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Barker S, Daniels L, Chang YS, Chikovani T, DunnGalvin A, Gerdts JD, Gerth Van Wijk R, Gibbs T, Villarreal Gonzalez RV, Guzman-Avilan RI, Hanna H, Hossny E, Kolotilina A, Ortega Martell JA, Pacharn P, de Lira Quezada CE, Sibanda E, Stukus D, Tham EH, Venter C, Gonzalez-Diaz SN, Levin ME, Martin B, Warner JO, Munblit D. Allergy education and training for physicians. World Allergy Organ J 2021; 14:100589. [PMID: 34820046 PMCID: PMC8591183 DOI: 10.1016/j.waojou.2021.100589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 12/23/2022] Open
Abstract
The increasing prevalence of allergic diseases has placed a significant burden on global healthcare and society as whole. This has necessitated a rapid development of "allergy" as a specialist area. However, as allergy is so common and, for most, relatively easy to diagnose and control, all clinicians need to have basic knowledge and competence to manage mild disease and recognize when referral is required. The allergology specialty has not yet been recognized in many countries and even where allergy is fully recognized as a specialty, the approach to training in allergy differs significantly. In the light of recent developments in allergy diagnosis and management, there is an urgent need to harmonize core competences for physicians, as well as the standardization of core principles for medical education and post-graduate training in allergy. All physicians and allied health professionals must appreciate the multidisciplinary team (MDT) approach to allergy, which is key to achieving the highest standards in holistic care. Due to worldwide variation in resources and personnel, some MDT roles will need to be absorbed by the treating physician or other healthcare professionals. We draw particular attention to the role of psychological input for all allergy patients, dietetic input in the case of food allergy and patient education to support all patients in the supported self-management of their condition on a daily basis. A strong appreciation of these multidisciplinary aspects will help physicians provide quality patient-centered care. We consider that harmonization of allergy components within undergraduate curricula is crucial to ensure all physicians develop the appropriate allergy-related knowledge and skills, particularly in light of inconsistencies seen in the primary care management of allergy. This review from the World Allergy Organization (WAO) Education and Training Committee also outlines allergy-related competences required of physicians working with allergic patients and provides recommendations to promote harmonization of allergy training and practice worldwide.
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Affiliation(s)
- Sally Barker
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Lydia Daniels
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Yoon-Seok Chang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Tinatin Chikovani
- Department of Immunology, Tbilisi State Medical University, Tbilisi, Georgia
| | - Audrey DunnGalvin
- Applied Psychology and Paediatrics and Child Health, University College Cork, Cork, Ireland.,Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | | | - Roy Gerth Van Wijk
- Section of Allergology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Trevor Gibbs
- Association for Medical Education in Europe (AMEE), Dundee, Scotland, UK.,Independant Consultant in Primary Care and Medical Education
| | - Rosalaura V Villarreal Gonzalez
- Regional Center of Allergy and Clinical Immunology, University Hospital "Dr. Jose Eleuterio Gonzalez", Faculty of Medicine, Autonomous University of Nuevo León, Monterrey, Mexico
| | - Rosa I Guzman-Avilan
- Regional Center of Allergy and Clinical Immunology, University Hospital "Dr. Jose Eleuterio Gonzalez", Faculty of Medicine, Autonomous University of Nuevo León, Monterrey, Mexico
| | | | - Elham Hossny
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Anastasia Kolotilina
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | | | - Punchama Pacharn
- Department of Pediatrics, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Cindy E de Lira Quezada
- Regional Center of Allergy and Clinical Immunology, University Hospital "Dr. Jose Eleuterio Gonzalez", Faculty of Medicine, Autonomous University of Nuevo León, Monterrey, Mexico
| | - Elopy Sibanda
- Asthma, Allergy and Immune Dysfunction Clinic, Twin Palms Medical Centre, Harare, Zimbabwe.,Department of Pathology, Medical School, National University of Science and Technology, Bulawayo, Zimbabwe
| | - David Stukus
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Elizabeth Huiwen Tham
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore, Singapore.,Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Carina Venter
- Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children's Hospital Colorado, Colorado, USA
| | - Sandra N Gonzalez-Diaz
- Regional Center of Allergy and Clinical Immunology, University Hospital "Dr. Jose Eleuterio Gonzalez", Faculty of Medicine, Autonomous University of Nuevo León, Monterrey, Mexico
| | - Michael E Levin
- Division of Paediatric Allergy, Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| | - Bryan Martin
- Division of Allergy and Immunology, Department of Otolaryngology, The Ohio State University, Columbus, OH, USA
| | - John O Warner
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Daniel Munblit
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation.,Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom.,Solov'ev Research and Clinical Center for Neuropsychiatry, Moscow, Russian Federation
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2
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Daniels L, Barker S, Chang YS, Chikovani T, DunnGalvin A, Gerdts JD, Gerth Van Wijk R, Gibbs T, Villarreal-Gonzalez RV, Guzman-Avilan RI, Hanna H, Hossny E, Kolotilina A, Ortega Martell JA, Pacharn P, de Lira Quezada CE, Sibanda E, Stukus D, Tham EH, Venter C, Gonzalez-Diaz SN, Levin ME, Martin B, Munblit D, Warner JO. Harmonizing allergy care-integrated care pathways and multidisciplinary approaches. World Allergy Organ J 2021; 14:100584. [PMID: 34820045 PMCID: PMC8591185 DOI: 10.1016/j.waojou.2021.100584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/08/2021] [Accepted: 08/26/2021] [Indexed: 01/14/2023] Open
Abstract
There is a wide time gap between the publication of evidence and the application of new knowledge into routine clinical practice. The consequence is sub-optimal outcomes, particularly concerning for long-term relapsing/remitting conditions such as allergic diseases. In response, there has been a proliferation of published guidelines which systematically review evidence for the gold-standard management of most allergic disorders. However, this has not necessarily been followed by improved outcomes, partly due to a lack of coordination across the patient pathway. This has become known as the "second translational gap". A proposed solution is the development and implementation of integrated care pathways (ICPs) to optimize patient outcomes, with the notion that evidence-based medicine requires evidence-based implementation. ICP implementation is shown to improve short-term outcomes for acute conditions and routine surgery, including reduced length of hospital stay, improved documentation and improved patient safety. However, this improvement is not reflected in patient experience or patient-centered functional outcomes. The implementation of life-long, cost-effective interventions within comprehensive pathways requires a deep appreciation for complexity within allergy care. We promote an evidence-based methodology for the implementation of ICPs for allergic disorders in which all stakeholders in allergy care are positioned equally and encouraged to contribute, particularly patients and their caregivers. This evidence-based process commences with scoping the unmet needs, followed by stakeholder mapping. All stakeholders are invited to meetings to develop a common vision and mission through the generation of action/effect diagrams which helps build concordance across the agencies. Dividing the interventions into achievable steps and reviewing with plan/do/study/act cycles will gradually modify the pathway to achieve the best outcomes. While the management guidelines provide the core knowledge, the key component of implementation involves education, training, and support of all healthcare professionals (HCPs), patients and their caregivers. The pathways should define the level of competence required for each clinical task. It may be useful to leave the setting of care delivery or the specific HCP involved undefined to account for variable patterns of health service delivery as well as local socioeconomic, ethnic, environmental, and political imperatives. In all cases, where competence is exceeded, it is necessary to refer to the next stage in the pathway. The success and sustainability of ICPs would ideally be judged by patient experience, health outcomes, and health economics. We provide examples of successful programs, most notably from Finland, but recommend that further research is required in diverse settings to optimize outcomes worldwide.
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Affiliation(s)
- Lydia Daniels
- Faculty of Medicine, Imperial College London, London, UK
| | - Sally Barker
- Faculty of Medicine, Imperial College London, London, UK
| | - Yoon-Seok Chang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Tinatin Chikovani
- Department of Immunology, Tbilisi State Medical University, Tbilisi, Georgia
| | - Audrey DunnGalvin
- Applied Psychology and Paediatrics and Child Health, University College Cork, Cork, Ireland
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | | | - Roy Gerth Van Wijk
- Section of Allergology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Trevor Gibbs
- Association for Medical Education in Europe (AMEE), Dundee, Scotland, UK
- Independant Consultant in Primary Care and Medical Education, UK
| | - Rosalaura V. Villarreal-Gonzalez
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. Jose Eleuterio Gonzalez”, Faculty of Medicine, Autonomous University of Nuevo León, Monterrey, Mexico
| | - Rosa I. Guzman-Avilan
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. Jose Eleuterio Gonzalez”, Faculty of Medicine, Autonomous University of Nuevo León, Monterrey, Mexico
| | | | - Elham Hossny
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Anastasia Kolotilina
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | | | - Punchama Pacharn
- Department of Pediatrics, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Cindy E. de Lira Quezada
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. Jose Eleuterio Gonzalez”, Faculty of Medicine, Autonomous University of Nuevo León, Monterrey, Mexico
| | - Elopy Sibanda
- Asthma, Allergy and Immune Dysfunction Clinic, Twin Palms Medical Centre, Harare, Zimbabwe
- Department of Pathology, Medical School, National University of Science and Technology, Bulawayo, Zimbabwe
| | - David Stukus
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Elizabeth Huiwen Tham
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Carina Venter
- Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children's Hospital Colorado, Colorado, USA
| | - Sandra N. Gonzalez-Diaz
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. Jose Eleuterio Gonzalez”, Faculty of Medicine, Autonomous University of Nuevo León, Monterrey, Mexico
| | - Michael E. Levin
- Division of Paediatric Allergy, Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| | - Bryan Martin
- Division of Allergy and Immunology, Department of Otolaryngology, The Ohio State University, Columbus, OH, USA
| | - Daniel Munblit
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
- Solov'ev Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - John O. Warner
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
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Gonzalez-Diaz SN, Martin B, de Lira-Quezada CE, Villarreal-Gonzalez RV, Guzman-Avilan RI, Macías-Weinmann A, Ortega-Martell JA, Macouzet-Sanchez C, Sánchez-Borges M, Rosario Filho NA, Yañez A, Guzman-Melendez MA, Cardona R, Monge-Ortega OP, Cherrez-Ojeda I, Herrera-Castro D, Valentin-Rostan M, Sisul-Alvariza JC, Ansotegui IJ, Elizondo-Villarreal B. Current situation of allergy education in Mexico and other parts of Latin America. World Allergy Organ J 2021; 14:100543. [PMID: 34093955 PMCID: PMC8142083 DOI: 10.1016/j.waojou.2021.100543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 03/17/2021] [Accepted: 04/14/2021] [Indexed: 11/21/2022] Open
Abstract
Allergic diseases are one of the most frequent chronic diseases in the world. It has been established that there is a worldwide epidemic of allergic diseases; therefore, the treatment of allergies should be acknowledged as a worldwide priority and the specialty of allergy should be considered an important field in medicine. Due to the fact that allergic diseases involve many organs, and Allergy and Clinical Immunology is one of the specialties in which physicians may be trained to treat patients of all ages, the subject in medical schools is not always taught as an individual specialty but often as part of another subject such as internal medicine or pediatrics. Certified allergists are an important contribution to health systems, providing the necessary care for patients who have allergic diseases. Undergraduate programs in many universities do not include allergy as a subject, contributing to a lack of knowledge regarding the correct management of allergic diseases. World Health Organization (WHO) recommends 1 allergist per 50,000 people; however, there is an uneven distribution of allergy and clinical immunology specialists. Most practitioners are localized mainly in larger cities and state capitals, while in other regions, specialists are still greatly needed. Support and training systems are required for allergy and clinical immunology specialists to promote continuing education and keep their clinical competence up to date, which will lead to better care for their patients. Increased exposure to the concepts of allergy and clinical immunology diagnosis and treatment in undergraduate education may also potentially lead to an increase in interest in the field of allergy and clinical immunology among physicians in training. This review will approach allergy education in Mexico and other parts of Latin America.
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Affiliation(s)
- Sandra Nora Gonzalez-Diaz
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. José Eleuterio González”, Gonzalitos y Madero s/n Colonia Mitras Centro, Monterrey, NL, CP 64460, Mexico
| | - Bryan Martin
- Allergy and Immunology, The Ohio State University, Columbus, OH, USA
| | - Cindy Elizabeth de Lira-Quezada
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. José Eleuterio González”, Gonzalitos y Madero s/n Colonia Mitras Centro, Monterrey, NL, CP 64460, Mexico
| | - Rosalaura Virginia Villarreal-Gonzalez
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. José Eleuterio González”, Gonzalitos y Madero s/n Colonia Mitras Centro, Monterrey, NL, CP 64460, Mexico
| | - Rosa Ivett Guzman-Avilan
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. José Eleuterio González”, Gonzalitos y Madero s/n Colonia Mitras Centro, Monterrey, NL, CP 64460, Mexico
| | - Alejandra Macías-Weinmann
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. José Eleuterio González”, Gonzalitos y Madero s/n Colonia Mitras Centro, Monterrey, NL, CP 64460, Mexico
| | | | - Carlos Macouzet-Sanchez
- Regional Center of Allergy and Clinical Immunology, University Hospital “Dr. José Eleuterio González”, Gonzalitos y Madero s/n Colonia Mitras Centro, Monterrey, NL, CP 64460, Mexico
| | - Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico Docente La Trinidad, Clinica El Avila, Caracas, Venezuela
| | | | - Anahí Yañez
- Investigaciones en Alergia y Enfermedades Respiratorias - InAER, Buenos Aires, Argentina
| | | | | | | | | | | | | | | | - Ignacio J. Ansotegui
- Department of Allergy and Immunology, Hospital Quirónsalud Bizkaia Erandio, Bilbao, Spain
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Passalacqua G, Bagnasco D, Canonica GW. 30 years of sublingual immunotherapy. Allergy 2020; 75:1107-1120. [PMID: 31715001 DOI: 10.1111/all.14113] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/28/2019] [Accepted: 11/02/2019] [Indexed: 12/12/2022]
Abstract
Allergen Immunotherapy (AIT) was introduced in clinical practice on an empirical basis more than 100 years ago. Since the first attempts, AIT was administered subcutaneously. Indeed, other routes of administration were proposed and studied, in particular to improve the safety, but only the sublingual route (SLIT) achieved a credibility based on evidence and was then accepted as a viable "alternative" option to the subcutaneous route. SLIT was largely used in clinical trials and clinical practice in this last 30 years. Thus, a large amount of data is available, coming from either controlled trials and postmarketing surveillance studies. It is clear that SLIT is overall effective, but it is also clear that the efficacy is not "class-related," as derived from meta-analyses, but restricted to each specific product. The 30-year lasting use of SLIT allowed to clarify many clinical aspects, such as efficacy, safety, use in asthma, regimens of administration, and optimal doses. In parallel, the mechanisms of action of AIT were elucidated, and new indications were proposed (eg food allergy, atopic dermatitis). In addition, the introduction of molecular-based diagnosis, allowed to better refine the prescription of SLIT, based on specific sensitization profiles. The present article will describe the origin and evolution of SLIT for respiratory allergy, taking into account the clinical context that suggested this form of treatment, the recently developed aspects, the future perspectives and unmet needs, This is not, therefore, a systematic review, rather a narrative historical description of the past history, and a look forward to the future opportunities.
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Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases IRCCS Policlinico San Martino ‐University of Genoa Genoa Italy
| | - Diego Bagnasco
- Allergy and Respiratory Diseases IRCCS Policlinico San Martino ‐University of Genoa Genoa Italy
| | - Giorgio Walter Canonica
- Allergy and Respiratory Diseases IRCCS Policlinico San Martino ‐University of Genoa Genoa Italy
- Personalized Medicine Asthma & Allergy ‐ Humanitas Clinical and Research Center IRCCS Rozzano (MI) Italy
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Hossny E, Ebisawa M, El-Gamal Y, Arasi S, Dahdah L, El-Owaidy R, Galvan CA, Lee BW, Levin M, Martinez S, Pawankar R, Tang ML, Tham EH, Fiocchi A. Challenges of managing food allergy in the developing world. World Allergy Organ J 2019; 12:100089. [PMID: 31871534 PMCID: PMC6909084 DOI: 10.1016/j.waojou.2019.100089] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 02/07/2023] Open
Abstract
Food allergy (FA) is currently a significant health care problem in the developing world. Widely varying study populations and methodologies, the use of surrogate markers such as self report or hospitalization rates due to anaphylaxis rather than objective methods, limits robust estimation of FA prevalence in low income settings. Also, allergy is under-recognized as a clinical specialty in the developing world which compromises the chance for accurate diagnosis. In this review, most published data on food allergens from developing or low income countries are displayed. The diagnostic challenges and limitations of treatment options are discussed. It seems that FA is an under-appreciated health care issue in the developing world, and accurate determination of its burden in low-income settings represents an important unmet need. Multicenter surveillance studies, using standardized methodologies, are, therefore, needed to reveal the true extent of the problem and provide epidemiological clues for prevention. Preventive strategies should be tailored to fit local circumstances in different geographic regions. In addition, studying the gene environment interactions and impact of early life microbiota on the expression of FA in developing communities would be worthwhile. Efforts and resources should be directed toward public health education and training of health care providers dealing with food allergic patients.
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Affiliation(s)
- Elham Hossny
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
| | - Yehia El-Gamal
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Lamia Dahdah
- Pediatric Hospital Bambino Gesù, Vatican City, Italy
| | - Rasha El-Owaidy
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Cesar A. Galvan
- Centro Nacional de Referencia de Alergia Asma e Inmunología (CERNAAI), Instituto Nacional de Salud del Niño, Lima-Perú, Peru
| | - Bee Wah Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Michael Levin
- Division Paediatric Allergology, University of Cape Town, Red Cross Children's Hospital, Cape Town, South Africa
| | - Santiago Martinez
- Arnold Palmer Hospital for Children, Florida State University College of Medicine, Florida, United States
| | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Mimi L.K. Tang
- Department of Allergy and Immunology, The Royal Children's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Department of Paediatrics, University of Melbourne, Victoria, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Victoria, Melbourne, Australia
| | - Elizabeth H. Tham
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Passalacqua G, Bagnasco D, Ferrando M, Heffler E, Puggioni F, Canonica GW. Current insights in allergen immunotherapy. Ann Allergy Asthma Immunol 2019; 120:152-154. [PMID: 29413339 DOI: 10.1016/j.anai.2017.11.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/26/2017] [Accepted: 11/03/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Allergen-specific immunotherapy (AIT) in its subcutaneous and sublingual forms is currently a well-established and experimentally supported treatment for respiratory allergy and hymenoptera venom allergy. There have been advances in its use linked strictly to the advancement in the knowledge of the molecular mechanisms of allergy, the production of well-characterized extracts, and diagnostic techniques. The use of AIT in asthma and the application of new approaches are expanding. We briefly review the advances and concerns in the use of AIT. DATA SOURCES PubMed and Scopus. STUDY SELECTIONS The most recent and clinically relevant literature was selected and reviewed. RESULTS The introduction of high-quality products supported by large dose-finding trials has yielded better defined indications, contraindications, and modalities of use. Some specific products in tablet form have recently been approved in the United States. Sublingual immunotherapy has been found to be effective in asthma, which until recently had been a matter of debate. Another promising therapy is oral and sublingual desensitization for food allergy, for which encouraging results have recently been reported. In the near future, other options will be available, including new routes of administration (intralymphatic and epicutaneous), allergoids, engineered allergens, and peptides. The use of component-resolved diagnosis techniques will further refine and target AIT prescriptions. CONCLUSION This condensed and updated review shows that AIT remains a viable treatment option, especially after the introduction of standardized tablets for some allergens. Food allergy and new administration routes represent a promising expansion.
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Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases, Policlinico San Martino, Department of Internal Medicine, University of Genoa, Genoa, Italy.
| | - Diego Bagnasco
- Allergy and Respiratory Diseases, Policlinico San Martino, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Matteo Ferrando
- Allergy and Respiratory Diseases, Policlinico San Martino, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Enrico Heffler
- Personalized Medicine Clinic Asthma and Allergy, Humanitas Clinical and Research Center, Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Francesca Puggioni
- Personalized Medicine Clinic Asthma and Allergy, Humanitas Clinical and Research Center, Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Giorgio Walter Canonica
- Allergy and Respiratory Diseases, Policlinico San Martino, Department of Internal Medicine, University of Genoa, Genoa, Italy; Personalized Medicine Clinic Asthma and Allergy, Humanitas Clinical and Research Center, Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
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Patient selection for subcutaneous versus sublingual immunotherapy. Curr Opin Allergy Clin Immunol 2016; 15:588-95. [PMID: 26485098 DOI: 10.1097/aci.0000000000000219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW With the Food and Drug Administration's approval of sublingual allergen-specific immunotherapy (SL-AIT) tablets for grass and ragweed pollen, SL-AIT is progressively gathering importance not only in Europe, but also in the United States and other parts of the world. We reviewed issues related to the selection of patients for the sublingual or the subcutaneous route for allergic patients, based on what has been published since January 2014 on subcutaneous-versus-SL-AIT efficacy, safety and other issues. (Figure is included in full-text article.) RECENT FINDINGS As patient's adherence seems one of the major problems in real-life AIT, investigators have sought how to enhance AIT simplicity by changing the route to home-administrated SL-AIT, and by shortening the subcutaneous-allergen-specific immunotherapy (SC-AIT) build-up or maintenance phase. The latter was safe with several hypoallergenic extracts. As for SL-AIT, double blind placebo-controlled large trials in patients with allergic rhinitis and asthma have shown the efficacy and safety of ragweed pollen and house dust mite SLIT tablets and highly concentrated liquid formulations, primarily in adults. A large trial with SLIT in 3-year-old children was effective. SUMMARY With the improvement of SL-AIT efficacy, the selection of SC-versus-SL-AIT will probably increasingly be based not on efficacy, but on practical aspects, without losing sight of which SL-AIT products have proven efficacy.
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8
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Passalacqua G, Canonica GW. Allergen Immunotherapy: History and Future Developments. Immunol Allergy Clin North Am 2015; 36:1-12. [PMID: 26617223 DOI: 10.1016/j.iac.2015.08.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Allergen immunotherapy (AIT) was introduced in clinical practice more than 100 years ago. The clinical effectiveness in allergic rhinitis (and asthma) and in hymenoptera allergy was apparent early on but it was not until the mid-1900s that randomized placebo-controlled trials proved its efficacy. In the 1980s, sublingual immunotherapy (SLIT) was accepted in official guidelines. The availability of safer routes, such as SLIT, prompted increasing investigation of AIT for food allergy. The introduction of molecular-based diagnosis introduced the possibility of better targeted prescription of AIT. Other approaches are being explored, such as immunogenic peptides, recombinant allergens, and adjuvants.
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Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino-IST, University of Genoa, Genoa 16132, Italy.
| | - Giorgio Walter Canonica
- Allergy and Respiratory Diseases, IRCCS San Martino-IST, University of Genoa, Genoa 16132, Italy
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Bachert C, Larché M, Bonini S, Canonica GW, Kündig T, Larenas-Linnemann D, Ledford D, Neffen H, Pawankar R, Passalacqua G. Allergen immunotherapy on the way to product-based evaluation-a WAO statement. World Allergy Organ J 2015; 8:29. [PMID: 26417398 PMCID: PMC4571059 DOI: 10.1186/s40413-015-0078-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/23/2015] [Indexed: 12/16/2022] Open
Abstract
Allergen immunotherapy (AIT) is widely used in clinical practice for patients with moderate to severe allergic rhinitis due to inhalant allergens and may be delivered via subcutaneous (SCIT) and sublingual routes (SLIT). However, the quality of evidence for individual AIT products is very heterogeneous, and extensions of overall conclusions ("class effects") on the efficacy and disease-modifying effects to all AIT products are unjustified. In contrast, each product needs to be evaluated individually, based on available study results, to justify efficacy and specific claims on sustained and disease modifying effects per allergen and targeted patient group (children vs. adults, allergic rhinitis vs. asthma). WAO intends to support the current development to evidence-based AIT, which ultimately will lead to a more efficacious treatment of allergic patients and the appropriate recognition of AIT.
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Affiliation(s)
- Claus Bachert
- />Upper Airway Research Laboratory, University of Ghent, Ghent, Belgium
| | - Mark Larché
- />Firestone Institute for Respiratory Health, Department of Medicine, St. Joseph’s Hospital Healthcare, McMaster University, Hamilton, Canada
| | | | - Giorgio Walter Canonica
- />Allergy and Respiratory Diseases, DIMI Department of Internal Medicine, University of Genova, IRCCS AOU S. Martino, Genova, Italy
| | - Thomas Kündig
- />Department of Dermatology, University Hospital Zurich, Zürich, Switzerland
| | | | - Dennis Ledford
- />Morsani College of Medicine, University of South Florida, Tampa, Florida USA
| | - Hugo Neffen
- />Head, Respiratory Medicine Unit, Orlando Alassia Hospital, Santa Fe, Argentina
| | - Ruby Pawankar
- />Division of Allergy, Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Giovanni Passalacqua
- />Allergy and Respiratory Diseases, DIMI Department of Internal Medicine, University of Genova, IRCCS AOU S. Martino, Genova, Italy
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Pajno GB, Nadeau KC, Passalacqua G, Caminiti L, Hobson B, Jay DC, Arasi S, Chiera F, Salzano G. The evolution of allergen and non-specific immunotherapy: past achievements, current applications and future outlook. Expert Rev Clin Immunol 2014; 11:141-54. [PMID: 25454510 DOI: 10.1586/1744666x.2015.977260] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Recent epidemiological studies estimated that more than 30% of European suffer from allergic rhinitis or conjunctivitis, while up to 20% suffer from asthma and 15% from allergic skin conditions, while for many other regions the prevalence is increasing. Allergen immunotherapy represents the only available treatment that can modify the allergic disease process, and thus is worth considering as a treatment in affected individuals. A beneficial effect of allergen immunotherapy has been shown in both adults and children affected by allergic rhinitis, allergic conjunctivitis, allergic asthma and hymenoptera venom allergy. The present study represents an overview on allergen immunotherapy, focusing on the principal aspects of the use of immunotherapy in the past, its recent clinical applications and future outlook.
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Affiliation(s)
- Giovanni B Pajno
- Department of Pediatrics- Allergy Unit, University of Messina, Via Consolare Valeria-Gazzi, 98124 Messina, Italy
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Diaz Rodriguez A, Rosado AL, Almarales RLC, Castelló MÁ. Current status and future perspectives of immunotherapy in Latin America and Cuba. World Allergy Organ J 2014; 7:28. [PMID: 25829980 PMCID: PMC4363362 DOI: 10.1186/1939-4551-7-28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 09/17/2014] [Indexed: 11/02/2022] Open
Abstract
Most Latin-American countries use subcutaneous immunotherapy (SCIT) extracts from the United States and Europe and sublingual immunotherapy (SLIT) from Europe, with the exception of Argentina, Brazil, Cuba and Mexico. The number of researches on immunotherapy (IT) in Latin America has increased extensively in the last years. Only few Latin American countries have their own guidelines on IT, and, in general, the economic resources for medical research on IT are still low in the area. A global approach for the future of IT in Latin America includes to improve standardization, quality control and the production of allergen products, to develop IT guidelines and clinical investigation by the highest number of countries, to improve the regulatory status for allergens products in the area, and to expand IT accessibility for low-income patients. In Cuba, the first registered allergen vaccines were developed and registered in 2006: a standardized (in biologic units) and freeze dried product for SCIT, with a sublingual version developed in 2009. As much as 23.000 IT treatments were applied in 2011, all provided to patients free of charge. In 2012, Cuban researchers developed an IT vaccine with adjuvant for subcutaneous route, which uses Neisseria meningitidis proteoliposome as an adjuvant, added to the purified Dermatophagoides siboney major allergens: Der s1 and Der s2. Since December 2012, this vaccine is in Phase I clinical trial, evaluating its safety, tolerability and immunogenicity in asthmatic patients sensitized to this allergen. Cuban perspectives on IT includes to work on new indications for IT, to investigate the preventive effect and cost-effectiveness for the current vaccines, to develop new products with mixed formulas of house dust mites for SLIT, to complete the phase I and II clinical study for dust mite plus adjuvant vaccine, to develop allergen vaccines for fungi allergy and to complete the Cuban guideline for allergen IT management.
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