSN in Massachusetts 18.5% ( P ≤ .02).

CONCLUSION

In a cohort of patients at a tertiary care "safety-net" center serving a low-income population, compliance to SCIT was found to be overall high but lower in the Medicaid population.

Administration and Burden of Subcutaneous Immunotherapy for Allergic Rhinitis in U.S. and Canadian Clinical Practice

BACKGROUND

Allergy immunotherapy (AIT) is the only available treatment that alters the natural course of allergies and has possible disease-modifying effects. AIT is administered primarily via subcutaneous injection delivered in a physician's office. Few studies have been conducted in the United States or Canada to evaluate the costs of subcutaneous immunotherapy (SCIT).

OBJECTIVES

To (a) describe SCIT administration processes, resources, and costs and (b) characterize the patient population receiving SCIT.

METHODS

A multisite, prospective, observational time and motion study was conducted. Injection and wait times were collected by a third-party observer on 1 visit for each patient. Extract preparation processes were also observed. Site staff reported on treatment protocols, administrative time, supplies, and patient medical history. Patients responded to questionnaires on demographics, reasons for treatment, medication use, productivity, and travel time. Costs were estimated by applying unit costs to the time observations and the patient- and staff-reported data.

RESULTS

A total of 670 SCIT patients were enrolled at 6 sites in the United States and 6 sites in Canada. Average age in the United States was 41 years (SD = 18) and 44 years (15) in Canada, with 10% of the patients aged ≥ 65 years. Annual incomes were over $100,000 for 40% of U.S. patients and 30% of Canadian patients. U.S. patients had over 4 times as many different allergens in their SCIT treatments as Canadian patients, with a mean of 18 versus 4. The most common reasons reported for starting SCIT was a "desire to cure allergies once and for all" (73%) and that "symptoms are not improved by allergy medications" (60%). Percentages of patients taking allergy medications in the 4 weeks prior to observation were 86% in the United States and 66% in Canada: antihistamines 75% United States, 54% Canada; inhaled corticosteroids 32% United States, 22% Canada. The predominant comorbidity was asthma, 43% United States, 24% Canada. Site protocols for build-up treatment phases were 1 to 2 injections per week for an average of 25 weeks (range 12-52). Maintenance phases were 1 injection every 3 to 4 weeks for an average of 4 years (range 2.5-5). Eight of the sites had total mean staff times per injection visit of 7 to 22 minutes; 1 site averaged fewer minutes, and 3 sites averaged more. Total direct medical costs were an average of $30 for Canadian patients per visit and $32 per visit for U.S. patients, half accounted for by the cost of the extract. Pre- and postinjection administrative tasks were the second largest driver of direct costs. Total injection visit-related time for patients, including round-trip travel time, averaged about 80 minutes per visit in the United States and in Canada.

CONCLUSIONS

Analyses revealed substantial variation in SCIT regimens among sites, but the sites had commonalities in the injection process components. SCIT requires patient commitment to a long-term treatment regimen involving numerous clinic visits and resources for administration.

Safety and tolerability of a short ragweed sublingual immunotherapy tablet

BACKGROUND

MK-3641 is a short ragweed sublingual tablet under investigation for immunotherapy of ragweed pollen-induced allergic rhinitis.

OBJECTIVE

To characterize the safety and tolerability of a ragweed sublingual tablet (Merck/ALK-Abelló) in ragweed-allergic adults with or without conjunctivitis.

METHODS

Data from 4 randomized, double-blinded, placebo-controlled trials of MK-3641 (2 28-day and 2 52-week trials) were evaluated. Pooled analyses examined short-term safety over 28 days from all 4 trials and long-term safety from the 52-week trials.

RESULTS

Across all studies, 757, 198, 454, and 1,058 subjects were randomized to placebo or 1.5, 6, or 12 Amb a 1-U of MK-3641, respectively. Treatment-related adverse events were more frequent in the 6- and 12-Amb a 1-U MK-3641 groups than in the placebo group and were primarily local application-site reactions occurring in the first few days of treatment. There was no treatment-associated loss of asthma control or worsening of asthma associated with treatment. No swellings led to airway obstruction or respiratory compromise. No treatment-related anaphylactic shock, life-threatening, or serious treatment-related adverse events were reported for any MK-3641 dose. Of the 1,707 MK-3641-treated subjects, 1 systemic (anaphylactic) reaction was reported (0.06%). The 52-week long-term assessment was generally similar to the safety profile based on the 28-day assessment.

CONCLUSION

MK-3641 doses up to and including 12 Amb a 1-U were well tolerated, with no unexpected safety findings. Sublingual immunotherapy risks such as worsening asthma or airway swellings that could cause airway obstruction were not observed. Systemic reactions and use of epinephrine were uncommon. In these studies, after the first dose was administered in a health care setting, self-administration was well tolerated.

TRIAL REGISTRATION

clinicaltrials.gov Identifiers: NCT01469182, NCT00783198, NCT00770315, and NCT00978029.

Efficacy and safety of grass sublingual immunotherapy tablet, MK-7243: a large randomized controlled trial

BACKGROUND

In North America, few studies have evaluated sublingual immunotherapy for allergic rhinitis with or without conjunctivitis (AR/C); pediatric data are sparse. The authors report findings from the largest published immunotherapy trial yet conducted in adults and children.

OBJECTIVE

To evaluate grass sublingual immunotherapy tablet (MK-7243) treatment in subjects with AR/C.

METHODS

North American subjects (5-65 years old) with grass allergy were randomized 1:1 to once-daily MK-7243 (2,800 BAU Phleum pratense) or placebo. The first dose was given at the investigator's office; subsequent doses were self-administered at home. The primary end point was total combined score (TCS; rhinoconjunctivitis daily symptom score [DSS] plus daily medication score [DMS]) over the entire grass pollen season (GPS). Key secondary end points included entire-season DSS, DMS, peak-season TCS, and rhinoconjunctivitis quality-of-life questionnaire scores. Safety outcomes included adverse events (AEs).

RESULTS

One thousand five hundred one subjects were randomized (85% polysensitized, 25% had asthma). MK-7243 yielded improvements vs placebo of 23% in entire-season TCS (median difference -0.98, P < .001), 29% in peak-season TCS (median difference -1.33, P < .001), 20% in entire-season DSS (median difference -0.64, P = .001), 35% in entire-season DMS (mean difference -0.48, P < .001), and 12% in peak-season rhinoconjunctivitis quality-of-life questionnaire (median difference -0.13, P = .027). Efficacy between children and adults was similar. Most AEs were transient local application-site reactions, with no serious treatment-related AEs or anaphylactic shock. Three subjects (1 placebo, 2 MK-7243) had moderate systemic allergic reactions.

CONCLUSION

MK-7243 was effective in polysensitized grass-allergic North American children and adults with AR/C in this large trial, confirming previous research.