Sublingual immunotherapy: A focused allergen immunotherapy practice parameter update

Anaphylaxis in Practice: A Guide to the 2023 Practice Parameter Update

This review summarizes new research developments and clinical practice recommendations for the diagnosis and management of anaphylaxis presented in the Joint Task Force on Practice Parameters 2023 Anaphylaxis practice parameter Update. It is intended to serve as a high-level summary of the 2023 practice parameter, which makes clinically impactful recommendations based on evidence that has emerged since the 2015 practice parameter. We invite clinicians to explore the full 2023 practice parameter to understand the research methods and underlying evidence that have informed the recommendations summarized here. There are new and evolving diagnostic criteria for anaphylaxis, rules for defining elevated tryptase levels, and recognition of signs and symptoms particular to infants and toddlers. The administration of epinephrine should not be used as a surrogate to diagnose anaphylaxis. Risk factors for anaphylaxis should be assessed on a case-by-case basis. Patient counseling and shared decision-making are essential to support patients' treatment decisions and capacity to manage the risk of anaphylaxis at home and in other community settings. Activation of emergency medical services after home epinephrine administration may not be required in all cases, and patients should be engaged in shared decision-making to determine when home management may be appropriate.

Allergen Immunotherapy: The Evidence Supporting the Efficacy and Safety of Subcutaneous Immunotherapy and Sublingual Forms of Immunotherapy for Allergic Rhinitis/Conjunctivitis and Asthma

Allergen immunotherapy (AIT) is a recognized key therapeutic modality for the treatment of allergic respiratory disease. Definitive studies have provided evidence-based data to demonstrate its effectiveness in allergic rhinitis and asthma due to the inhalation of proteinaceous allergic substances from specific seasonal pollens, dust mites, animal allergens, and certain mold spores. Over the ensuing decades, laboratory investigations have provided objective evidence to demonstrate immunologic changes, including production of protective IgG antibody, suppression of IgE antibody, upregulation of regulatory T cells, and induction of a state of immune tolerance to the offending allergen(s). Tangential to this work were carefully designed clinical studies that defined allergen dose and duration of treatment, established the importance of preparing extracts with standardized allergens (or well-defined extracts) based on major protein moieties, and used allergen provocation models to demonstrate efficacy superior to placebo. In the United States, the use of subcutaneous immunotherapy extracts for AIT was grandfathered in by the Food and Drug Administration based on expert literature review. In contrast, sublingual tablet immunotherapy underwent formal clinical development programs (phase I-III clinical trials) that provided the necessary clinical evidence for safety and efficacy that led to regulatory agency approvals for the treatment of allergic rhinitis in properly characterized patients with allergy. The allergy specialist's treatment options currently include traditional subcutaneous AIT and specific sublingual tablets approved for grass, ragweed, house dust mites, trees belonging to the birch-homologous group, and Japanese cedar. Tangential to this are sublingual drops that are increasingly being used off-label (albeit not approved by the Food and Drug Administration) in the United States. This article will review the evidence-based literature supporting the use of these forms of AIT, as well as focus on several current controversies and gaps in our knowledge base that have relevance for the appropriate selection of patients for treatment with specific AIT.

Clinical Practice Guideline: Immunotherapy for Inhalant Allergy

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.

Anaphylaxis: A 2023 practice parameter update

This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.

The KAAACI Guidelines for Sublingual Immunotherapy

Allergen immunotherapy is regarded as the only disease-modifying treatment option for various allergic conditions, including allergic rhinitis and asthma. Among the routes of administration of allergens, sublingual immunotherapy (SLIT) has gained clinical interest recently, and the prescription of SLIT is increasing among patients with allergies. After 30 years of SLIT use, numerous pieces of evidence supporting its efficacy, safety, and mechanism allows SLIT to be considered as an alternative option to subcutaneous immunotherapy. Based on the progressive development of SLIT, the current guideline from the Korean Academy of Asthma, Allergy, and Clinical Immunology aims to provide an expert opinion by allergy, pediatrics, and otorhinolaryngology specialists with an extensive literature review. This guideline addresses the use of SLIT, including 1) mechanisms of action, 2) appropriate patient selection for SLIT, 3) the currently available SLIT products in Korea, and 4) updated information on its efficacy and safety. This guideline will facilitate a better understanding of practical considerations for SLIT.

Approach to Idiopathic Anaphylaxis in Adolescents

Anaphylaxis is a potentially-life threatening condition. Adolescents are particularly vulnerable due to increased risk-taking behaviors, poor disease management, and minimized perception of risk. Although most anaphylaxis can be attributed to food, drug, or venom allergy via a detailed history and confirmatory studies, in nearly 1 in 5 cases, the cause may not be obvious. Clinical differentials including rare allergens, cofactors, mast-cell disorders, and mimic disorders can increase the likelihood of discovering of the cause of anaphylaxis.

Safety of allergen immunotherapy in children

PURPOSE OF REVIEW

The current review discusses allergen immunotherapy (AIT) safety in children.

RECENT FINDINGS

AIT is a well tolerated and effective treatment for pediatric allergic conditions. While mostly well tolerated, severe reactions and near fatal reactions may occur with subcutaneous immunotherapy (SCIT) once in every 160 000 visits. Sublingual immunotherapy (SLIT) is associated more with local side effects, but severe systemic reactions, including anaphylaxis, have been rarely reported. Providing informed consent, recognizing risk factors for severe systemic reactions, such as severe or uncontrolled asthma, and mitigating the risk of severe reactions are important components to improving the safety of AIT.

SUMMARY

Overall, AIT is well tolerated in children, and data suggest that the incidence of systemic reactions in children receiving SCIT is no less than mixed populations of adult and pediatric patients. SLIT carries less risk for systemic reactions, and local oral site-application reactions are usually mild and resolve within 15 days of treatment.

Efficacy of Sublingual Immunotherapy in Allergic Rhinitis Patients with Asthma: A Systematic Review and Meta-Analysis

OBJECTIVE

Sublingual immunotherapy (SLIT) has been widely applied to treat patients with allergic rhinitis (AR). However, meta-analyses on the efficacy of SLIT in AR patients with asthma are still limited.

METHODS

Literature without language limitation published before October 28, 2022, were retrieved from PubMed, EMBASE, and Cochrane Library. STATA 16.0 software was used for the meta-analysis of the extracted data. The results reported were symptom scores, drug scores, adverse effects rates, and cost of treatment.

RESULTS

Ten studies involving 1722 patients met the inclusion criteria. The total rhinitis score (TRSS) (weighted mean difference [WMD] = -1.23, 95% CI: -1.39--1.06, P < .001) and total asthma symptom score (TASS) (WMD = -1.00, 95% CI: -1.12-0.89, P < .001) were significantly lower in the SLIT group than the placebo group. The SLIT group had higher rates of treatment-related adverse events (relative risk [RR] = 2.82, 95% CI: 1.77-4.48, P < .001) and total costs of treatment (standardized mean difference [SMD] = 0.71, 95% CI: 0.45-0.97, P < .001). There was no significant difference in inhaled corticosteroids (ICS) dose (P = .195), fractional exhaled nitric oxide (FeNO) (P = .158), forced expiratory volume in 1 s (FEV1) (P = .237), and direct costs of treatment (P = .630) between the SLIT and placebo groups.

CONCLUSION

SLIT may be a therapeutic method for improving rhinitis symptoms and asthma symptoms in AR patients with asthma. However, as there was significant heterogeneity in results, more high-quality and well-designed studies are needed in the future to elucidate the efficacy of SLIT.

KAAACI Guidelines for Allergen Immunotherapy

Allergen immunotherapy (AIT) is a causative treatment for various allergic diseases such as allergic rhinitis, allergic asthma, and bee venom allergy that induces tolerance to offending allergens. The need for uniform practice guidelines in AIT is continuously growing because of the increasing discovery of potential candidates for AIT and evolving interest in new therapeutic approaches. This guideline is an updated version of the Korean Academy of Asthma Allergy and Clinical Immunology recommendations for AIT published in 2010. This updated guideline proposes an expert opinion by allergy, pediatrics, and otorhinolaryngology specialists with an extensive literature review. The guideline deals with basic knowledge and methodological aspects of AIT, including mechanisms, clinical efficacy, patient selection, allergens extract selection, schedule and doses, management of adverse reactions, efficacy measurements, and special consideration in pediatrics. The guidelines for sublingual immunotherapy will be covered in detail in a separate article.

A practical guide to prescribing sublingual immunotherapy tablets in North America for pediatric allergic rhinoconjunctivitis: an injection-free allergy immunotherapy option

Allergic rhinoconjunctivitis (ARC) is a common disease that affects individuals of all ages. Pediatricians may be the first (and only) point of care for children with ARC. Sublingual immunotherapy (SLIT)-tablets are a convenient at-home, injection-free allergy immunotherapy option that can be used for the treatment of ARC. This paper provides a practical guide for pediatricians to aid in prescribing SLIT-tablets to children with ARC in North America. Topics include a summary of the available SLIT-tablets and their efficacy and safety, guidance on when SLIT-tablets are an appropriate option, and how to diagnose ARC and identify culprit allergens. Practical guidance is also provided through a proposed decision tree, a prescribing checklist and prescribing procedures, and suggested follow-up assessments.

A case of food and aeroallergen sublingual immunotherapy inducing eosinophilic esophagitis

Eosinophilic esophagitis (EoE) has been reported secondary to aeroallergen sublingual immunotherapy (SLIT) and food allergen oral immunotherapy. Gastrointestinal symptoms with food allergen SLIT are uncommon, with no prior reports of cases of food allergen SLIT inducing EoE. Here we report a patient who developed EoE secondary to food and aeroallergen SLIT therapy that resolved with SLIT cessation.

Adverse events in children and adolescents undergoing allergen immunotherapy for respiratory allergies-Report from the Allergen Immunotherapy Adverse Events Registry (ADER), a European Academy of Allergy and Clinical Immunology taskforce

BACKGROUND

Although it has been shown that allergen immunotherapy (AIT) is well-tolerated in children, systematic and prospective surveillance of AIT safety in real life settings is needed.

METHODS

The multinational Allergen Immunotherapy Adverse Events Registry (ADER) was designed to address AIT safety in real life clinical practice. Data on children ≤18 years old with respiratory allergies undergoing AIT were retrieved. Patient- and AIT-related features were collected and analyzed. The characteristics of adverse events (AE) and risk factors were evaluated.

RESULTS

A total of 851 patients, 11.3 ± 3.4 years old, with rhinitis only (47.6%); asthma and rhinitis (44.5%); asthma (7.9%), receiving 998 AIT courses were analyzed. Sublingual immunotherapy (SLIT) accounted for 51% of the courses. In 84.5% of patients only one AIT treatment was prescribed. Pollen was the most frequent sensitizer (57.1%), followed by mites (53.4%), molds (18.2%) and epithelia (16.7%). Local and systemic AEs were reported in 85 patients (9.9%). Most AEs (83.1%) were mild and occurred in <30 min (87%). Respiratory and cutaneous symptoms were more frequent. Only 4 patients (0.47%) had severe AE (none after 6 weeks of maintenance). The risk of AE was higher in patients undergoing SCIT.

CONCLUSIONS

AIT is safe and well tolerated in children and adolescents with respiratory allergies in real-life clinical practice. Though SCIT is more prone to AE compared to SLIT, overall severe reactions are rare and occur during build-up and early maintenance.

Comparison of allergen immunotherapy practice patterns in inhalant allergies in the United States of America and Europe: Similarities and differences 2023

IgE-mediated atopic diseases such as allergic rhinitis and rhinoconjunctivitis are common chronic diseases in the western world. Allergen immunotherapy (AIT) plays a fundamental role in the treatment of allergic patients by modulating the underlying immune mechanisms. Though this treatment is integrated in practice-patterns globally, many differences are found in the application of AIT on the national or international level due to heterogeneous methods, and clinical recommendations are given in different parts of the world. This review from authors in Europe and the United States highlights differences and similarities in important aspects of AIT application in the 2 global regions. First, the regulatory situation differs regarding marketing authorization and licensing. Secondly, differences are elaborated in manufacturing practices, marketing distribution and formulations of AIT products. Thirdly, clinical administration patterns in the current guidelines show similarities in indications and contraindications of AIT, but also are divergent in some practical aspects. Informing the readership on similarities, as well as differences of standards in AIT in the United States and Europe, the authors highlight the unmet need of thorough harmonization of standards of AIT, as it is the only disease modifying treatment option available for patients with allergic rhinitis and rhinoconjunctivitis.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Allergen immunotherapy for allergic asthma: The future seems bright

Allergen specific immunotherapy (AIT) is the only causal therapeutic option for allergic airway diseases including asthma and allergic rhinitis. AIT has been shown to restore the allergen immune tolerance, can modify both the early and late-onset allergen-specific airway hyperreactivity, helps to achieve disease control/remission and prevents new sensitisations. Recent real life data on long-term effectiveness of house dust mite (HDM) AIT in a large group of patients with HDM-driven asthma further underscored its unique therapeutic potential as well as confirmed previous data with pollen AIT. More widespread use of this causal treatment in select patient populations should further move this promising therapeutic field. In this mini-review, we discuss updates on new insights based on real world patient data.

A Synopsis of Guidance for Allergic Rhinitis Diagnosis and Management From ICAR 2023

An updated edition of the International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR) has recently been published. This consensus document, which included the participation of 87 primary authors and 40 additional consultant authors, who critically appraised evidence on 144 individual topics concerning allergic rhinitis, provides guidance for health care providers using the evidence-based review with recommendations (EBRR) methodology. This synopsis highlights topical areas including pathophysiology, epidemiology, disease burden, risk and protective factors, evaluation and diagnosis, aeroallergen avoidance and environmental controls, single and combination pharmacotherapy options, allergen immunotherapy (subcutaneous, sublingual, rush, cluster), pediatric considerations, alternative and emerging therapies, and unmet needs. Based on the EBRR methodology, ICAR:AR includes strong recommendations for the treatment of allergic rhinitis: (1) for the use of newer generation antihistamines compared with first-generation alternatives, intranasal corticosteroid, intranasal saline, combination therapy with intranasal corticosteroid plus intranasal antihistamine for patients not responding to monotherapy, and subcutaneous immunotherapy and sublingual tablet immunotherapy in properly selected patients; (2) against the use of oral decongestant monotherapy and routine use of oral corticosteroids.

A Cost-Utility Analysis of SQ® Tree SLIT-Tablet versus Placebo in the Treatment of Birch Pollen Allergic Rhinitis from a Swedish Societal Perspective

Background and Aims

Allergic rhinitis (AR) is an immunoglobulin E antibody-mediated inflammatory condition that arises in response to inhaled allergens such as pollen. Pollens from trees in the birch homologous group are the most common allergenic tree pollens in Northern and Central Europe and North America. SQ® Tree SLIT-Tablet (ITULAZAX®) is a sublingual immunotherapy tablet indicated for moderate-to-severe AR and/or conjunctivitis induced by pollen from the birch homologous group. The present analysis evaluated the cost-utility of treating adults with AR with SQ Tree SLIT-Tablet versus placebo, both in combination with symptom-relieving medications, from a Swedish societal perspective.

Methods

A model was developed to evaluate changes in cost and quality of life associated with using SQ Tree SLIT-Tablet relative to placebo in an adult population of individuals with AR. The model captured costs associated with symptom-relieving medications, healthcare professional interactions, SQ Tree SLIT-Tablet, and indirect costs arising from absenteeism and reduced workplace productivity. The analysis was conducted over 10 years with costs captured in 2021 Swedish Krona (SEK) and future costs and effects discounted at 3% per annum. One-way and probabilistic sensitivity analyses were conducted.

Results

Treatment with SQ Tree SLIT-Tablet resulted in an improvement of 0.041 quality-adjusted life years (QALYs) over 10 years versus placebo. From a Swedish societal perspective, costs increased by SEK 9077 over the same period, resulting in an incremental cost-utility ratio of SEK 223,445 per QALY gained. One-way sensitivity analysis showed that the model was most sensitive to assumptions around the disease-modifying effect of SQ Tree SLIT-Tablet.

Conclusion

SQ Tree SLIT-Tablet improved quality of life in moderate-to-severe AR and/or conjunctivitis induced by pollen from the birch homologous group in Sweden, with only a modest increase in societal costs over a medium-term time horizon, representing good value for money at a willingness-to-pay threshold of SEK 700,000 per QALY.

Allergen immunotherapy for atopic dermatitis: Systematic review and meta-analysis of benefits and harms

BACKGROUND

Atopic dermatitis (AD, eczema) is driven by a combination of skin barrier defects, immune dysregulation, and extrinsic stimuli such as allergens, irritants, and microbes. The role of environmental allergens (aeroallergens) in triggering AD remains unclear.

OBJECTIVE

We systematically synthesized evidence regarding the benefits and harms of allergen immunotherapy (AIT) for AD.

METHODS

As part of the 2022 American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters AD Guideline update, we searched the MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Global Resource for Eczema Trials, and Web of Science databases from inception to December 2021 for randomized controlled trials comparing subcutaneous immunotherapy (SCIT), sublingual immunotherapy (SLIT), and/or no AIT (placebo or standard care) for guideline panel-defined patient-important outcomes: AD severity, itch, AD-related quality of life (QoL), flares, and adverse events. Raters independently screened, extracted data, and assessed risk of bias in duplicate. We synthesized intervention effects using frequentist and Bayesian random-effects models. The GRADE approach determined the quality of evidence.

RESULTS

Twenty-three randomized controlled trials including 1957 adult and pediatric patients sensitized primarily to house dust mite showed that add-on SCIT and SLIT have similar relative and absolute effects and likely result in important improvements in AD severity, defined as a 50% reduction in SCORing Atopic Dermatitis (risk ratio [95% confidence interval] 1.53 [1.31-1.78]; 26% vs 40%, absolute difference 14%) and QoL, defined as an improvement in Dermatology Life Quality Index by 4 points or more (risk ratio [95% confidence interval] 1.44 [1.03-2.01]; 39% vs 56%, absolute difference 17%; both outcomes moderate certainty). Both routes of AIT increased adverse events (risk ratio [95% confidence interval] 1.61 [1.44-1.79]; 66% with SCIT vs 41% with placebo; 13% with SLIT vs 8% with placebo; high certainty). AIT's effect on sleep disturbance and eczema flares was very uncertain. Subgroup and sensitivity analyses were consistent with the main findings.

CONCLUSIONS

SCIT and SLIT to aeroallergens, particularly house dust mite, can similarly and importantly improve AD severity and QoL. SCIT increases adverse effects more than SLIT. These findings support a multidisciplinary and shared decision-making approach to optimally managing AD.

Immunotherapy in the Treatment of Allergic Rhinitis in Children

Allergic rhinitis (AR) is an inflammation of the nasal membranes characterized by multiple allergic symptoms. It is a widespread health problem that affects patients' ability to engage in social and physical activity, which lowers their quality of life. The pathophysiology of AR is complex and requires sensitization and the development of a specific immune response to the allergen. Allergen-specific immunotherapy (AIT) is a therapeutic method that induces specific immune tolerance to allergens. The objectives of this review are to demonstrate the mechanism of action of immunotherapy, explain how it alleviates clinical symptoms of allergic rhinitis, list the indications and contraindications of immunotherapy in the treatment of allergic rhinitis, and identify different modalities of allergen immunotherapy, their disease-modifying effects, as well as their potential risks and benefits. The review of the literature highlights that T-cell and B-cell responses to inhaled allergens are altered by AIT, which decreases both early and late reactions to allergen exposure. To induce clinical and immunologic tolerance, especially in the pediatric age, escalating dosages of the causing allergen are administered subcutaneously or sublingually. AIT is indicated for severe persistent AR when avoidance measures and medications are inadequate to control the symptoms. To conclude, AIT is a disease-modifying therapy that is safe and effective for the treatment of allergic rhinitis. It is indicated when the symptoms are uncontrolled or when there are undesirable effects from pharmacotherapy.

Treating allergies via skin - Recent advances in cutaneous allergen immunotherapy

Subcutaneous allergen immunotherapy has been practiced clinically for decades to treat airborne allergies. Recently, the cutaneous route, which exploits the immunocompetence of the skin has received attention, which is evident from attempts to use it to treat peanut allergy. Delivery of allergens into the skin is inherently impeded by the barrier imposed by stratum corneum, the top layer of the skin. While the stratum corneum barrier must be overcome for efficient allergen delivery, excessive disruption of this layer can predispose to development of allergic inflammation. Thus, the most desirable allergen delivery approach must provide a balance between the level of skin disruption and the amount of allergen delivered. Such an approach should aim to achieve high allergen delivery efficiency across various skin types independent of age and ethnicity, and optimize variables such as safety profile, allergen dosage, treatment frequency, application time and patient compliance. The ability to precisely quantify the amount of allergen being delivered into the skin is crucial since it can allow for allergen dose optimization and can promote consistency and reproducibility in treatment response. In this work we review prominent cutaneous delivery approaches, and offer a perspective on further improvisation in cutaneous allergen-specific immunotherapy.

Efficacy and safety of house dust mite sublingual immunotherapy tablets in allergic rhinitis: A systematic review and meta-analysis

Background

House dust mite (HDM) sublingual immunotherapy (SLIT) tablets have been approved for the treatment of patients with allergic rhinitis (AR). However, the meta-analysis on the efficacy of HDM-SLIT tablets for HDM-induced AR patients remained limited.

Methods

Five databases were searched including: PubMed/MEDLINE, EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials, and CINAHL for randomized controlled trials (RCTs) that addressed the efficacy and safetyof HDM-SLIT tablets compared with placebo until January 2022. The primary outcome was a combined symptom and medication score (CSMS) after treatment.

Results

Eight eligible RCTs were identified with a total of 3601 patients treated with HDM-SLIT tablets and 2783 patients who received a placebo. The CSMS was significantly lower in the HDM-SLIT tablet group compared with the placebo (standardized mean difference (SMD) -0.28 [95% CI: -0.32 to -0.23]). There was a significant reduction in rhinitis symptom scores, rhinitis medication scores, total combined conjunctivitis scores, and rhinoconjunctivitis quality of life questionnaire scores. The consistent efficacy compared to the placebo has been exhibited over the different kinds and doses of HDM tablets (6 SQ, 12 SQ, 300 IR, and 500 IR) and age groups (>5 years old, adolescents and adults) with low degrees of variability across the studies. There was no significant difference in proportions of participants who were injected with epinephrine between the treatment- and placebo groups.

Conclusions

HDM-SLIT tablet is an effective treatment in reducing rhinitis symptoms and medication use in AR patients with favorable safety. They also improve quality of life and conjunctivitis symptoms.

Efficacy and safety of sublingual allergen immunotherapy

Sublingual immunotherapy (SLIT)-tablets represent a new allergen immunotherapy option for clinicians. In North America, there are five SLIT-tablets approved for the treatment of allergic rhinoconjunctivitis (ARC). No SLIT-drops products are currently approved in the United States or Canada. This work reviewed the efficacy of the timothy grass SLIT-tablet, five-grass SLIT-tablet, ragweed SLIT-tablet, house-dust mite SLIT-tablet, and tree SLIT-tablet in patients with ARC. All the SLIT-tablets showed consistent clinical efficacy for the treatment of ARC in large, double-blind, placebo-controlled trials, including for both patients who were monosensitized and those who were polysensitized. Treatment with house-dust mite SLIT-tablet has shown efficacy in patients who are pollen sensitized during their respective pollen seasons. In contrast to SLIT-tablets, efficacy studies of SLIT-drops show high heterogeneity of treatment effect. Although data are scarce, data that compared the efficacy of SLIT-tablets versus ARC pharmacotherapy generally indicated that SLIT-tablets had a greater benefit than pharmacotherapy when compared with placebo, particularly for perennial ARC. When compared with subcutaneous immunotherapy, analysis of these data indicated that SLIT-tablets had a benefit over subcutaneous immunotherapy in regard to safety but somewhat less benefit in regard to efficacy. The safety of SLIT-tablets has been well documented, and a U.S. Food and Drug Administration class label with safety considerations is present in the prescribing information for all SLIT-tablets. No new safety signals have been observed after reinitiating SLIT-tablets after a short treatment interruption.

Essentials of allergen immunotherapy: A primer for the practitioner

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.

Delivery options for sublingual immunotherapy for allergic rhinoconjunctivitis: clinical considerations for North America

Background: Sublingual immunotherapy (SLIT) can be delivered via tablets (SLIT-T) or aqueous drops (SLIT-D). SLIT-D dosing recommendations using North American extracts were published in 2015. We review the 2015 recommendations in the context of recent research, and compare and contrast dosing, efficacy, safety, adherence, and cost of SLIT-T and SLIT-D for allergic rhinoconjunctivitis (ARC) in North America. Methods: Randomized controlled trials (RCT) of SLIT-D and SLIT-T trials were identified by a systematic PubMed search through March 1, 2022. Results: Dose-finding studies have been conducted for all approved SLIT-T; efficacy in North American populations was demonstrated in 11 RCTs. Approved SLIT-T are uniform internationally. Few dose-finding studies for SLIT-D have been conducted using North American extracts; efficacy was demonstrated in 2 RCTs. Extrapolation of dosing from SLIT-D studies conducted with extracts from other geographic regions is unreliable. Since the 2015 SLIT-D dosing recommendations, no new RCTs of SLIT-D have been conducted with North American extracts, whereas 6 SLIT-T RCTs have since been conducted in North America. Local allergic reactions are the most common adverse events with SLIT-T and SLIT-D, but both can induce systemic allergic reactions. Adherence to SLIT-D and SLIT-T remains a challenge. Patients must pay for SLIT-D directly, whereas SLIT-T is usually covered by insurance. Conclusion: As part of shared decision-making, patients should be informed about the scientific evidence supporting the use of SLIT-T and SLIT-D for ARC.

Efficacy and Safety of House Dust Mite Sublingual Immunotherapy Tablet in Allergic Asthma: A Systematic Review of Randomized Controlled Trials

BACKGROUND

House dust mite sublingual immunotherapy (HDM SLIT) effectively treats allergic rhinitis (AR). However, the evidence of HDM SLIT for allergic asthma remained limited.

OBJECTIVE

To systematically review the efficacy and safety of HDM SLIT tablets in patients with allergic asthma.

METHODS

We performed a systematic search through PubMed, Scopus, EMBASE, Web of Science, the Cochrane Center of Controlled Trials, and Google Scholar for randomized controlled trials (RCTs) that addressed the efficacy and safety of HDM SLIT tablets compared with placebo or no intervention in allergic asthma from their inception date until September 2021. The primary outcome was the reduction in inhaled corticosteroids (ICS) dose. Additional outcomes were asthma control, exacerbation, lung function, quality-of-life, and adverse events.

RESULTS

There were 7 RCTs, 5 studies in allergic asthma (4 in adults and 1 in children), and 2 in AR with or without asthma. The 6 standardized quality (SQ) HDM effectively reduced ICS dose in well- to partly controlled mild-to-moderate asthma in 1 RCT. Two RCTs evaluated the efficacy of 6 SQ and 12 SQ HDM in reducing asthma exacerbation in partly controlled moderate-to-severe asthma, and their results were inconsistent. One study in children with mild-to-moderate asthma found no benefit of HDM SLIT. Two RCTs in AR with or without mild-to-moderate asthma showed improvement of asthma symptoms. Adverse events were primarily local, and anaphylaxis treated with epinephrine was reported in 3 patients.

CONCLUSIONS

The HDM SLIT tablets tend to effectively reduce ICS use in adults and adolescents with well- to partly controlled mild-to-moderate allergic asthma with a favorable safety profile.

Allergen Immunotherapy in Young Children

PURPOSE OF REVIEW

Allergen immunotherapy (AIT) has been shown to be safe and effective in children and is a unique treatment strategy that has disease-modifying and preventative effects that are not shared with other treatment options for allergic diseases. This article reviews the present knowledge and relevant updates on AIT in children.

RECENT FINDINGS

Although there is no definite lower age limit for starting AIT, clear indications for AIT are established and each case should be considered individually by weighing risks and benefits. Documented short- and long-term benefits of AIT in children with allergic disease include significant improvement of symptoms and quality of life, and decreased use of medications as well as preventing the development of new allergen sensitizations and the progression of allergic rhinitis to asthma. This review provides a comprehensive overview of the present knowledge and key updates on AIT in the pediatric population.

Atopic dermatitis: Current standards of diagnosis and treatment, including the latest methods of management

Atopic dermatitis (AD) is a chronic relapsing disease which causes characteristic eczematous skin lesions. The most common symptoms of atopic dermatitis are persistent pruritus, xerosis, and skin lesions with a typical location and appearance that changes with the patient’s age. The prevalence of the disease in the pediatric population is estimated at 10% to 30%, while in adults it ranges from 1% to 3%. The number of people who suffer from AD is rising every year. The pathophysiology of the disease is complex and multifactorial. It involves elements of epidermal barrier dysfunction, alterations in cellular immune response, IgE hypersensitivity, and environmental factors. AD significantly reduces the quality of life of both patients and their families. Patients with AD are at higher risk for neuropsychiatric disorders such as depression, attention-deficit/hyperactivity disorder, and headaches. The decreased quality of life of AD patients and their families is associated with the discomfort of recurrent and chronic inflammatory skin lesions, persistent pruritus, and the inconvenience of long-term therapy. It also affects the psychological development of children, contributes to behavioral disorders (hyperactivity, hypersensitivity) and impacts many areas of family life such as sleep, leisure activities, and relationships between family members. The basic treatment of AD is avoidance of potential harmful factors, proper care in the treatment of exacerbations, topical corticosteroids, and calcineurin inhibitors in proactive therapy. In some patients who meet age criteria, phototherapy and cyclosporine should be considered. In individuals with severe AD who do not respond to topical treatment and who will not benefit from general therapy, dupilumab, a biologic drug, is the treatment of choice. Biologic treatment has an increasingly important place in the effective and modern therapy of AD. Currently, new biologic drugs are being researched, which may bring a therapeutic revolution in AD in the future. Allergen immunotherapy in patients with AD should be carefully evaluated on an individual basis, as proper selection of patients with documented IgE-dependent sensitization is important for the success of this therapy. Close collaboration with the patient and their caregivers, education, and psychological support as appropriate are integral to the treatment.

Systemic Allergic Reactions and Anaphylaxis Associated with Allergen Immunotherapy

Subcutaneous allergen immunotherapy (SCIT) is a proven treatment of allergic rhinitis, asthma, atopic dermatitis, and prevention of Hymenoptera venom anaphylaxis. The known benefit of SCIT, however, must be considered in each patient relative to the potential risks of systemic allergic reactions (SRs). A mean of 1 SR per 1000 injection visits (0.1%) was estimated to occur between 2008 and 2018. Life-threatening anaphylactic events are estimated to occur in 1/160,000 injection visits. The factors that contribute to SRs and fatal reactions (FRs) are reviewed. Risk management strategies are proposed to prevent and decrease future SCIT associated with SRs, anaphylaxis, and FR.

Allergic Rhinitis in Children and Adolescents

Allergic rhinitis is a common disorder that regularly occurs in children and adolescents. The disease is associated with other allergic diseases, such as asthma, and it carries a heavy burden, with effects on sleep, school performance, and quality of life. Classic symptoms include sneezing, rhinorrhea, nasal obstruction, and nasal itching. When the eyes are involved, the term allergic rhinoconjunctivitis is used. Triggers may include airborne pollens, molds, dust mites, and animals. Skin or blood allergy testing can be a useful diagnostic modality that may guide therapy. Immunotherapy can prevent the development of further allergic sensitizations as well as subsequent asthma.

Asthma in pregnancy: An update

AIM

To update obstetric care providers about asthma management.

SUMMARY

Asthma is the most frequent comorbid chronic illness in pregnancy. Convincing evidence shows that uncontrolled asthma magnifies the risk of maternal, fetal and neonate complications. Unfortunately, one in four women take no inhaler during pregnancy, and it is likely that decreased adherence, rather than changes in pathology, explains uncontrolled maternal asthma. Patient surveys reveal a need for information and reassurance. Although some molecules are preferred in pregnancy, there is currently no basis to withhold any asthma medication - old or new. Biomarkers such as blood eosinophils and fractional exhaled nitric oxide are an effective way to assess the risk of asthma attacks and the likelihood of responding to inhaled steroids. Furthermore, practice-changing trials in mild asthma show that switching reliever-only regimens to as-needed 'controller-and-reliever' therapy is effective. We suggest that applying these changes can alleviate women's concerns and improve outcomes.

Shifts in allergy practice in a COVID-19 world: Implications of pre-COVID-19 national health care provider and patient surveys of treatments for nasal allergies

Background: Most U.S. patient and health care provider surveys with regard to nasal allergy treatments were conducted before sublingual immunotherapy (SLIT)-tablets and allergy immunotherapy (AIT) shared decision-making tools were available. Objective: Patient and health care provider surveys with regard to current perceptions of nasal allergy burden, symptoms, and treatments were conducted to compare with previous surveys and provide insight into the use of SLIT-tablets and AIT shared decision-making tools. Methods: From November-December 2019, adults (N = 510) diagnosed with nasal allergies and health care providers (N = 304) who treated nasal allergies in the United States completed surveys with regard to nasal allergy management. Results: Of the patient respondents, 42% reported that their symptoms were only somewhat controlled and 48% had avoided activities because of their nasal allergies. In all, 38% were using only over-the-counter (OTC) medications for treatment, and 42%, 7%, and 8% had ever received subcutaneous immunotherapy (SCIT), sublingual allergy drops, or SLIT-tablets, respectively; 56% and 85% reported that they had never discussed SCIT or SLIT, respectively, with their health care provider. Of the health care provider respondents, 45%, 58%, and 20% were very likely to discuss OTC medications, SCIT, or SLIT, respectively. Allergists were more inclined to discuss SCIT with their patients than other health care providers (82% versus 33%, respectively). Most allergists (67%) and other health care providers (62%) reported that they did not use an AIT shared decision-making tool, primarily because of unawareness. Conclusion: The patients with nasal allergies continued to report inadequate symptom control and activity impairment. SLIT-tablets and AIT shared decision-making tools were underused. In the coronavirus disease 2019 era, social distancing may limit office visits, which impacts SCIT administration and prompts increased use of telemedicine and a possible advantage for at-home-administered SLIT-tablets over SCIT.

Worldwide surveys on anaphylaxis to sublingual immunotherapy with house dust mite tablets are urgently needed

In the 1980s, a global number of 72 fatalities were reported in the UK and the USA following the application of subcutaneous immunotherapy (SCIT). This resulted in a significant limitation of SCIT use and in the search of other routes of administration, among which sublingual immunotherapy (SLIT) showed the best balance between efficacy and safety. Data from controlled studies suggest that tablets‐related anaphylaxis is an uncommon event. However, in the Eudravigilance (European database of suspected adverse drug reactions from Europe) we found reports of life‐threatening events or severe local reactions under SLIT increasing over the last few years. Therefore, all efforts to minimize the related risk have to be strongly encouraged.

The safety of sublingual immunotherapy, can the rare systemic reactions be prevented?

Introduction: The safety of subcutaneous immunotherapy (SCIT), and particularly the dramatic issue of fatal reactions, has been an obstacle that limited the implementation of a therapy with unique characteristics of action on the causes of allergy. The introduction of sublingual immunotherapy (SLIT) was aimed at solving safety problems while maintaining clinical efficacy.Areas covered: For more than 20 years, SLIT has been based on allergen extracts in drops at low average doses. As evidenced by meta-analyses, the typical adverse events (AE) have consisted of local reactions in the mouth and throat. Unlike the injection route, no correlation was observed between the administered dose and AEs. The development of SLIT products in tablets, based on higher doses than drops, has somewhat changed the concept of SLIT safety. Although large trials, performed to obtain regulatory agency approval, have shown overall high safety, rare anaphylactic reactions have been described.Expert opinion: SLIT is globally safe, and no fatal reactions have ever been reported, but with currently available high biological potency products it is necessary to follow prudential rules, such as the administration of the first dose under medical supervision and the thorough education of patients to avoid taking of higher doses than recommended.

Use of Sublingual Immunotherapy for Aeroallergens in Children with Asthma

Asthma is a heterogeneous disease that in children is often allergen-driven with a type 2 inflammation. Sublingual immunotherapy represents an important progress in the use of personalized medicine in children with allergic asthma. It is a viable option for house dust mite-driven asthma and in subjects with the asthma associated with allergic rhinitis. The use and indications for isolated asthma caused by other allergens are still controversial owing to heterogeneity of commercially available products and methodological limitations of studies in children. Nevertheless, most studies and meta-analyses found the efficacy of sublingual immunotherapy. Sublingual immunotherapy is safe but cannot be recommended in children with uncontrolled asthma.

Biologics and Allergy Immunotherapy in the Treatment of Allergic Diseases

Allergic diseases represent some of the most chronic and costly chronic conditions. Medical management may require long-term pharmacotherapy, which is often associated with poor adherence. Although medications provide symptomatic control, they do not modify the allergic disease. Patients may prefer disease-modifying treatments that provide lasting benefits after discontinuation. To date, allergy immunotherapy is the only proved disease modification therapy associated with lasting benefits after discontinuation. However, allergy immunotherapy safety and efficacy has only been established in allergic rhinitis, mild to moderate asthma, and some patients with atopic dermatitis.

β-Blockers and angiotensin-converting enzyme inhibitors with sublingual immunotherapy: are risks related to individual product safety profile?

PURPOSE OF REVIEW

The objective of this article is to review the available literature regarding the risks associated with sublingual immunotherapy and angiotensin-converting enzyme (ACE) inhibitors or β-blocker use. It also evaluates for any differences in these risks among the available sublingual immunotherapy (SLIT) tablets.

RECENT FINDINGS

A literature search was conducted in PubMed to identify peer-reviewed articles using the following keywords: anaphylaxis, ACE inhibitor, β-blocker, and sublingual immunotherapy. Minimal data exist regarding their safety of SLIT in patients concomitantly taking ACE inhibitors or β-blockers. The adverse reaction rates seem similar between SLIT products.

SUMMARY

A risk-versus-benefit discussion should be communicated with the patient taking a β-blocker before beginning SLIT but automatic denial of SLIT to these patients is not warranted.

Rhinitis 2020: A practice parameter update

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.

Eosinophilic esophagitis during sublingual and oral allergen immunotherapy

PURPOSE OF REVIEW

The aim of this review is to discuss the current evidence regarding the development of eosinophilic esophagitis (EoE) in individuals undergoing oral and sublingual immunotherapy (SLIT) for both food and environmental allergens. Cumulative incidence of EoE in patients on allergen immunotherapy for peanut, milk, and egg is estimated.

RECENT FINDINGS

De novo development of EoE in patients undergoing oral and SLIT has been demonstrated on the scale of case reports and prospective randomized trials. However, few individuals with EoE-like symptoms during immunotherapy undergo endoscopy, and the long-term outcomes of immunotherapy-associated EoE are unknown.

SUMMARY

Evidence exists to suggest that allergen immunotherapy could place individuals at risk for the development of EoE, the true incidence of which may vary depending on antigen exposure and methods used to define the condition.

Shared decision making in allergic rhinitis: An approach to the patient

OBJECTIVE

To review what is known about the importance of shared decision making (SDM) in allergic rhinitis.

DATA SOURCES

MEDLINE and PubMed database searches for SDM, patient preferences, patient motivation with mobile apps, over-the-counter medications, adherence, complementary and alternative therapies, nasal steroids, and immunotherapy.

STUDY SELECTIONS

No articles directly dealt with the effects of SDM on outcomes in allergic rhinitis. Thus, of the 77 articles produced by these searches, 41 were selected based on the information relevant to evaluating the need for SDM in these patients.

RESULTS

Poorly controlled allergic rhinitis continues to be associated with substantial morbidity. Complicating the effective control of the disease is the tendency of patients to self-manage using information from a variety of sources other than health care providers. Although direct evidence in allergic rhinitis is lacking, controlled trials have found the benefits of SDM in improving adherence and outcomes in at least 50 other disease states. Thus, this review explores the aspects of the disease that are complicated by poor adherence, establishing the case for the need for widespread use of SDM techniques.

CONCLUSION

Patients are confronted with a complex array of treatment options for allergic rhinitis, and a consistent SDM approach can better equip them to make the requisite care decisions needed to achieve optimal control. Furthermore, improving patient education through SDM provides a framework that enables long-term adherence for maximal outcomes.

A comparative study of subcutaneous, intralymphatic and sublingual immunotherapy for the long-term control of dogs with nonseasonal atopic dermatitis

BACKGROUND

Allergen-specific immunotherapy (ASIT) is the only causative treatment of canine atopic dermatitis (cAD). Different routes for administration of ASIT have been used; however, comparative studies are lacking.

HYPOTHESIS/OBJECTIVES

The present study compared the efficacy and safety of subcutaneous (SCIT), intralymphatic (ILIT) and sublingual (SLIT) immunotherapy.

ANIMALS

30 atopic dogs were included and allocation to three groups (SCIT, n = 8; ILIT, n = 12; SLIT, n = 10) was determined by the owners.

METHODS AND MATERIALS

ASIT was administered using routine protocols. The pruritus Visual Analog Scale (PVAS), canine atopic dermatitis extent and severity index (CADESI), concurrent medications and adverse events were recorded initially and one, three, six and 12 months later. The main outcome measure was return to a normal status, which included CADESI <12, PVAS <2.5 and medication score <10.

RESULTS

Drop-outs were distributed evenly and 23 dogs finished the study (SCIT, n = 6; ILIT, n = 10; SLIT, n = 7). Adverse reactions to treatment were rare. At the start of the study, the three groups were homogeneous with respect to clinical signs and concurrent medications. After 12 months of ASIT, the CADESI and PVAS had decreased with a stable medication score in the ILIT and SCIT groups (P < 0.05), while all three scores had increased in the SLIT group. Return to normal state was achieved in one of six (17%) dogs receiving SCIT, in six of 10 (60%) dogs receiving ILIT and in one of seven (14%) dogs receiving SLIT.

CONCLUSIONS AND CLINICAL IMPORTANCE

These findings suggest that SCIT and ILIT improved clinical signs of cAD, whereas ILIT had a much higher return to normal rate.

Clinical Practice of Allergen Immunotherapy for Allergic Rhinoconjunctivitis and Asthma: An Expert Panel Report

Allergen immunotherapy (AIT) reduces symptoms and medication use associated with allergic rhinitis with or without conjunctivitis and allergic asthma. Although several AIT guidelines exist, there remain unanswered questions about AIT that are relevant to everyday practice. Our objective was to prepare an evidence-based overview addressing the practical aspects of AIT in clinical practice based on published evidence and the experience of international experts in the field. Topics covered include interpretation and translation of clinical trial data into everyday clinical practice (eg, allergen doses and treatment duration), assessment of risk and treatment of local and systemic allergic reactions, recommendations for improvement of AIT guidelines, and identification of appropriate data for seeking regulatory approval, to name a few. Many informational gaps in AIT practice need further evaluation as products and practices evolve.

30 years of sublingual immunotherapy

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.

Clinical Efficacy Evaluation of 1-Year Subcutaneous Immunotherapy for Artemisia sieversiana Pollen Allergic Rhinitis by Serum Metabolomics

Subcutaneous immunotherapy is the only treatment that improves the natural progression of allergic rhinitis and maintains long-term outcomes after discontinuation of the drug. Metabolomics is increasingly applied in the study of allergic diseases, including allergic rhinitis. However, little is known about the discovery of metabolites that can evaluate clinical efficacy and possible mechanisms of Artemisia sieversiana pollen subcutaneous immunotherapy. Thirty-three patients with Artemisia sieversiana pollen allergic rhinitis significantly improved after 1-year subcutaneous immunotherapy treatment, while ten patients were ineffective. Pre- and post-treatment serum samples from these patients were analyzed by metabolomics based on the combined detection of liquid chromatography-mass spectrometry and gas chromatography-mass spectrometry. As a result, L-Tyrosine can be a potential biomarker because of its opposite trend in effective patients and ineffective patients. And mechanism of immunotherapy may be closely related to NO and nitric oxide synthase. The discovery of potential biomarkers and metabolic pathways has contributed to the in-depth study of mechanisms of subcutaneous immunotherapy treatment of Artemisia sieversiana pollen allergic rhinitis.

Understanding differences in allergen immunotherapy products and practices in North America and Europe

Allergen immunotherapy (AIT) is thought to be clinically effective and safe in treating allergic rhinitis, asthma, and stinging insect allergy in Europe and North America. However, there are intercontinental differences in AIT therapeutic products in terms of their application and regulation. In North America unmodified standardized and nonstandardized aqueous aeroallergen extracts are approved and used almost exclusively for subcutaneous immunotherapy, whereas more product options are available in Europe, including adsorbed allergens, chemically modified allergens, or both. Both liquid extracts and tablets are approved for sublingual immunotherapy in Europe. Nevertheless, within the European Union, there are major differences in AIT products approved and used in individual countries. There are major differences in the clinical approach to subcutaneous immunotherapy in polysensitized patients; in the United States mixed extracts containing multiple aeroallergens are used, whereas European allergists preferably administer separate injections of single allergen sources or homologous groups deemed to be clinically relevant. Moreover, the regulatory approach differs between the European Union and United States. In contrast to the United States, where common allergen standards exist based on biologic activity, no common standards exist in Europe. In terms of development of new investigational products, the United States has followed the European example for phase II and III studies; no formal US Food and Drug Administration guidance has been issued.

Clinical aspects of sublingual immunotherapy tablets and drops

BACKGROUND

Sublingual immunotherapy (SLIT) is administered via tablets (SLIT-T) or liquid drops (SLIT-D). In North America, currently 4 SLIT-T formulations are approved by the US Food and Drug Administration for allergy immunotherapy, and SLIT-D is an off-label use of subcutaneous immunotherapy (SCIT) extracts.

OBJECTIVE

To compare and contrast aspects of SLIT-T and SLIT-D, including physical characteristics, mechanism of action, dosing, efficacy, safety, adherence, and cost.

DATA SOURCES

PubMed literature review (no limits), product prescribing information, and manufacturer websites.

STUDY SELECTIONS

Publications related to physical characteristics, mechanism of action, dosing, efficacy, safety, and adherence.

RESULTS

Published evidence indicates that tablet and drop formulations differ in regard to physical characteristics, dosing, and strength of evidence for efficacy. Whether there are any differences in absorption and mechanism of action between the 2 formulations is currently unknown. Optimal dosing, efficacy, and safety have been established for SLIT-T. In contrast, in North America there is little support for efficacy of SLIT-D from randomized double-blind, placebo-controlled trials, and dose ranges have not been appropriately evaluated. SLIT-T treats a single allergen, whereas in the United States SLIT-D often contains multiple allergens to treat polysensitization. The safety profiles of SLIT-T and SLIT-D appear similar, and both formulations are considered safer than SCIT.

CONCLUSION

Professional guidelines should make a clear distinction between SLIT-T and SLIT-D in their recommendations to minimize confusion with the umbrella term SLIT.

Illustrative Case Series and Narrative Review of Therapeutic Failure of Immunotherapy for Allergic Rhinitis

This is a series of 4 cases (3 therapeutic failure and 1 early relapse) in adult patients treated with allergen immunotherapy (AIT) for allergic rhinitis (AR) in our immunotherapy clinic, which treats 110 new patients per year. AIT includes both subcutaneous and sublingual routes. The current national/international AIT recommendations and the literature have been searched to identify guidance for the optimal management of therapeutic failure of AIT in AR. There is scant information available to support clinicians when treatment failure and/or intolerable side effects occur. The importance is highlighted for developing the guidance and evidence base for the benefit of this patient subgroup. The potential strategies that clinicians have proposed are discussed in this article, though it is acknowledged that these are mostly not evidence-based.

Advances in aeroallergen immunotherapy

PURPOSE OF REVIEW

Allergic rhinoconjunctivitis is the most common manifestation of allergic disease. This break in the normal natural function of the immune system to ignore harmless molecules such as pollen and pet dander to now aggressively react has lead to a substantial disease burden that is not always recognized and adequately treated.

RECENT FINDINGS

Individual molecular component testing may increase the predictive value of blood sIgE and clinical symptoms. Defining the most symptoms inducing allergenic protein has led to advances in peptide-based allergen immunotherapy. There have been steady consistent reports that allergy immunotherapy for children with symptomatic allergic rhinitis prevents the onset of asthma.

SUMMARY

Allergy immunotherapy is an effective disease-modulating treatment that alters the underlying immune dysfunction which is a currently underutilized therapy especially as it is likely effective in preventing the onset of asthma in children, at least in the short term.

Allergic Rhinitis in Children and Adolescents

Allergic rhinitis is a common disorder that regularly occurs in children and adolescents. The disease is associated with other allergic diseases, such as asthma, and it carries a heavy burden, with effects on sleep, school performance, and quality of life. Classic symptoms include sneezing, rhinorrhea, nasal obstruction, and nasal itching. When the eyes are involved, the term allergic rhinoconjunctivitis is used. Triggers may include airborne pollens, molds, dust mites, and animals. Skin or blood allergy testing can be a useful diagnostic modality that may guide therapy. Immunotherapy can prevent the development of further allergic sensitizations as well as subsequent asthma.

What you should not miss from the systematic reviews and meta-analyses on allergen-specific immunotherapy in 2017

PURPOSE OF REVIEW

Allergen immunotherapy (AIT) is a well recognized and extensively studied therapeutic intervention for some allergic diseases. Every year new systematic reviews and meta-analysis provide the most powerful source of evidence to orient decision making on prevention or efficacy of AIT. We here discuss systematic reviews and meta-analyses on AIT (published January 2017 to February 2018).

RECENT FINDINGS

We identified 4 systematic reviews and 10 meta-analyses. Subcutaneous and sublingual AIT (SCIT/SLIT) significantly reduced the development of asthma in children-adolescents with moderate/severe allergic rhinitis, but evidence for a short-term, preventive effect for new allergic sensitizations was nonconclusive. SCIT/SLIT proved to significantly improve symptom and medication scores versus placebo or active comparators in respiratory allergy, with various effect sizes. Oral immunotherapy for IgE-mediated food allergy resulted in substantial benefit in desensitization rates. Data on venom AIT and latex AIT, although limited in quantity and quality, respectively, suggest a large and discrete beneficial effect.

SUMMARY

Although current evidence extracted from meta-analyses and systematic reviews support AIT as an effective, relatively safe, and well tolerated alternative for some allergic diseases, heterogeneity and some methodological inconsistencies represent matters of concern as they may affect the validity and applicability of their results, especially in the context of individual, real-life settings.