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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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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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Recent Updates of Immunotherapy for Allergic Rhinitis in Children. CURRENT OTORHINOLARYNGOLOGY REPORTS 2023; 11:37-43. [PMID: 36721660 PMCID: PMC9880370 DOI: 10.1007/s40136-023-00440-x] [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] [Accepted: 12/19/2022] [Indexed: 01/28/2023]
Abstract
Purpose of Review Allergen immunotherapy (AIT) is a novel treatment approach with disease-modifying and preventative benefits that are not shared with other strategies for treating allergic illnesses. It has been demonstrated to be safe and effective in children. This review provides the most recent information on AIT in children as well as any pertinent updates. Recent Findings Although there is not a standard way to begin AIT, there are clear indications for AIT. Each case needs to be evaluated on its own by weighing the pros and downsides. AIT has been proven to significantly improve symptoms and quality of life in children with allergic illness, reduce medication use, stop the development of new allergen sensitizations, and stop the progression of allergic rhinitis to asthma. Novel approaches are under investigation to overcome some known AIT disadvantages. Summary This review provides a thorough summary of the most recent research and updates on AIT in children.
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Bellanti JA, Settipane RA, DuBuske L. Essentials of allergen immunotherapy: A primer for the practitioner. Allergy Asthma Proc 2022; 43:245-247. [PMID: 35818156 PMCID: PMC9274934 DOI: 10.2500/aap.2022.43.220039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
It has been more than a decade since the most recent allergen immunotherapy (AIT) practice parameter was published and 5 years since a focused practice parameter on sublingual immunotherapy (SLIT) was issued. There is an unmet need, therefore, for a more up-to-date, concise summary of AIT to be published to provide allergy/immunology practitioners, allergy/immunology fellows-in-training, medical students, residents, and other health-care practitioners with the most current information available on AIT. The Allergen Immunotherapy Primer (AITP) is not intended to define a standard of care or to be inclusive of all proper methods of care, nor is it intended to replace or supplant established AIT practice parameters; rather, the goal of this AITP is to supplement the established practice parameters and to serve primarily as an updated tool for the practicing allergist/immunologist, allergy/immunology trainees, and health-care professionals seeking practical and concise information with regard to AIT. Primer topics include the history of AIT; descriptions of the mechanisms and biomarkers of subcutaneous immunotherapy (SCIT) and SLIT; the efficacy and safety of SCIT; the efficacy and safety of SLIT, pediatric SLIT, and SCIT; the long-term efficacy of SLIT and SCIT; long-term adherence strategies for AIT; the implications of real-world data for AIT; the role of AIT for asthma; patterns of cross-allergenicity among pollens; a practical implementation guide for optimized construction of AIT vaccines; standardization of allergen extracts; updated information on federal regulations about the United States Pharmacopeia and the compounding of allergenic extracts; an update on AIT venom immunotherapy; the advantages and disadvantages of accelerated immunotherapy regimens; the important role of shared decision-making in AIT and how it can be incorporated into the informed consent process; and a forecast of future directions in allergen immunotherapy.
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Affiliation(s)
- Joseph A. Bellanti
- From the Department of Pediatrics and Microbiology-Immunology; ,The International Center for Interdisciplinary Studies of Immunology, Georgetown University Medical Center, Washington, D.C
| | - Russell A. Settipane
- Department of Medicine at the Alpert Medical School, Brown University, Providence, Rhode Island; ,Asthma, Nasal Disease and Allergy Research Center of New England, East Providence, Rhode Island
| | - Lawrence DuBuske
- George Washington University Hospital, Washington, D.C.; and ,Immunology Research Institute of New England, Gardner, Massachusetts
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Allergen Immunotherapy in Pediatric Respiratory Allergy. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00280-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Abstract
Purpose of Review
Atopic diseases such as asthma and allergic rhinitis are highly prevalent in children. Common triggers include tree and grass pollens, house dust mites, molds, and animal dander. These diseases are most often treated symptomatically; however, many patients show partial or poor response and require long-term medication use. Allergen immunotherapy (AIT) stands as the only treatment modality that can alter the underlying disease process and potentially offer a cure. In this review article, we discuss the merits of AIT with particular emphasis on its efficacy and safety in pediatric patients. We also discuss the challenges for AIT implementation and present an overview of current research that aims at improving its applicability for the treatment of allergic diseases.
Recent Findings
Subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) are both safe and efficacious treatment options in children with allergic rhinitis and allergic asthma. Additionally, AIT has efficacy in preventing the development of asthma in children. Although there are clear advantages with AIT, there are challenges to overcome to optimize treatment. Solutions include improved diagnostics with pre-treatment biomarkers and molecular multiplex assays, biomarkers for prediction of response (e.g., basophil activation markers), improved allergen immunogenicity with the use of recombinant AIT, adjuvants, and allergoids, and lastly improved safety with the concurrent use of omalizumab.
Summary
AIT has shown safety and efficacy in major clinical trials for the treatment of allergic rhinitis and allergic asthma in children. AIT provides a curative treatment option for atopic disorders and should be considered in children with allergic rhinitis and allergic asthma. There are many continued advances being made in the field of allergy to further improve the safety and efficacy profile and shorten the duration of AIT treatment.
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Epstein TG, Murphy-Berendts K, Liss GM, Bernstein DI. Risk factors for fatal and nonfatal reactions to immunotherapy (2008-2018): postinjection monitoring and severe asthma. Ann Allergy Asthma Immunol 2021; 127:64-69.e1. [PMID: 33753219 DOI: 10.1016/j.anai.2021.03.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Subcutaneous allergen immunotherapy (SCIT) is highly effective but risks exist. OBJECTIVE To identify practices that influence systemic allergic reactions (SRs) to SCIT and SCIT-associated infections. METHODS Members of the American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma and Immunology completed an annual survey of SCIT-related SRs of varying severity (2008-2018). Injection-related infections were queried (2014-2018). Strategies to enforce postinjection waiting times and to reduce risks from asthma/severe asthma were queried (2016-2018). RESULTS Data were gathered on 64.5 million injection visits. Ten confirmed fatalities occurred since 2008, including 3 new fatalities since 2017. One fatal reaction occurred per 7.2 million injection visits (2008-2018). No infections occurred. Practices that tracked the time after injections, and required checking out with office personnel, had significantly lower total (P < .001), grade 3 (severe) (P < .001), and grade 4 (very severe) SRs (P < .001). Having more individuals with asthma on SCIT was associated with more grade 3 SRs (P < .02). Not prescribing SCIT in individuals with uncontrolled asthma was associated with fewer grade 3 SRs (P = .02). Having individuals with more severe asthma on SCIT was associated with more total, grade 1, and grade 2 SRs (P < .001); 50% of grade 3 and 4 SRs occurred in individuals with severe asthma. CONCLUSION SCIT-related fatalities have declined since 2008, with a slight increase in recent years. SCIT is not associated with an increased risk of infections. Tracking the time after injections and checking out with office staff confer significantly lower risks of severe SRs. Asthma, especially severe asthma, is a major risk factor for severe and fatal SRs. Strategies that reduce risks for individuals with asthma, such as not prescribing SCIT to patients with uncontrolled asthma, may lower the risks.
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Affiliation(s)
- Tolly G Epstein
- Division of Immunology, Allergy, and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Allergy Partners of Central Indiana, Indianapolis, Indiana.
| | | | - Gary M Liss
- Division of Occupational and Environmental Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - David I Bernstein
- Division of Immunology, Allergy, and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Clinical Research Center, LLC, Cincinnati, Ohio
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Felix M, Vera Paz C, Mata VL, Vanegas E, Larenas-Linnemann D, Rosario NA, Letort J, Cherrez-Ojeda I. Perceptions and Management of Allergic Rhinitis Among Ecuadorian Otorhinolaryngologists: A Survey-Based Study. J Multidiscip Healthc 2020; 13:1975-1981. [PMID: 33364779 PMCID: PMC7751582 DOI: 10.2147/jmdh.s269531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/03/2020] [Indexed: 01/10/2023] Open
Abstract
Objective Allergic rhinitis (AR) represents a large burden to the healthcare system due to its high prevalence and impact on patients’ lives. Despite the existence of evidence-based guidelines, some studies have found that physicians do not always follow the latest recommendations. The aim of our study was to determine how Ecuadorian otorhinolaryngologists (ENTs) perceive some epidemiological aspects related to AR, as well as their preferences for managing the disease. Methods We conducted an observational, survey-based cross-sectional study, among 116 Ecuadorian ENTs. The survey used was adapted from a previous publication and consisted of 30 multiple choice questions, concerning several topics of AR. Descriptive statistics (frequency, and standard deviation) were performed for clinical and demographic variables. Results A total of 116 Ecuadorian ENTs completed the survey. Of them, 62.9% were male, with an average age of 42 years (SD ± 11.58). Computed tomography (CT) scan and nasal cytology were selected as the main diagnostic tests for AR by 62/91 (68.1%) and 45/91 (49.5%) of participants, respectively. Moreover, only 12/116 (10.3%) of participants performed skin prick tests (SPT). Allergen immunotherapy (AIT) was performed by 37/107 (36.4%) of participants. Conclusion In general, most participants agreed that the prevalence of AR appears to be increasing, with increased exposure to allergens, irritants, and pollutants as the main probable cause. Children and adolescents were accounted as the group most affected by AR, with sinusitis and asthma identified as the most frequent comorbidities. Finally, we found unmet needs in the diagnostic and management of AR that should be addressed among Ecuadorian ENTs, in particular the high use of CT scans as part of routine evaluations, as well as the low use of allergen immunotherapy.
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Affiliation(s)
- Miguel Felix
- Universidad Espíritu Santo, Samborondón, Ecuador.,RespiraLab Research Group, Guayaquil, Ecuador
| | - Carlos Vera Paz
- Universidad Espíritu Santo, Samborondón, Ecuador.,RespiraLab Research Group, Guayaquil, Ecuador
| | - Valeria L Mata
- Universidad Espíritu Santo, Samborondón, Ecuador.,RespiraLab Research Group, Guayaquil, Ecuador
| | - Emanuel Vanegas
- Universidad Espíritu Santo, Samborondón, Ecuador.,RespiraLab Research Group, Guayaquil, Ecuador
| | | | - Nelson A Rosario
- Departamento de Pediatria, Universidade Federal do Parana, Curitiba, Brazil
| | - Jose Letort
- Departamento de Otorrinolaringología, Hospital, Quito, Ecuador
| | - Ivan Cherrez-Ojeda
- Universidad Espíritu Santo, Samborondón, Ecuador.,RespiraLab Research Group, Guayaquil, Ecuador
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Mindaye ST, David NA, Zarkesh Esfahani SA, Schal C, Matsui EC, Rabin RL, Slater JE. Measurement of German cockroach allergens and their isoforms in allergen extracts with mass spectrometry. Clin Exp Allergy 2020; 50:741-751. [PMID: 32243003 DOI: 10.1111/cea.13604] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/11/2020] [Accepted: 03/22/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Allergen extracts are the primary tool for diagnosis and treatment of allergic diseases. In the United States, most allergen extracts are non-standardized. More sophisticated analytical approaches are needed to characterize these products and enable manufacturers and regulators to better determine potency. OBJECTIVE To expand the multiple reaction monitoring (MRM) assay for an in-depth characterization of German cockroach (GCr; Blattella germanica) allergen extracts. METHODS We applied advanced liquid chromatography (LC) and mass spectrometry (MS) techniques including MRM. The expanded LC/MRM-MS method was optimized to measure known GCr allergens and their isoforms/variants in commercial extracts and environmental samples. We performed isoform-specific allergen measurements in multiple extracts from four commercial sources and extracts prepared using environmental samples from urban homes. To investigate causes of heterogeneity, we examined over 30 extraction process variables. RESULTS Evaluation of the commercial extracts confirmed the variability of production lots and commercial sources. Commonly used defatting and extraction protocols yielded extracts with comparable allergen profiles and content. However, the identity and quality of source materials was a major contributor to variability. In comparing commercial GCr extracts to environmental samples, relative quantities of Bla g 1, Bla g 2, Bla g 3, Bla g 4 and Bla g 11 were similar, while Bla g 5, Bla g 6, Bla g 7 and Bla g 8 were present in the environmental samples but largely absent for the commercial extracts. CONCLUSIONS AND CLINICAL RELEVANCE LC/MRM-MS can be used to measure all known GCr allergens in commercial allergen extracts and environmental samples. Significant differences exist between allergen profiles of commercial extracts and the profiles of environmental samples from dwellings. This analytical platform can serve as a template to achieve better product characterization of similarly complex products.
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Affiliation(s)
- Samuel T Mindaye
- Laboratory of Immunobiochemistry, Division of Bacterial, Parasitic, and Allergenic Products, Office of Vaccines Research and Review, CBER/FDA, Silver Spring, MD, USA
| | - Natalie A David
- Laboratory of Immunobiochemistry, Division of Bacterial, Parasitic, and Allergenic Products, Office of Vaccines Research and Review, CBER/FDA, Silver Spring, MD, USA
| | - Sayyed Amin Zarkesh Esfahani
- Laboratory of Immunobiochemistry, Division of Bacterial, Parasitic, and Allergenic Products, Office of Vaccines Research and Review, CBER/FDA, Silver Spring, MD, USA
| | - Coby Schal
- Department of Entomology and Plant Pathology, North Carolina State University, Raleigh, NC, USA
| | - Elizabeth C Matsui
- Department of Population Health and Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Ronald L Rabin
- Laboratory of Immunobiochemistry, Division of Bacterial, Parasitic, and Allergenic Products, Office of Vaccines Research and Review, CBER/FDA, Silver Spring, MD, USA
| | - Jay E Slater
- Laboratory of Immunobiochemistry, Division of Bacterial, Parasitic, and Allergenic Products, Office of Vaccines Research and Review, CBER/FDA, Silver Spring, MD, USA
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Agache I, Lau S, Akdis CA, Smolinska S, Bonini M, Cavkaytar O, Flood B, Gajdanowicz P, Izuhara K, Kalayci O, Mosges R, Palomares O, Papadopoulos NG, Sokolowska M, Angier E, Fernandez‐Rivas M, Pajno G, Pfaar O, Roberts G, Ryan D, Sturm GJ, Ree R, Varga EM, Wijk RG, Yepes‐Nuñez J, Jutel M. EAACI Guidelines on Allergen Immunotherapy: House dust mite-driven allergic asthma. Allergy 2019; 74:855-873. [PMID: 31095767 DOI: 10.1111/all.13749] [Citation(s) in RCA: 158] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/12/2019] [Indexed: 12/14/2022]
Abstract
Allergen immunotherapy (AIT) has been in use for the treatment of allergic disease for more than 100 years. Asthma treatment relies mainly on corticosteroids and other controllers recommended to achieve and maintain asthma control, prevent exacerbations, and improve quality of life. AIT is underused in asthma, both in children and in adults. Notably, patients with allergic asthma not adequately controlled on pharmacotherapy (including biologics) represent an unmet health need. The European Academy of Allergy and Clinical Immunology has developed a clinical practice guideline providing evidence-based recommendations for the use of house dust mites (HDM) AIT as add-on treatment for HDM-driven allergic asthma. This guideline was developed by a multi-disciplinary working group using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. HDM AIT was separately evaluated by route of administration and children and adults: subcutaneous (SCIT) and sublingual AIT (SLIT), drops, and tablets. Recommendations were formulated for each. The important prerequisites for successful treatment with HDM AIT are (a) selection of patients most likely to respond to AIT and (b) use of allergen extracts and desensitization protocols of proven efficacy. To date, only AIT with HDM SLIT-tablet has demonstrated a robust effect in adults for critical end points (exacerbations, asthma control, and safety). Thus, it is recommended as an add-on to regular asthma therapy for adults with controlled or partially controlled HDM-driven allergic asthma (conditional recommendation, moderate-quality evidence). HDM SCIT is recommended for adults and children, and SLIT drops are recommended for children with controlled HDM-driven allergic asthma as the add-on to regular asthma therapy to decrease symptoms and medication needs (conditional recommendation, low-quality evidence).
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Affiliation(s)
- Ioana Agache
- Faculty of Medicine Department of Allergy and Clinical Immunology Transylvania University Brasov Brasov Romania
| | - Susanne Lau
- Department for Pediatric Pneumology, Immunology and Intensive Care Charité Universität Medizin Berlin Germany
| | - Cezmi A. Akdis
- University of Zürich Swiss Institute of Allergy and Asthma Research (SIAF) Davos Switzerland
- Christine Kühne‐Center for Allergy Research and Education (CK‐CARE) Davos Switzerland
| | - Sylwia Smolinska
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- “ALL‐MED” Medical Research Institute Wroclaw Poland
| | - Matteo Bonini
- National Heart and Lung Institute (NHLI) Royal Brompton Hospital & Imperial College London UK
| | - Ozlem Cavkaytar
- Faculty of Medicine Department of Pediatric Allergy Istanbul Medeniyet University Goztepe Training and Research Hospital Istanbul Turkey
| | - Breda Flood
- European Federation of Allergy and Airways Diseases, Patients Association Brussels Belgium
| | - Pawe Gajdanowicz
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
| | | | - Omer Kalayci
- Hacettepe University School of Medicine Ankara Turkey
| | - Ralph Mosges
- Universität zu Koln Institute of Medical Statistics, Informatics and Epidemiology (IMSIE) Koln Germany
| | - Oscar Palomares
- Department of Biochemistry and Molecular Biology Complutense University of Madrid Madrid Spain
| | - Nikolaos G. Papadopoulos
- Division of Infection, Immunity and respiratory medicine University of Manchester Manchester UK
- Allergy Department 2nd Pediatric Clinic University of Athens Athens Greece
| | - Milena Sokolowska
- University of Zürich Swiss Institute of Allergy and Asthma Research (SIAF) Davos Switzerland
- Christine Kühne‐Center for Allergy Research and Education (CK‐CARE) Davos Switzerland
| | | | | | - Giovanni Pajno
- Allergy Unit Department of Pediatrics University of Messina Messina Italy
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital Marburg Philipps‐Universität Marburg Marburg Germany
| | - Graham C. Roberts
- The David Hide Asthma and Allergy Research Centre St Mary's Hospital Newport Isle of Wight UK
- NIHR Biomedical Research Centre University Hospital Southampton NHS Foundation Trust Southampton UK
- Faculty of Medicine University of Southampton Southampton UK
| | - Dermot Ryan
- Usher Institute of Population Health Sciences and Informatics University of Edinburgh Edinburgh UK
- Asthma UK Centre for Applied Research The University of Edinburgh Edinburgh UK
| | - Gunter J. Sturm
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
- Outpatient Allergy Clinic Reumannplaz Vienna Austria
| | - Ronald Ree
- Department of Experimental Immunology Academic Medical Center University of Amsterdam Amsterdam The Netherlands
- Department of Otorhinolaryngology Academic Medical Center University of Amsterdam Amsterdam The Netherlands
| | - Eva M. Varga
- Department of Pediatric and Adolescent Medicine Respiratory and Allergic Disease Division Medical University of Graz Graz Austria
| | - Roy Gerth Wijk
- Section of Allergology Department of Internal Medicine Erasmus Medical Center Rotterdam The Netherlands
| | | | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- “ALL‐MED” Medical Research Institute Wroclaw Poland
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Frew AJ. Immunotherapy of Allergic Disease. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00091-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
House dust mite (HDM) is a predominant source of indoor aeroallergen worldwide, which induces allergic diseases including allergic rhinoconjunctivitis, allergic asthma, atopic eczema and other allergic skin diseases. Allergen specific immunotherapy (AIT) is the only potential disease-modifying treatment of HDM allergic subjects. However, AIT remains underused due to no universally accepted allergen standardization and a shortage of rigorous clinical studies to confirm safety and efficacy. With the effort of doctors and researchers in allergy field, efficacy, safety, standardization and strategy of AIT are being continuously developed. This review presents the updated research based on recently published trials and meta-analyses.
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Affiliation(s)
- Lin Yang
- a Department of Allergy , Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology , Wuhan , China
| | - Rongfei Zhu
- a Department of Allergy , Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology , Wuhan , China
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Arianpour K, Svider PF, Yuhan B, Hooda Z, Eloy JA, Folbe AJ. Evolving patterns in the diagnosis and management of allergy-mediated disorders. Int Forum Allergy Rhinol 2018; 8:928-933. [PMID: 29782070 DOI: 10.1002/alr.22111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/21/2018] [Accepted: 02/14/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND This analysis explores the increasing heterogeneity of trends in allergy management under the premise that the practice of allergy has undergone significant changes in national economics, healthcare delivery, and treatment options from 2007 to 2016. METHODS Centers for Medicare and Medicaid Services (CMS) data were obtained for: (1) temporal trends in allergy immunotherapy injection (Current Procedural Terminology [CPT] codes 95115, 95117) and testing (CPT 95004, 95024) from 2007 to 2016; (2) geographic trends; and (3) practitioners administering immunotherapy. Although there are no sublingual immunotherapy (SLIT) CPT codes, billing for unlisted allergy/immunologic services (CPT 95199) were obtained. RESULTS Since 2007, there were 99.5 million allergy tests and 33.5 million immunotherapy injections billed to Medicare beneficiaries. Increases in testing have outpaced rising immunotherapy administration (49.7% vs 19.6% increase). Significant regional variation in testing rates was noted, with the greatest ratio of testing to immunotherapy in the South (0.35) and smallest ratio in the Northeast (0.18). The maximum unlisted allergy services billed was 594 (of which includes SLIT), compared to annual subcutaneous immunotherapy (SCIT) totals in the millions. The majority of immunotherapy in 2016 was administered by allergists/immunologists (51.6%) followed by otolaryngologists (31.2%), trends that have remained consistent since 2012. CONCLUSION Physicians have been more aggressive in the workup of allergy-mediated disorders in recent years. Although differences in allergen load exist, there is tremendous geographic variation in the ratio of testing to immunotherapy. While the role otolaryngologists play in immunotherapy remains stable, allergists manage the majority of patients, reinforcing the importance of interdisciplinary cooperation and outreach. SLIT does not appear to play a significant role in this population.
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Affiliation(s)
| | - Peter F Svider
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Brian Yuhan
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, MI
| | - Zamaan Hooda
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, MI
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ
| | - Adam J Folbe
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, MI
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Zielen S, Gabrielpillai J, Herrmann E, Schulze J, Schubert R, Rosewich M. Long-term effect of monophosphoryl lipid A adjuvanted specific immunotherapy in patients with grass pollen allergy. Immunotherapy 2018; 10:529-536. [PMID: 29562801 DOI: 10.2217/imt-2018-0004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Ultra-short course pollen immunotherapy adjuvanted with monophosphoryl lipid A (MPL) is attractive to conventional allergen-specific immunotherapy (AIT). Long term efficacy of MPL-AIT has not been evaluated. METHODS 68 patients (age 16.75 ± 5.3 years) with allergic rhinitis to grass pollen were investigated. Group 1: 21 controls; Group 2: 19 after complete AIT, and Group 3: 28 with AIT and treatment cessation: 4 years range 3-6 years ago. RESULTS The clinical symptoms (running nose, sneezing, conjunctivitis and the weekly overall score) were significantly reduced in patients group 2 and 3 compared with controls without AIT p < 0.0001. T-regulatory cells and TH1/TH2 cytokine pattern did not differ between patient groups. CONCLUSION The patients in our trial with grass pollen allergy exhibited significant and long-lasting improvements after MPL-AIT, however larger trials are needed to support this finding.
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Affiliation(s)
- Stefan Zielen
- Department for Children & Adolescents, Division of Allergology, Pulmonology & Cystic fibrosis, Children's Hospital, Goethe University, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Jennis Gabrielpillai
- Department for Children & Adolescents, Division of Allergology, Pulmonology & Cystic fibrosis, Children's Hospital, Goethe University, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Eva Herrmann
- Department of Biostatistics, Goethe University, Frankfurt am Main, Germany
| | - Johannes Schulze
- Department for Children & Adolescents, Division of Allergology, Pulmonology & Cystic fibrosis, Children's Hospital, Goethe University, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Ralf Schubert
- Department for Children & Adolescents, Division of Allergology, Pulmonology & Cystic fibrosis, Children's Hospital, Goethe University, Theodor Stern Kai 7, 60590 Frankfurt, Germany
| | - Martin Rosewich
- Department for Children & Adolescents, Division of Allergology, Pulmonology & Cystic fibrosis, Children's Hospital, Goethe University, Theodor Stern Kai 7, 60590 Frankfurt, Germany
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Hur GY, Lee JH, Park HS. Allergen immunotherapy for the treatment of respiratory allergies in the elderly. Curr Opin Allergy Clin Immunol 2018; 17:304-308. [PMID: 28525399 DOI: 10.1097/aci.0000000000000370] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Respiratory allergies, including asthma and allergic rhinitis can also occur in the elderly. Allergen immunotherapy for allergic diseases is the only disease-modifying treatment for patients with allergies available thus far. Here, we review current evidence supporting the use of allergen immunotherapy in the elderly and discuss its efficacy and utility for the treatment of respiratory allergic diseases in this setting. RECENT FINDINGS Subcutaneous and/or sublingual immunotherapy are effective therapeutic options in not only young but also older patients. Allergen immunotherapy reduces medication and symptom scores in the elderly and can thus be safely prescribed in this population. SUMMARY Elderly individuals with proven, clinically relevant immunoglobulin E sensitization to inhalant allergens may benefit from allergen immunotherapy for respiratory allergic diseases. Older patients without contraindications should therefore be considered for treatment, with the additional benefit of reduced medication and symptom scores.
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Affiliation(s)
- Gyu-Young Hur
- aDepartment of Internal Medicine, Korea University College of Medicine, Seoul bDepartment of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
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Safety considerations in providing allergen immunotherapy in the office. Curr Opin Otolaryngol Head Neck Surg 2018; 24:226-30. [PMID: 27092905 DOI: 10.1097/moo.0000000000000257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review highlights the risks of allergy immunotherapy, methods to improve the quality and safety of allergy treatment, the current status of allergy quality metrics, and the future of quality measurement. In the current healthcare environment, the emphasis on outcomes measurement is increasing, and providers must be better equipped in the development, measurement, and reporting of safety and quality measures. RECENT FINDINGS Immunotherapy offers the only potential cure for allergic disease and asthma. Although well tolerated and effective, immunotherapy can be associated with serious consequence, including anaphylaxis and death. Many predisposing factors and errors that lead to serious systemic reactions are preventable, and the evaluation and implementation of quality measures are crucial to developing a safe immunotherapy practice. Although quality metrics for immunotherapy are in their infancy, they will become increasingly sophisticated, and providers will face increased pressure to deliver safe, high-quality, patient-centered, evidence-based, and efficient allergy care. SUMMARY The establishment of safety in the allergy office involves recognition of potential risk factors for anaphylaxis, the development and measurement of quality metrics, and changing systems-wide practices if needed. Quality improvement is a continuous process, and although national allergy-specific quality metrics do not yet exist, they are in development.
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Abstract
PURPOSE OF REVIEW To describe recent insights into how molecular diagnosis can improve indication and selection of suitable allergens for specific immunotherapy and increase the safety of this therapy. RECENT FINDINGS As specific allergen immunotherapy targets specific allergens, identification of the disease-eliciting allergen is a prerequisite for accurate prescription of treatment. In areas of complex sensitization to aeroallergens or in cases of hymenoptera venom allergy, the use of molecular diagnosis has demonstrated that it may lead to a change in indication and selection of allergens for immunotherapy in a large proportion of patients when compared with diagnosis based on skin prick testing and/or specific IgE determination with commercial extracts. These changes in immunotherapy prescription aided by molecular diagnosis have been demonstrated to be cost-effective in some scenarios. Certain patterns of sensitization to grass or olive pollen and bee allergens may identify patients with higher risk of adverse reaction during immunotherapy. SUMMARY Molecular diagnosis, when used with other tools and patients' clinical records, can help clinicians better to select the most appropriate patients and allergens for specific immunotherapy and, in some cases, predict the risk of adverse reactions. The pattern of sensitization to allergens could potentially predict the efficacy of allergen immunotherapy provided that these immunotherapy products contain a sufficient amount of these allergens. Nevertheless, multiplex assay remains a third-level approach, not to be used as screening method in current practice.
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Son JY, Jung MH, Koh KW, Park EK, Heo JH, Choi GS, Kim HK. Changes in skin reactivity and associated factors in patients sensitized to house dust mites after 1 year of allergen-specific immunotherapy. Asia Pac Allergy 2017; 7:82-91. [PMID: 28487839 PMCID: PMC5410415 DOI: 10.5415/apallergy.2017.7.2.82] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 04/25/2017] [Indexed: 12/04/2022] Open
Abstract
Background Allergen-specific immunotherapy (SIT) can significantly improve symptoms and reduce the need for symptomatic medication. Objective The aim of this study was to investigate changes in skin reactivity to house dust mites (HDMs) as an immunologic response and associated factors after 1 year of immunotherapy. Methods A total of 80 patients with allergic airway diseases who received subcutaneous SIT with HDMs from 2009 to 2014 were evaluated. The investigated parameters were basic demographic characteristics, skin reactivity and specific IgE for HDM, serum total IgE level, blood eosinophil counts, and medication score. Results The mean levels of skin reactivity to HDMs, blood eosinophil counts, and medication scores after 1 year were significantly reduced from baseline. In univariate comparison of the changes in skin reactivity to HDMs, age ≤30 years, HDMs only as target of immunotherapy, and high initial skin reactivity (≥2) to HDMs were significantly associated with the reduction in skin test reactivity. In multivariate analysis, high initial skin reactivity and HDMs only as target allergens were significantly associated with changes in skin reactivity to HDMs. In the receiver operating characteristic curve of the initial mean skin reactivity to HDMs for more than 50% reduction, the optimal cutoff value was 2.14. Conclusion This study showed significant reductions in allergen skin reactivity to HDMs after 1 year of immunotherapy in patients sensitized to HDMs. The extent of initial allergen skin reactivity and only HDMs as target allergen were important predictive factors for changes in skin reactivity.
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Affiliation(s)
- Jeong-Yeop Son
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, Korea
| | - Mann-Hong Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, Korea
| | - Kwang-Wook Koh
- Department of Preventive Medicine, Kosin University College of Medicine, Busan 49267, Korea
| | - Eun-Kee Park
- Department of Medical Humanities and Social Medicine, Kosin University College of Medicine, Busan 49267, Korea
| | - Jeong-Hoon Heo
- Department of Molecular Biology & Immunology, Kosin University College of Medicine, Busan 49267, Korea
| | - Gil-Soon Choi
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, Korea
| | - Hee-Kyoo Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan 49267, Korea
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Park KH, Lee SC, Son YW, Jeong KY, Shin YS, Shin JU, Sim DW, Park HJ, Lee JH, Lee KH, Park JW. Different Responses in Induction of Allergen Specific Immunoglobulin G4 and IgE-Blocking Factors for Three Mite Subcutaneous Immunotherapy Products. Yonsei Med J 2016; 57:1427-34. [PMID: 27593871 PMCID: PMC5011275 DOI: 10.3349/ymj.2016.57.6.1427] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/13/2016] [Accepted: 05/15/2016] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Specific immunoglobulin G4 (sIgG4) and immunoglobulin E (IgE)-blocking factors produced by subcutaneous immunotherapy (SCIT) play a critical role in the induction of allergen tolerance. However, comparative studies of available SCIT reagents on the induction of sIgG4 are limited. We compared increases in sIgG4 for three different house dust mite (HDM) SCIT reagents. MATERIALS AND METHODS Seventy-two HDM sensitized allergic patients were enrolled and classified into four groups: 1) control (n=27), 2) SCIT with Hollister-Stier® (n=19), 3) Tyrosine S® (n=16), and 4) Novo-Helisen® (n=10). Levels of specific IgE (sIgE), sIgG4, and IgE blocking factor to Dermatophagoides farinae (D. farinae) were measured using ImmunoCAP (sIgE, sIgG4) and enzyme-linked immunosorbent assay (ELISA) (IgE-blocking factors). Levels were measured before and 13.9±6.6 months after the SCIT. The allergen specificity and the induction levels of sIgE and sIgG4 were confirmed by immunoblot analysis. RESULTS After SCIT, sIgG4 levels to D. farinae increased significantly; however, the increases differed significantly among the SCIT groups (p<0.001). Specific IgG4 levels to D. farinae were highest in Hollister-Stier® (3.7±4.1 mg/L), followed by Novo-Helisen® (2.2±2.3 mg/L) and Tyrosine S® (0.7±0.5 mg/L). In addition, patients who were administered using Hollister-Stier® showed the most significant decrease in IgE/IgG4 ratio (p<0.001) and increase in blocking factor (p=0.009). Finally, according to IgE immunoblot results, the Hollister-Stier® group showed the most significant attenuation of IgE binding patterns among others. CONCLUSION Currently available SCIT reagents induce different levels of specific IgG4, IgE/IgG4 ratio, and IgE-blocking factor.
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Affiliation(s)
- Kyung Hee Park
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Chul Lee
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Woong Son
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyoung Yong Jeong
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Yoo Seob Shin
- Department of Allergy and Clinical Immunology, Ajou Medical School of Medicine, Suwon, Korea
| | - Jung U Shin
- Department of Dermatology & Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Da Woon Sim
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Jung Park
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hyun Lee
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang Hoon Lee
- Department of Dermatology & Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Won Park
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea.
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Chen H, Zhang K, Wang S, Xu C, Zou Z, Tao A. Generation and purification of monoclonal antibodies against Der f 2, a major allergen from Dermatophagoides farinae. Drug Discov Ther 2016; 10:103-8. [PMID: 27210892 DOI: 10.5582/ddt.2016.01029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Monoclonal antibodies (mAbs) are needed for the quantitation of environmental allergens for precise diagnosis and immunotherapy. In this study, we produced and purified monoclonal antibodies against Der f 2, one of the major allergens of the house dust mite Dermatophagoides farina, in order to develop an assay for the detection of this allergen. BALB/c mice were immunized four times with the protein Der f 2 together with an adjuvant after which splenocytes were collected and fused with SP2/0 (myeloma cells) in the presence of polyethylene glycol (PEG). The fused cells were selected in the presence of Hypoxanthine-Aminopterin-Thymidine (HAT) and then Hypoxanthine-Thymidine (HT) medium. Positive cells were screened with ELISA and subcloned by limited dilution at least three times to achieve stable mAb-producing clones. Four stable mAb-producing clones were obtained. One clone with IgG1 isotype and another with IgG2b isotype were chosen to produce large amounts of mAb by inoculation of the cells into the abdominal cavity of mice. Ascites were collected and the mAbs were purified using protein A affinity chromatography. Testing of the ascites by ELISA showed the titration of IgG1 and IgG2b to be higher than 1/10(6) dilution. The specificity of both antibodies was confirmed by immunoblotting. Thus, we produced two mAb clones against Der f 2 that can be used to create a precise quantitative method to identify allergen components in dust samples and facilitate further study in Der f 2 component-resolved diagnosis (CRD).
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Affiliation(s)
- Huifang Chen
- The Second Affiliated Hospital of Guangzhou Medical University, The State Key Laboratory of Respiratory Disease, Guangdong Provincial Key Laboratory of Allergy & Clinical Immunology
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Wang HY, Shen YH, Yang XY, Tang LF, Zhou JY. Diagnosis and treatment of allergic diseases in Zhejiang Province: a cross-sectional survey. J Zhejiang Univ Sci B 2016; 16:640-50. [PMID: 26160722 DOI: 10.1631/jzus.b1400284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The specialty of allergy developed quickly in western countries because of the rapid increase of allergic diseases, whereas it developed relatively slowly in China. The prevalence of allergen sensitization and allergic diseases in Zhejiang Province of China is high and improving the medical services for these diseases is critically needed. OBJECTIVE To investigate the working status of the diagnosis and treatment of allergic diseases, including doctor resources, diagnostic methods, and allergen-specific immunotherapy in patients of Zhejiang Province, and to provide instructions for the strategic development of subspecialties of allergic diseases. METHODS First we defined the doctors who treat allergic diseases, and designed a comprehensive questionnaire to collect personal and hospital information for these doctors. The questionnaires were distributed to hospitals with different ranks and from different areas in the province. The general condition of doctor's resources, carryout of diagnostic methods, and allergen-specific immunotherapy were described and variations in the different specialties, hospitals, and areas were further analyzed. RESULTS Doctors in their thirties with bachelor's degrees were the mainstream for diagnosing and treating allergic diseases. The main specialties of the doctor resources were the specialties of Ear, Nose and Throat (ENT), Respirology, Pediatrics, and Dermatology. The Pediatrics specialty had a more reasonable infrastructure of doctor resources with more young doctors working in this subspecialty. The development of allergy subspecialty varied within hospitals at different levels or from different areas. The carryout of the skin prick test (SPT), serum specific IgE (ssIgE), and subcutaneous immunotherapy (SCIT) was best performed in provincial hospitals, while sublingual immunotherapy (SLIT) was prescribed most commonly in municipal hospitals. The performance of SPT and ssIgE in Hangzhou, Jiaxing, and Wenzhou areas was much better than that in other places. The performance of SCIT and SLIT was best in Wenzhou. CONCLUSIONS Our survey revealed a very initial and unbalanced development for the allergy subspecialty in Zhejiang Province. Doctor resources for allergic diseases were mainly from the specialties of ENT, Respirology, and Pediatrics, and the performance of diagnosis and treatment was mainly focused on provincial and municipal hospitals. Continuous education of allergies could be extended to primary healthcare centers and more efforts should be directed to those areas with poor medical resources.
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Affiliation(s)
- Hui-ying Wang
- Department of Allergy, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China; Department of Respirology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China; Department of Rheumatology and Clinical Immunology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China; Department of Respirology, Children's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
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Grier TJ, Converse LM, Rekkerth DJ, Renahan KE. Math-free guides for glycerin and allergens at variable subcutaneous injection volumes: How's my dosing? Update. Ann Allergy Asthma Immunol 2016; 116:455-60. [PMID: 27017565 DOI: 10.1016/j.anai.2016.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/03/2016] [Accepted: 02/24/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Current summaries of effective maintenance dose ranges for subcutaneous immunotherapy (SCIT) are based on administration of 0.5-mL volumes. Extract formulations delivering equivalent dose ranges for practices using different injection volumes have not been reported, and calculation of the final glycerin concentrations in these solutions remains an inconvenient and repetitive process. OBJECTIVE To create math-free guides for allergen doses and glycerin concentrations that identify the extract concentrate volumes required to deliver doses within the ranges cited in the 2011 immunotherapy practice parameters for clinicians using 5.0-mL maintenance vials and injection volumes ranging from 0.2 to 1.0 mL. METHODS Algebraic calculations were performed to determine the specific combinations of extract concentrate strengths, volumes of these products in patient vaccines, and injection volumes needed for administration of target allergen doses spanning the current SCIT practice parameter recommendations. RESULTS For each product or group (nonstandardized extracts), tables were constructed to define the allergen doses provided by various combinations of extract concentrate volumes and injection volumes. The values within the effective dose ranges for each product were highlighted to facilitate comparisons of specific conditions relevant to allergy specialists. Glycerin tables were also created to permit convenient assessments of the final concentrations of this stabilizer in patient prescriptions. CONCLUSION SCIT dosing and glycerin tables are useful tools to assist allergists with practice decisions that involve variable patient formulas and injection volumes and can help identify suitable conditions for treatment of patients presenting with diverse allergen sensitivities and specificity profiles.
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Affiliation(s)
- Thomas J Grier
- Medical and Scientific Affairs, Stallergenes Greer, Lenoir, North Carolina.
| | - Lorie M Converse
- Medical and Scientific Affairs, Stallergenes Greer, Lenoir, North Carolina
| | - Donna J Rekkerth
- Medical and Scientific Affairs, Stallergenes Greer, Lenoir, North Carolina
| | - Kevin E Renahan
- Medical and Scientific Affairs, Stallergenes Greer, Lenoir, North Carolina
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Codina R, Lockey RF. Pollen used to produce allergen extracts. Ann Allergy Asthma Immunol 2016; 118:148-153. [PMID: 26993170 DOI: 10.1016/j.anai.2016.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/13/2016] [Accepted: 02/15/2016] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To review the use of pollen for the production of allergen extracts to diagnose and treat allergic diseases, examine the associated regulations, and highlight candidate areas for improvement. DATA SOURCES A PubMed search was performed using focused keywords combined with a review of regulatory documents and industry guidelines. STUDY SELECTIONS The information obtained through literature, documents, and industry was scrutinized and used with personal experience and expertise to write this article. RESULTS Both genetic and environmental factors affect the allergenic composition of pollen because it is a biologically active pharmaceutical ingredient obtained from nature. The potential effect of airborne contaminants in pollen requires major attention but can be properly addressed through careful collection practices, combined with a proper interpretation of the data on purity obtained for each pollen lot. The regulations associated with pollen used to manufacture allergen extracts in the United States and Europe and the numbers of pollen allergen extracts commercially available in both areas of the world differ. A critical parameter to select the appropriate extracts for diagnosis and allergen immunotherapy is to understand the phenomenon of cross-reactivity among pollen families, genera, and species. CONCLUSION Physicians should be aware of the factors responsible for the qualitative and quantitative composition of pollen allergen extracts and the associated regulations to produce suitable extracts to diagnose and treat allergic diseases. Collaboration and cooperation among allergen manufacturing companies and regulatory agencies are necessary.
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Affiliation(s)
- Rosa Codina
- Allergen Science and Consulting, Lenoir, North Carolina; Division of Allergy and Immunology, Department or Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida.
| | - Richard F Lockey
- Division of Allergy and Immunology, Department or Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida
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Grier TJ, Hall DM, Duncan EA, Gada SM. Allergen stabilities and compatibilities in immunotherapy mixtures that contain cat, dog, dust mite, and cockroach extracts. Ann Allergy Asthma Immunol 2015; 115:496-502. [PMID: 26522255 DOI: 10.1016/j.anai.2015.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/01/2015] [Accepted: 10/02/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Indoor allergen mixtures that contain cat, dog, dust mite, and cockroach extracts are commonly used in allergy clinics for subcutaneous immunotherapy, but product-specific stabilities and mixing compatibilities in these complex patient formulas have not been determined. OBJECTIVES To assess the recoveries of cat, dog epithelia, dog dander, dust mite Dermatophagoides farinae, and cockroach mix allergen activities in 5 component mixtures and 1:10 (vol/vol) dilutions stored for up to 12 months. METHODS Concentrated stock mixtures, 10-fold dilutions of these mixtures in human serum albumin-saline diluent, and analogous single-extract controls were analyzed for major allergen concentrations (cat Fel d 1, dog dander Can f 1) and multiallergen IgE-binding potencies (dog epithelia, D farinae, cockroach mix) after storage for 3, 6, 9, and 12 months at 2°C to 8°C. RESULTS The selected immunoassays were specific for individual target extracts in the 5-component mixtures and exhibited analytical sensitivities sufficient for evaluation of both the concentrated and diluted indoor allergen formulas. All control samples except diluted cockroach extract had near-complete stabilities during refrigerated storage. Mixtures that contained cat, dog epithelia, dog dander, and D farinae extracts exhibited favorable mixing compatibilities in 1:1 (vol/vol) concentrates (47.5% glycerin) and 1:10 (vol/vol) dilutions (4.75% glycerin), relative to corresponding control sample reactivities. Cockroach allergens in both 1:1 (vol/vol) and 1:10 (vol/vol) concentrations were stabilized significantly by mixing with the other 4 indoor allergen extracts. CONCLUSION Extracts in mixtures that contained 5 common sources of indoor allergens possess favorable stabilities and mixing compatibilities and support the practice of combining these products in the same patient treatment formulations for subcutaneous immunotherapy.
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Affiliation(s)
- Thomas J Grier
- Research and Development Laboratory, Greer Laboratories Inc, Lenoir, North Carolina.
| | - Dawn M Hall
- Research and Development Laboratory, Greer Laboratories Inc, Lenoir, North Carolina
| | - Elizabeth A Duncan
- Research and Development Laboratory, Greer Laboratories Inc, Lenoir, North Carolina
| | - Satyen M Gada
- Walter Reed National Military Medical Center, Bethesda, Maryland
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Stone SF, Phillips EJ, Wiese MD, Heddle RJ, Brown SGA. Immediate-type hypersensitivity drug reactions. Br J Clin Pharmacol 2015; 78:1-13. [PMID: 24286446 DOI: 10.1111/bcp.12297] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 11/18/2013] [Indexed: 11/27/2022] Open
Abstract
Hypersensitivity reactions including anaphylaxis have been reported for nearly all classes of therapeutic reagents and these reactions can occur within minutes to hours of exposure. These reactions are unpredictable, not directly related to dose or the pharmacological action of the drug and have a relatively high mortality risk. This review will focus on the clinical presentation, immune mechanisms, diagnosis and prevention of the most serious form of immediate onset drug hypersensitivity reaction, anaphylaxis. The incidence of drug-induced anaphylaxis deaths appears to be increasing and our understanding of the multiple and complex reasons for the unpredictable nature of anaphylaxis to drugs is also expanding. This review highlights the importance of enhancing our understanding of the biology of the patient (i.e. immune response, genetics) as well as the pharmacology and chemistry of the drug when investigating, diagnosing and treating drug hypersensitivity. Misdiagnosis of drug hypersensitivity leads to substantial patient risk and cost. Although oral provocation is often considered the gold standard of diagnosis, it can pose a potential risk to the patient. There is an urgent need to improve and standardize diagnostic testing and desensitization protocols as other diagnostic tests currently available for assessment of immediate drug allergy are not highly predictive.
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Affiliation(s)
- Shelley F Stone
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research and the University of Western Australia, Perth, Western Australia; Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia
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Sandrini A, Rolland JM, O'Hehir RE. Current developments for improving efficacy of allergy vaccines. Expert Rev Vaccines 2015; 14:1073-87. [PMID: 26013124 DOI: 10.1586/14760584.2015.1050385] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Allergic diseases are prevalent worldwide. Allergen immunotherapy (AIT) is a current treatment for allergy, leading to modification of the natural course of disease. Mechanisms of efficacy include Treg through release of IL-10 and TGF-β and specific IgG4 blocking antibodies. Subcutaneous and sublingual routes are popular, but uptake is limited by inconvenience and safety concerns. Inclusion criteria limit application to a small proportion of allergic patients. New forms of immunotherapy are being investigated for more efficacious, convenient and safer options with promising advances in recent years. The rationale of reducing vaccine allergenicity to increase safety while improving immunogenicity led to investigation of T-cell epitope-based peptides and recombinant allergen derivatives. Additionally, different routes of administration and adjuvants and adjunct therapies are being explored. This review discusses the current status of AIT and recent advances to improve clinical efficacy, safety and long-term immune tolerance.
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Affiliation(s)
- Alessandra Sandrini
- Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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Lee S. Practical clinical approaches to the allergic rhinitis patient. Int Forum Allergy Rhinol 2015; 4 Suppl 2:S66-9. [PMID: 25182359 DOI: 10.1002/alr.21389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 06/30/2014] [Indexed: 11/12/2022]
Abstract
BACKGROUND Numerous treatment strategies are available for the treatment of allergic rhinitis (AR), including environmental controls, pharmacotherapy, immunotherapy, and surgery in appropriately selected patients. A stepwise algorithmic approach based on disease severity and persistence of symptoms is often advocated to effectively manage patients with AR. METHODS A review is provided of current evidence and guidelines for the management of AR. Practical clinical strategies to improve patient adherence to therapy and outcome are described. RESULTS Algorithms to manage AR are based on the severity and persistence of disease. A tailored strategy geared toward addressing symptoms that are most troublesome to the patient is beneficial, as is the assessment of comorbid conditions such as rhinosinusitis, asthma, and laryngopharyngeal reflux. Allergen-specific immunotherapy (AIT) is an underused treatment modality and patients with persistent AR should be considered candidates for desensitization, if appropriate. Assessment of patient outcome is important and the use of validated symptom surveys can provide an objective measure of quality of life. CONCLUSION A large armamentarium of treatment options is available to the otolaryngologist treating the patient with AR. A step-wise and tailored approach with equal attention dedicated to patient education and assessment of patient outcome can be helpful to improve efficacy of treatment.
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Affiliation(s)
- Stella Lee
- Division of Sinonasal Disorders and Allergy, University of Pittsburgh Medical Center, Pittsburgh, PA
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Karam M, Samuels K, Holland C, Hernandez C, Greenhawt M. Adherence with allergen immunotherapy labeling guidelines. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2015; 3:250-5. [PMID: 25609334 PMCID: PMC10636704 DOI: 10.1016/j.jaip.2014.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 07/21/2014] [Accepted: 08/14/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Little is known about the adherence rate to allergen immunotherapy (AIT) labeling guidelines. OBJECTIVE To assess adherence to labeling guidelines of AIT Practice Parameter 2011 at University of Michigan Health Service. METHODS AIT vials of 320 patients who received their care at the University of Michigan Health Service were reviewed. Data collected looked at patient identifiers (PI), concentrations in volume/volume (v/v) format, color coding, allergen content, expiration date and instructions about AIT dosing, and systemic reaction treatment. Data were analyzed by using χ(2) test and the Fisher exact test and logistic regression. RESULTS Of 238 non-university formulated labels, 65% had 2 PIs, 62% had a v/v concentration, 41% had color coding, 71% had the content listed, and 100% had a recorded expiration date. Only 21% had all 5 recommended components. All 82 University vials had 5 components. Labels with 2 PIs were more likely to have a v/v concentration with its corresponding color coding (odds ratio [OR] 3.84 [95% CI, 1.9-7.7]; P < .001). Labels that specified the extract's content were more likely to be color coded or to have a v/v concentration listed (OR 6.3 [95% CI, 3.4-11.8]; P < .001). For all AIT vials, complete labels were significantly more likely to have a clear buildup schedule (OR 9.6 [95% CI, 4.2-23.2]; P < .001), dosing adjustment after a missed dose (OR 8.2 [95% CI, 3.4-19.8]; P < .001) or after a reaction (OR 13.7 [95% CI, 7.8-2.1]; P < .001), and clear systemic reaction treatment instructions (OR 9.7 [95% CI, 7.8-24.1]; P < .001). CONCLUSION Fewer than 25% of the nonuniversity prescribers adhered to AIT practice parameters 5 years after publication. Recording 2 PIs, the v/v concentration, or the color coding increased the likelihood of having a complete label. Complete label contents were associated with clear instructions about AIT dosing and reaction treatment and/or dose adjustments.
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Affiliation(s)
- Marilyn Karam
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | - Kiela Samuels
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich; University of Michigan School of Pharmacy, Ann Arbor, Mich
| | - Christine Holland
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich
| | | | - Matthew Greenhawt
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Mich; Child Health Evaluation and Research Unit, Division of General Pediatrics, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Mich.
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Schaffer FM, Naples AR, Ebeling M, Hulsey TC, Garner LM. The safety of self-administered allergen immunotherapy during the buildup and maintenance phases. Int Forum Allergy Rhinol 2015; 5:149-56. [PMID: 25476041 PMCID: PMC4465093 DOI: 10.1002/alr.21443] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 09/30/2014] [Accepted: 10/05/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Self-administered allergen immunotherapy is considered controversial. We believe the implementation of a self-administration protocol characterized by patient preselection and a slow buildup phase is safe. METHODS We analyzed 23,614 patient records and associated immunotherapy injections for systemic reactions (SR) during a 1-year period (2011 to 2012). SRs were graded in accordance with the World Allergy Organization (WAO) criteria. RESULTS Thirty-seven SRs were reported for 23,614 patients who self-administered 2,021,600 injections yielding an annual SR rate of 0.16% (per patient) or 0.002% (per injection). Only 9 of 4643 pediatric (0.19%) and 28 of 18,971 adult patients (0.15%) experienced 1 or more SRs. No deaths (grade V SR) occurred. From 2009 through early 2014, over 90,000 patients received more than 10 million injections in accordance with the United Allergy Services (UAS) protocol without fatalities. CONCLUSION We believe this safety profile is due to a preselection of patients to exclude those with a high risk for adverse reactions and a slow immunotherapy buildup phase. In contrast, previous studies documented office-based SRs ranging from approximately 3% to greater than 14%. Thus, the UAS home-immunotherapy SR rate is significantly lower than office-based immunotherapy SR rates (p < 0.0001). The enhanced safety of this protocol results in a decreased frequency and severity of SRs. This safety report, derived from analyses of one of the largest patient cohorts studied, corroborates and expands the observations of previous studies of self-administered subcutaneous immunotherapy in a low-risk patient population by assessing self-administered allergen immunotherapy during the buildup and maintenance phases.
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Affiliation(s)
- Frederick M. Schaffer
- United Allergy Services (UAS), San Antonio, TX
- Division of Pediatric Pulmonary, Allergy and Immunology, Medical University of South Carolina, Charleston, SC
| | | | - Myla Ebeling
- Division of Pediatric Epidemiology, Medical University of South Carolina, Charleston, SC
| | - Thomas C. Hulsey
- Division of Pediatric Epidemiology, Medical University of South Carolina, Charleston, SC
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Mixing compatibilities of Aspergillus and American cockroach allergens with other high-protease fungal and insect extracts. Ann Allergy Asthma Immunol 2015; 114:233-9. [PMID: 25578248 DOI: 10.1016/j.anai.2014.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 11/24/2014] [Accepted: 11/26/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Recent studies have shown that Alternaria and German cockroach allergens can be degraded by endogenous proteases from other insect and fungal extracts when combined for immunotherapy, but data supporting the compatibilities of other high-protease products in comparable mixtures have not been reported. OBJECTIVE To assess the stabilities and compatibilities of Aspergillus fumigatus and American cockroach allergens after mixing with protease-rich extracts from other insects or fungi at concentrations similar to those recommended for subcutaneous immunotherapy. METHODS Mixtures containing A fumigatus, American cockroach, and other fungal or insect extracts were evaluated by quantitative (enzyme-linked immunosorbent assays) and qualitative (immunoblotting) methods. Test mixtures and control samples at 10% to 50% glycerin concentrations were analyzed after storage for up to 12 months at 2°C to 8°C. RESULTS Moderate to high recoveries of Aspergillus extract activities were retained in control samples and extract mixtures under all conditions examined. American cockroach extract controls were partly degraded at 10% to 25% glycerin, and cockroach allergen compatibilities were decreased significantly in mixtures with several fungal extracts at 25% glycerin. Mixing with other insects did not compromise the stability of American cockroach allergens at 25% to 50% glycerin. CONCLUSION Aspergillus extracts exhibited favorable stabilities after mixing with other high-protease products. American cockroach extract potencies were unstable in less than 50% glycerin, even in the absence of other protease-containing allergens, and were destabilized in mixtures with several fungal extracts. Addition of fungal and insect extracts to separate treatment vials or preparation of fungal-insect mixtures at elevated glycerin concentrations might be necessary to produce compatible patient formulations for allergen immunotherapy injections.
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Park KH, Son M, Choi SY, Park HJ, Lee JH, Jeong KY, Lee JS, Park JW. In vitro evaluation of allergen potencies of commercial house dust mite sublingual immunotherapy reagents. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2014; 7:124-9. [PMID: 25729619 PMCID: PMC4341333 DOI: 10.4168/aair.2015.7.2.124] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 03/19/2014] [Accepted: 05/15/2014] [Indexed: 11/20/2022]
Abstract
Purpose The clinical efficacy of allergen-immunotherapy is known to be dose dependent. However, optimal maintenance dosage has not yet been determined for sublingual immunotherapy (SLIT). Furthermore, since companies adopt their own units for expression of allergenicity, the allergen concentrations of individual reagents cannot be compared easily. We sought to measure and compare the allergenicities of 3 commercially available house dust mite (HDM) SLIT regents and a subcutaneous immunotherapy reagent. Methods We measured the HDM allergenic potency of the maintenance dosages of three SLIT reagents: Staloral® (300 index of reactivity [IR] /mL, recommended maintenance dosage [MD]: 120 IR), SLITone® (1,000 standard therapeutic unit [STU]/mL, recommended MD: 200 STU), Wolwopharma® (100 µg/mL, recommended MD: 20 µg), and subcutaneous immunotherapy regents of Hollister-Stier (10,000 allergy unit [AU] /mL). The allergenic potency was assessed by measuring the total protein concentrations, mite group 1 and 2 allergens using 2-site ELISA, and an inhibition test against IgE specific to Dermatophagoides farinae and Dermatophagoides pteronyssinus. Results The protein content of the Wolwopharma® reagent was 1.5-261.4 times higher than that of the other 2 SLIT reagents. The concentration of group 1 major allergens in Staloral® (132.03 µg/mL) was 33- to 44.5-fold higher than in SLITone® (4.00 µg/mL) and Wolwopharma® (2.97 µg/mL). The concentration of group 2 major allergen was also 8.9- to 10.5-fold higher in Staloral® (15.7 µg/mL) than in SLITone® (1.8 µg/mL) or Wolwopharma® (1.5 µg/mL). An ELISA inhibition study against HDM-specific IgE showed that the allergen potency of Staloral® reagent is 8.5-fold and 21-fold higher than that of SLITone® or Wolwopharma®, respectively. The differences between the maintenance dosages are further exaggerated by the differences in the recommended volumes of SLIT reagents. Conclusions The allergen potencies of commercially available HDM SLIT reagents are markedly different. Consensus regarding the optimal allergen concentration for SLIT reagents used to treat HDM respiratory allergies is needed.
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Affiliation(s)
- Kyung Hee Park
- Department of Internal Medicine and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Mina Son
- Department of Internal Medicine and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Soo-Young Choi
- Department of Internal Medicine and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Hey Jung Park
- Department of Internal Medicine and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Hyun Lee
- Department of Internal Medicine and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Kyoung Yong Jeong
- Department of Internal Medicine and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
| | - Joo-Shil Lee
- Center for Immunology and Pathology, Korea National Institute of Health, Osong, Korea
| | - Jung-Won Park
- Department of Internal Medicine and Institute of Allergy, Yonsei University College of Medicine, Seoul, Korea
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Vieths S, Bieber T. [Personalised medicine for the diagnosis and treatment of allergic diseases]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2014; 56:1531-7. [PMID: 24170082 DOI: 10.1007/s00103-013-1821-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Immunoglobulin E (IgE) mediated allergic diseases are characterised by heterogeneous clinical phenotypes and a large variety of different sensitisation patterns. Apart from genetic predisposition several environmental factors play a role in sensitisation and elicitation of symptoms. Since the majority of clinically relevant allergens are now available as purified recombinant allergens component-resolved in vitro diagnosis allows the sensitization profile of allergic patients to be determined at the molecular level. Such data may allow physicians to draw conclusions on the severity and persistence of a given allergic disease and to predict the outcome of allergen-specific immunotherapy (SIT) However, the potential of this approach needs to be demonstrated in controlled clinical trials. Moreover, in the context of atopic dermatitis, allergic rhinitis, allergic bronchial asthma as well as the atopic march several screening-biomarkers, diagnostic and prognostic biomarkers, biomarkers of severity and predictive biomarkers are presented and discussed in this article. Traditionally a relevant proportion of allergen-specific immunotherapies is performed in a personalised manner using named patient products manufactured on the basis of an individual prescription. Such named patient products are often mixtures containing several allergen extracts from different sources. However, there is no proven evidence for the safety and efficacy of this approach. In Germany the Therapy Allergen Ordinance ("Therapieallergene-Verordnung", TAV) regulates that in the future allergen products for SIT of insect venom allergies, allergies to pollen of early flowering trees and grass pollen and house dust mite allergies cannot be marketed as named patient products, but always require a marketing authorisation. Thus personalised SIT with named patient products is restricted to the treatment of less prevalent allergies, for which the generation of state-of-the-art clinical data is more difficult. Several recombinant allergens are currently evaluated in phase III clinical trials. In contrast to allergen extracts recombinant allergens offer the possibility to treat patients with a precisely adjusted mixture of the disease-eliciting allergen molecules. However, the implementation of this personalised approach to SIT within the given regulatory framework represents a challenge to regulators.
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Affiliation(s)
- S Vieths
- Paul-Ehrlich-Institut, Bundesinstitut für Impfstoffe und biomedizinische Arzneimittel, Paul-Ehrlich-Str. 51-59, 63225, Langen, Deutschland,
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Lee S, Stachler RJ, Ferguson BJ. Defining quality metrics and improving safety and outcome in allergy care. Int Forum Allergy Rhinol 2014; 4:284-91. [PMID: 24449697 DOI: 10.1002/alr.21284] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 11/12/2013] [Accepted: 12/07/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND The delivery of allergy immunotherapy in the otolaryngology office is variable and lacks standardization. Quality metrics encompasses the measurement of factors associated with good patient-centered care. These factors have yet to be defined in the delivery of allergy immunotherapy. We developed and applied quality metrics to 6 allergy practices affiliated with an academic otolaryngic allergy center. METHODS This work was conducted at a tertiary academic center providing care to over 1500 patients. We evaluated methods and variability between 6 sites. Tracking of errors and anaphylaxis was initiated across all sites. A nationwide survey of academic and private allergists was used to collect data on current practice and use of quality metrics. RESULTS The most common types of errors recorded were patient identification errors (n = 4), followed by vial mixing errors (n = 3), and dosing errors (n = 2). There were 7 episodes of anaphylaxis of which 2 were secondary to dosing errors for a rate of 0.01% or 1 in every 10,000 injection visits/year. Site visits showed that 86% of key safety measures were followed. Analysis of nationwide survey responses revealed that quality metrics are still not well defined by either medical or otolaryngic allergy practices. Academic practices were statistically more likely to use quality metrics (p = 0.021) and perform systems reviews and audits in comparison to private practices (p = 0.005). CONCLUSION Quality metrics in allergy delivery can help improve safety and quality care. These metrics need to be further defined by otolaryngic allergists in the changing health care environment.
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Affiliation(s)
- Stella Lee
- Department of Otolaryngology-Head and Neck Surgery, Division of Sinonasal Disorders and Allergy, University of Pittsburgh Medical Center, Pittsburgh, PA
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Aryan Z, Compalati E, Comapalati E, Canonica GW, Rezaei N. Allergen-specific immunotherapy in asthmatic children: from the basis to clinical applications. Expert Rev Vaccines 2013; 12:639-59. [PMID: 23750794 DOI: 10.1586/erv.13.45] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Atopic asthma in childhood with the tendency to persist into adult life is an important issue in pediatrics. Allergen-specific immunotherapy (SIT) is the only curative treatment option for these children, being directed to the causes of the disease. The Th2 phenotype is a predominant immunological pattern in atopic asthma and SIT leads to apoptosis/anergy of T cells and induces immune-regulatory responses and immune deviation towards Th1. Many factors can affect the safety and efficacy of SIT, such as pattern of sensitization, allergy vaccine (allergen extracts, adjuvants and conjugated molecules), route of administration (subcutaneous or sublingual) and different treatment schedules. Overall, asthma symptoms and medication scores usually decrease following a SIT course and the most common observed side effects are restricted to local swelling, erythema and pruritus. Compared with conventional pharmacotherapy, SIT may be more cost effective, providing a benefit after discontinuation and a steroid-sparing effect. In addition, it can prevent new sensitizations in monosensitized asthmatic children. Microbial supplements such as probiotics, immunomodulatory substances like anti-IgE/leukotrienes, antibodies and newer allergen preparations such as recombinant forms have been tested to improve the efficacy and safety of SIT with inconclusive results. In conclusion, SIT provides an appropriate solution for childhood asthma that should be employed more often in clinical practice. Further studies are awaited to improve current knowledge regarding the mechanisms behind SIT and determine the most appropriate materials and schedule of immunotherapy for children with asthma.
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Affiliation(s)
- Zahra Aryan
- Molecular Immunology Research Center, Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Esch RE, Plunkett GA. Immunotherapy preparation guidelines, rules, and regulation. Curr Allergy Asthma Rep 2013; 13:406-13. [PMID: 23722699 DOI: 10.1007/s11882-013-0358-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Allergen immunotherapy has been used to treat allergic diseases for more than 100 years. In the U.S., the preparation of diagnostic and therapeutic extracts requires the cooperation of the extract manufacturer, who provides the individual allergen concentrates, and the practicing physician who formulates, dilutes, and administers the final patient-specific treatment extract. The guidelines, rules, and regulations for these activities have been established and continue to be developed as progress is made. The molecular characterization and standardization of allergenic extracts has allowed for improvements in defining the potency of these products. In turn, these advances have led to improved dosing regimens and formulation practices. This review will describe in detail some of these interactions and will identify issues that require more attention.
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Affiliation(s)
- Robert E Esch
- Greer Laboratories, 639 Nuway Circle, Lenoir, NC 28645, USA.
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Allergen immunotherapy extract treatment set preparation: making a safer and higher quality product for patients. Curr Allergy Asthma Rep 2013; 13:399-405. [PMID: 23881510 DOI: 10.1007/s11882-013-0362-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The best possible allergen immunotherapy clinical outcomes require the provision of high quality and safe allergen immunotherapy extract preparations. Evolving national guidelines and regulatory bodies have devoted special attention to the safe compounding of sterile products, including allergen extracts. It is incumbent upon allergists preparing extract treatment sets for patients to be familiar with and adopt training, procedures and safety measures that lead to standardized high quality products. Preparers and supervisors must maintain ongoing competency in aseptic technique and prescribing principles, such as probable effective dose ranges, allergen cross-reactivity, and separation of high protease-containing extracts from susceptible extracts. Accordingly, knowledge and application of vial labeling, diluent selection, standard operating procedures, mixing log documentation, and mixing condition principles are a necessity. Although there have been no instances of infectious complications from allergen immunotherapy in a century of clinical practice, continued vigilance in the use of measures that ensure extract sterility is paramount. A review of allergen immunotherapy preparation recommendations and best practices based on published national guidelines is presented. Further study of preparation measures and prescribing principles will continue to advance the practice of allergen immunotherapy and offer opportunities for refinement of current recommendations.
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Buckley L, Schmidt V, McEwan N, Nuttall T. Cross-reaction and co-sensitization among related and unrelated allergens in canine intradermal tests. Vet Dermatol 2013; 24:422-7, e91-2. [PMID: 23745529 DOI: 10.1111/vde.12044] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2013] [Indexed: 12/24/2022]
Abstract
BACKGROUND Intradermal tests are used to identify allergens for avoidance and immunotherapy in atopic dogs. HYPOTHESIS/OBJECTIVES To evaluate cross-reaction or co-sensitization among 53 intradermal test allergens. ANIMALS Six hundred and fifty-one client-owned dogs with atopic dermatitis. METHODS Intradermal tests were performed with 53 house dust/storage mite, epidermal, insect, tree, weed and grass pollen and mould allergens. Pairwise comparisons were used to calculate the odds ratios (ORs), 95% confidence intervals (CIs) and statistical significance for the results of each allergen pair, with significance at P < 0.0006 (Holm-Bonferroni correction to reduce the false-detection rate). RESULTS Apart from cotton, cockroach, red clover, grain smut and Penicillium, the results for the allergens within each group were statistically associated [ORs from 4.7 (CI 2.5-8.9) to 1229.4 (CI 166.5-1795.1); P = 0.0005 to P < 0.0001]. Excluding red clover and cotton, 94% of results between tree, weed and grass pollens were also statistically associated [ORs from 8.3 (CI 3.6-24.7) to 117 (CI 29.1-341); P = 0.0005 to P < 0.0001]. In contrast, few allergens from unrelated groups were statistically associated [ORs from 0.12 (CI 0.03-1.1) to 27.7 (CI 0.2-93); P = 1.0 to P < 0.0001]. The mean (SD) of the log e transformed ORs for the related and statistically associated allergens [5.3 (1.3)] was significantly greater than those for related but nonstatistically associated [1.7 (1.6)] or unrelated allergens [1.4 (1.4); P < 0.0001]. CONCLUSIONS AND CLINICAL IMPORTANCE This suggests that there is cross-reaction or co-sensitization between related allergens. This could have implications for allergen selection in testing and immunotherapy, but further studies are required to differentiate cross-reaction from co-sensitization.
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Affiliation(s)
- Laura Buckley
- The University of Liverpool School of Veterinary Science, Leahurst Campus, Chester High Road, Neston, Cheshire, CH64 7TE, UK
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37
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Frew AJ. Immunotherapy of allergic disease. Clin Immunol 2013. [DOI: 10.1016/b978-0-7234-3691-1.00104-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Frew AJ, DuBuske L, Keith PK, Corrigan CJ, Aberer W, Fischer von Weikersthal-Drachenberg KJ. Assessment of specific immunotherapy efficacy using a novel placebo score-based method. Ann Allergy Asthma Immunol 2012; 109:342-347.e1. [PMID: 23062390 DOI: 10.1016/j.anai.2012.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 07/25/2012] [Accepted: 08/25/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND In trials of allergen immunotherapy, allergen exposure is typically assessed by pollen counts, but these may misrepresent exposure if performed remotely from multiple study centers. OBJECTIVE To assess whether symptomatology in placebo-treated patients is a better measure of local allergen burden at individual centers in such trials. METHODS Data from a multicenter, placebo-controlled trial of preseasonal grass pollen immunotherapy were reanalyzed to identify the 4 weeks at each center in which the placebo-treated subjects had the highest combined symptom/medication scores (CSMS). The difference in CSMS between active and placebo groups was compared during the 4 peak placebo score weeks (PlSW) and the 4 peak pollen count weeks (PoCW). RESULTS The benefit of immunotherapy over placebo in the PlSW analysis (18.5%) was greater than in the PoCW analysis (13.6%), with increased statistical significance (P = .0001, .0038, respectively). Similar improved discrimination was observed when analyzing benefits in subgroups of patients with severe symptoms, a high disease burden, and in different geographical locations. CONCLUSION This novel PlSW analysis results in better discrimination of the effects of allergen immunotherapy compared with placebo and may be widely applicable in similar studies, both prospectively and retrospectively.
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Affiliation(s)
- Anthony J Frew
- Department of Respiratory Medicine, Royal Sussex County Hospital, Brighton, UK.
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Greenberger PA. Terminology, close-calls, and bracketology for allergy, asthma, and immunology. Ann Allergy Asthma Immunol 2012; 110:141-5. [PMID: 23548520 DOI: 10.1016/j.anai.2012.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 10/24/2012] [Accepted: 11/01/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Paul A Greenberger
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Pacciani V, Corrente S, Gregori S, Pierantozzi A, Silenzi R, Chianca M, Moschese V, Chini L, Angelini F. Correlation of Der p 2 T-cell responses with clinical characteristics of children allergic to house dust mite. Ann Allergy Asthma Immunol 2012. [PMID: 23176885 DOI: 10.1016/j.anai.2012.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND An understanding of the mechanisms responsible for the development and maintenance of allergic inflammation and their clinical implications is needed to develop specific and successful treatment for allergy. OBJECTIVES To characterize in vitro T-cell responses to Der p 2, one of the major allergens of house dust mite (HDM), and investigate potential correlations between clinical and laboratory parameters. METHODS Forty-two patients monosensitized to HDM and 10 age-matched, healthy children were studied. Dendritic cells pulsed with Der p 2 were used to stimulate autologous CD14(-) cells. Der p 2-specific T-cell activation markers, proliferation, and cytokine production profiles were examined. RESULTS Der p 2-specific T-cell activation markers, proliferation, and T(H)2 cytokine production were significantly higher in HDM patients compared with healthy controls. Moreover, a significant correlation between proliferation and T(H)2 cytokine production was observed. Within the allergic group, skin reaction to HDM was significantly stronger in patients with a Der p 2-specific T-cell response. Levels of HDM-specific IgE directly correlated with interleukin 5 and interleukin 13 levels and with skin prick test results and, ultimately, with the patient's family history of allergy. Furthermore, the presence of atopic march correlated with T-cell proliferation. CONCLUSION We found that, in HDM patients, Der p 2-specific T(H)2 responses, promoted by autologous dendritic cells in vitro, correlate with clinical parameters.
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Affiliation(s)
- Valentina Pacciani
- Department of Pediatrics, University of Rome Tor Vergata, Children's Hospital Bambino Gesù, Rome, Italy
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Bonini S. Regulatory aspects of allergen-specific immunotherapy: europe sets the scene for a global approach. World Allergy Organ J 2012; 5:120-3. [PMID: 23282336 PMCID: PMC3651208 DOI: 10.1097/wox.0b013e318272484e] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Sergio Bonini
- Department of Medicine Second University of Naples and Institute of Translational Pharmacology Italian National Research Council, Rome Italy
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Food and Drug Administration reclassification of allergens for diagnosis and treatment: now is the time to be heard. Ann Allergy Asthma Immunol 2012; 109:6-9. [PMID: 22727150 DOI: 10.1016/j.anai.2012.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 03/08/2012] [Accepted: 03/09/2012] [Indexed: 11/23/2022]
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