The safety of self-administered allergen immunotherapy during the buildup and maintenance phases

Predictors of Completion of Sublingual Immunotherapy

OBJECTIVES

Sublingual immunotherapy (SLIT) has emerged as an effective treatment alternative to subcutaneous immunotherapy (SCIT) given its improved safety profile and more convenient dosing. However, SLIT still relies on daily dosing for many years to optimize effectiveness. This study sought to investigate factors that influence patient completion of SLIT.

METHODS

We performed an institutional retrospective review of patients who received SLIT (2008-2020). Completion was defined as completing at least 36 months of SLIT. Patient demographics and characteristics, including the number of allergens treated, history of asthma and sinus surgery, number of clinic visits, and total time undergoing SLIT, were documented. Multivariate models were used to analyze predictors of SLIT completion. Subgroup analysis was performed among pediatric patients and patients who discontinued SLIT.

RESULTS

Of the 404 total patients, 249 (61.6%) discontinued, 47 (11.6%) completed, and 108 (26.7%) were currently undergoing SLIT. The mean duration of therapy was 11.2 months for those who discontinued and 49.4 months for patients who completed SLIT. The odds of SLIT completion were twice as high with each additional clinic visit (P < .001), and twice as high when the dosage was increased during therapy (P = .06). Pediatric patients younger than age 12 with a history of asthma were over five times more likely to complete therapy (P = .045). Patients with more clinic visits (P < .001) and higher associated costs (P = .003) were less likely to be lost to follow-up.

CONCLUSION

Increasing the frequency of clinic visits, improving therapy availability, and mitigating concerns about clinical efficacy may increase patient completion of SLIT.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2111-E2115, 2021.

Decision-making for pediatric allergy immunotherapy for aeroallergens: a narrative review

There has been exciting progress in diagnosis and in the treatment of allergic patients. The objective of this review is to summarize the most relevant contributions in the past 10 years with a special focus on the pediatric population allergic to aeroallergens and provide the most relevant references and practical issues for the decision-making. Current guidelines on allergy diagnosis recommend a thorough clinical history as the first step, followed by allergen extract testing using an in vivo prick test and/or an in vitro specific IgE test. Molecular diagnosis is recommended when previous tests are inconclusive. In practice, the most important factors to decide the AIT treatment are the actual intensity and duration of the patient's symptoms and the availability of appropriate AIT products for the patient's sensitization profile at high allergen concentrations and with confirmed efficacy and safety from clinical trials. This document summarizes outstanding references for allergic immunotherapy decision-making and provides summary tables and figures analyzing the most important factors related to the decision for allergen immunotherapy and the safety risks related. The experts concluded that AIT is efficacious and safe for the treatment of allergic patients that is available for the most frequent aeroallergens.What is Known:• The prevalence of allergic asthma and rhinitis in children has increased in recent decades.• The efficacy and safety of allergen immunotherapy has been shown in multiple studies and systematic reviews.What is New:• This document summarizes outstanding references for allergic immunotherapy decision-making and provides summary tables and figures analyzing the most important factors related to the decision for allergen immunotherapy and the safety risks related. Recommendations of expert authors for the decision of the patients more suitable for allergen immunotherapy are included.

Contemporary analysis of otolaryngic allergy

OBJECTIVES

Investigate the current trends in otolaryngic allergy (OA).

STUDY DESIGN

Cross-sectional survey.

METHODS

Survey of active AAOA membership.

RESULTS

Response rate was 27.3%. Regional response distribution rates were proportional to the AAOA membership distribution within the United States (R2 = 0.95; P < 0.001), with no significant regional response bias demonstrated (P = 0.428). Self-reported duration to OA competency was 5.8 years. Physicians reporting OA competency were more likely to be board-certified (P < 0.001) and have AAOA fellowship status (P < 0.001). The AAOA was reported to be the most valuable educational resource toward achieving OA competency, with residency training being least valuable (P < 0.001). 91.5% of respondents' practices offered OA services. Subcutaneous injections predominated at twice the utilization of sublingual immunotherapy. Allergy immunotherapy tablets were rarely utilized. Home allergy shots were offered by 45.2% of respondents. In-office immunotherapy vial compounding was preferred (95.8%) to third-party vendors. 94% of AAOA respondents identified patient compliance to be an issue within OA. Non-inhalant allergy service integration included food allergy (63.5%), asthma (44.9%), allergic fungal sinusitis (43.8%), penicillin allergy (18%), stinging insect allergy (12.6%), and aspirin desensitization (3.9%).

CONCLUSION

Reported duration to OA competency after residency was surprisingly long. Further investigation of current and future educational/clinical training is warranted given clinical integration reported for OA. Otolaryngology is in the unique position to develop a comprehensive sino-allergy evidence-based strategy integrating the extensive diagnostic and medical treatment arms alongside the surgical expertise of the specialty within a clinical sino-allergy home concept.

LEVEL OF EVIDENCE

5 Laryngoscope, 130:283-289, 2020.

Evidence in immunotherapy for paediatric respiratory allergy: Advances and recommendations

Allergic respiratory diseases are major health problems in paediatric population due their high level of prevalence and chronicity, and to their relevance in the costs and quality of life. One of the most important risk factors for the development of airway diseases in children and adolescents is atopy. The mainstays for the treatment of these diseases are avoiding allergens, controlling symptoms, and preventing them through sustained desensitization by allergen immunotherapy (AIT). AIT is a treatment option that consists in the administration of increasing amounts of allergens to modify the biological response to them, inducing long-term tolerance even after treatment has ended. This treatment approach has shown to decrease symptoms and improve quality of life, becoming cost effective for a large number of patients. In addition, it is considered the only treatment that can influence the natural course of the disease by targeting the cause of the allergic inflammatory response. The aim of this publication is to reflect the advances of AIT in the diagnosis and treatment of allergic respiratory diseases in children and adolescents reviewing articles published since 2000, establishing evidence categories to support the strength of the recommendations based on evidence. The first part of the article covers the prerequisite issues to understand how AIT is effective, such as the correct etiologic and clinical diagnosis of allergic respiratory diseases. Following this, the article outlines the advancements in understanding the mechanisms by which AIT achieve immune tolerance to allergens. Administration routes, treatment regimens, dose and duration, efficacy, safety, and factors associated with adherence are also reviewed. Finally, the article reviews future advances in the research of AIT.

The efficacy assessment of a self-administered immunotherapy protocol

Background

We previously reported the safety of a self‐administered subcutaneous immunotherapy (SCIT) protocol. Here we report the results of the retrospective efficacy trial of the United Allergy Service (UAS) self‐administered SCIT protocol. We hypothesized that by utilizing a slow SCIT buildup phase, designed to attain recommended allergen concentrations on a cumulative basis, efficacious outcomes and clinical relevance would be achieved.

Methods

We enrolled 60 SCIT patients and 56 control patients. The study contrasted baseline and treatment period combined symptom plus medication scores (CSMS) as the primary outcome measure and rhinoconjunctivitis quality of life questionnaire (RQLQ) scores as the secondary study outcome measure. Changes in pollen counts were also examined with regard to effects on these efficacy parameters.

Results

The treatment group showed significantly improved CSMS (standardized mean difference [SMD]: −1.57; 95% confidence interval [CI], −1.97 to −1.18; p < 0.001) and RQLQ (SMD: −0.91; 95% CI, −1.23 to −0.59; p < 0.001). These treatment group outcome measures were respectively improved by 33% and 29% compared to baseline and greater than 40% in comparison to the control group (p < 0.0001). Significant results were also shown when examining these outcome measures with regards to either monotherapy or poly‐allergen SCIT. Furthermore, a comparison to recent meta‐analyses of SCIT studies showed equivalent efficacy and clinical relevance. Assessment of pollen counts during the baseline and treatment periods further corroborated the efficacy of the UAS SCIT protocol.

Conclusion

These efficacy results, and our previous safety results, show that a carefully designed and implemented self‐administered SCIT protocol is efficacious and safe.