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Csonka P, Hamelmann E, Turkalj M, Roberts G, Mack DP. SQ sublingual immunotherapy tablets for children with allergic rhinitis: A review of phase three trials. Acta Paediatr 2024; 113:1209-1220. [PMID: 38529710 DOI: 10.1111/apa.17221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 03/08/2024] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
AIM To provide paediatricians with a summary of efficacy and safety of SQ sublingual immunotherapy (SLIT) tablets from phase three, randomised, double-blind, placebo-controlled trials in children and adolescents with allergic rhinitis or rhinoconjunctivitis, with and without asthma. METHODS PubMed searches were conducted and unpublished data were included if necessary. RESULTS Of the 93 publications, 12 were identified reporting 10 trials. One trial was excluded as paediatric-specific efficacy data were unavailable. The nine eligible trials evaluated grass, house dust mite, ragweed and tree SLIT tablets. Consistent reductions in allergic rhinitis or rhinoconjunctivitis symptoms and medication use were observed with SQ SLIT tablets versus placebo. In a five-year trial, sustained reduction of allergic rhinoconjunctivitis symptoms, asthma symptoms and medication use were observed with SQ grass SLIT tablet versus placebo. The number-needed-to-treat to prevent asthma symptoms and medication use in one additional child during follow-up was lowest in younger children. SQ SLIT tablets were generally well tolerated across trials. CONCLUSION Evidence supports use of SQ SLIT tablets in children and adolescents with allergic rhinitis or rhinoconjunctivitis, with and without asthma. Long-term data demonstrate disease-modifying effects of SQ grass SLIT tablet and suggest the clinical relevance of initiating allergy immunotherapy earlier in the disease course.
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Affiliation(s)
- Péter Csonka
- Tampere Center for Child, Adolescent and Maternal Health Research, Tampere University and Tampere University Hospital, Tampere, Finland
- Terveystalo Healthcare Oy, Tampere, Finland
| | - Eckard Hamelmann
- Department of Paediatrics, Children's Center Bethel, University Bielefeld, Bielefeld, Germany
| | - Mirjana Turkalj
- Department of Pulmonology, Allergy and Immunology, Srebrnjak Children's Hospital, Zagreb, Croatia
- Medical School, Catholic University of Croatia, Zagreb, Croatia
- Medical School, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Graham Roberts
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport, UK
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University of Southampton Faculty of Medicine, Southampton, UK
| | - Douglas P Mack
- Department of Pediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Olivieri B, Gil AJ, Stoenchev K, Durham SR, Scadding G. Utility of silver birch and house dust mite extracts derived from licensed sublingual tablets for nasal allergen challenge. Clin Transl Allergy 2024; 14:e12360. [PMID: 38779783 PMCID: PMC11112400 DOI: 10.1002/clt2.12360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/16/2024] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Nasal allergen challenge (NAC) is used to investigate the effects of allergen exposure and assess treatment efficacy in allergic rhinitis (AR). This study aims to establish dose-responses to NAC using licensed silver birch (SB) pollen and house dust mite (HDM) sublingual tablets as sources of the allergen extracts in participants with AR. METHODS Sixteen volunteers with HDM-induced perennial AR and 15 volunteers with SB pollen-induced seasonal rhinitis underwent a graded up-dosing NAC with extracts derived from HDM allergen (Acarizax®) and SB (Itulazax®) tablets, respectively. Total nasal symptom score (TNSS, range 0-12) and peak nasal inspiratory flow (PNIF) were recorded before, at 10 min and at the end of the NAC. The dose of each allergen that provoked a TNSS of at least 7 ("provoking dose 7") in most allergic participants was identified. NACs using the "provoking dose 7" were performed on 5 non-allergic individuals to test for irritant effects. The "provoking dose 7" of HDM extract was used in a subgroup of two SB allergic, non-HDM allergic, volunteers, and vice versa for SB extract, to test for allergen specificity of the responses. RESULTS Most patients experienced a TNSS of at least 7/12 at a median concentration of 1500 AU/mL for both SB pollen and HDM. The average decline in PNIF at this dose was 63.15% for SB and 63.99% for HDM. NACs using the 1500 AU/mL concentrations were performed on 5 non-allergic individuals with no symptomatic or PNIF response. 1500 AU/mL of HDM extract produced no symptoms in SB allergics nor 1500 AU/mL SB extract in HDM allergics. CONCLUSION For both SB and HDM extracts, the optimal allergen dose for NAC to cause a moderate-severity response ("provoking dose 7/12") was 1500 AU/mL. Licensed sublingual allergen tablets provide a readily available and inexpensive source of SB and HDM extracts for use in future interventional studies in AR.
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Affiliation(s)
- Bianca Olivieri
- Asthma, Allergy and Clinical Immunology SectionUniversity Hospital of VeronaVeronaItaly
| | - Ana Jimenez Gil
- Department of AllergyRoyal Brompton & Harefield Hospitals NHS TrustLondonUK
- Allergy and Clinical ImmunologyNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Kostadin Stoenchev
- Department of AllergyRoyal Brompton & Harefield Hospitals NHS TrustLondonUK
| | - Stephen R. Durham
- Department of AllergyRoyal Brompton & Harefield Hospitals NHS TrustLondonUK
- Allergy and Clinical ImmunologyNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Guy Scadding
- Department of AllergyRoyal Brompton & Harefield Hospitals NHS TrustLondonUK
- Allergy and Clinical ImmunologyNational Heart and Lung InstituteImperial College LondonLondonUK
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Bashir S, Fitaihi R, Abdelhakim HE. Advances in formulation and manufacturing strategies for the delivery of therapeutic proteins and peptides in orally disintegrating dosage forms. Eur J Pharm Sci 2023; 182:106374. [PMID: 36623699 DOI: 10.1016/j.ejps.2023.106374] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 01/08/2023]
Abstract
Therapeutic proteins and peptides (TPPs) are increasingly favoured above small drug molecules due to their high specificity to the site of action and reduced adverse effects resulting in increased use of these agents for medical treatments and therapies. Consequently, there is a need to formulate TPPs in dosage forms that are accessible and suitable for a wide range of patient groups as the use of TPPs becomes increasingly prevalent in healthcare settings worldwide. Orally disintegrating dosage forms (ODDF) are formulations that can ensure easy-to-administer medication to a wider patient population including paediatrics, geriatrics and people in low-resource countries. There are many challenges involved in developing suitable pharmaceutical strategies to protect TPPs during formulation and manufacturing, as well as storage, and maintenance of a cold-chain during transportation. This review will discuss advances being made in the research and development of pharmaceutical and manufacturing strategies used to incorporate various TPPs into ODDF systems.
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Affiliation(s)
- Shazia Bashir
- School of Cancer and Pharmaceutical Sciences, King's College London, Franklin-Wilkins Building, 150 Stamford Street, London SE1 9NH, UK
| | - Rawan Fitaihi
- Department of Pharmaceutics, UCL School of Pharmacy, 29-39 Brunswick Square, London WC1N 1AX, UK; Department of Pharmaceutics, College of pharmacy, King Saud University, Riyadh, KSA
| | - Hend E Abdelhakim
- Department of Pharmaceutics, UCL School of Pharmacy, 29-39 Brunswick Square, London WC1N 1AX, UK.
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4
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Ohashi-Doi K, Utsumi D, Mitobe Y, Fujinami K. Japanese Cedar Pollen Allergens in Japan. Curr Protein Pept Sci 2022; 23:837-850. [PMID: 36200245 DOI: 10.2174/1389203723666220930155719] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 07/15/2022] [Accepted: 09/06/2022] [Indexed: 01/20/2023]
Abstract
Pollen from members of the Cupressaceae tree family is one of the most important causes of allergic disease in the world. Cryptomeria japonica (Japanese cedar) and Chamaecyparis obtusa (Japanese cypress) are Japan's most common tree species. The pollen dispersal season is mainly from February to May. The major allergens of Japanese cedar and Japanese cypress exhibit high amino acid sequence similarity due to the phylogenetic relationship between the two species. An epidemiological study has shown that the prevalence of Japanese cedar pollinosis is approximately 40%. Younger children (5 to 9 years old) showed a high prevalence of Japanese cedar pollinosis as 30% in 2019, indicating that season pollinosis is getting worse. Pharmacotherapy is the most common treatment for pollinosis induced by Japanese cedar and Japanese cypress. Patients' satisfaction with pharmacotherapy is low due to insufficient experienced effect and daytime somnolence. Unlike pharmacotherapy, allergy immunotherapy (AIT) addresses the basic immunological mechanisms of allergic disease and activates protective allergen-reactive pathways of the immune system. AIT is now recognized as the only treatment option with the potential to provide long-term post-treatment benefits and alter the natural course of the allergic disease, including Japanese cedar pollinosis.
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Affiliation(s)
- Katsuyo Ohashi-Doi
- Medical Affairs, Torii Pharmaceutical Co., Ltd., 4-1, Nihonbashi-Honcho 3-chome, Chuo-ku, Tokyo, 103-8439, Japan
| | - Daichi Utsumi
- Medical Affairs, Torii Pharmaceutical Co., Ltd., 4-1, Nihonbashi-Honcho 3-chome, Chuo-ku, Tokyo, 103-8439, Japan
| | - Yuko Mitobe
- Medical Affairs, Torii Pharmaceutical Co., Ltd., 4-1, Nihonbashi-Honcho 3-chome, Chuo-ku, Tokyo, 103-8439, Japan
| | - Koji Fujinami
- Medical Affairs, Torii Pharmaceutical Co., Ltd., 4-1, Nihonbashi-Honcho 3-chome, Chuo-ku, Tokyo, 103-8439, Japan
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Lam K, Pinto J, Lee S, Rance K, Nolte H. Delivery options for sublingual immunotherapy for allergic rhinoconjunctivitis: clinical considerations for North America. RHINOLOGY ONLINE 2022. [DOI: 10.4193/rhinol/22.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
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.
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Aswathy K, Asdaq SMB, Saritha C, Thomas L, Haridas N, Viswanad V, Sahu RK, Fattepur S, Alamri AS, Alsanie WF, Alhomrani M, Sreeharsha N, Khalid Anwer M. Formulation and in-vitro characterization of fast-disintegrating herbal extract sublingual immunotherapy tablet for peanut-induced allergic asthma. Saudi J Biol Sci 2022; 29:1283-1297. [PMID: 35280568 PMCID: PMC8913557 DOI: 10.1016/j.sjbs.2021.12.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/06/2021] [Accepted: 12/12/2021] [Indexed: 01/17/2023] Open
Abstract
Background Allergen immunotherapy (AIT) involves the regimen of gradually incrementing doses of the allergen, thereby inducing desensitization and tolerance. Sublingual Immunotherapy tablets (SLIT-tablets) have been formulated for several allergies and had manifested efficacy for allergic rhinitis and allergic asthma. SLIT promises an alternative method to other routes of AIT enabling patients to self-administer AIT. Objective The study aimed to formulate fast disintegrating SLIT containing crude peanut extract for peanut-induced allergic asthma. Methods The crude peanut extract was prepared by a simple extraction method and was subjected to quantitative and qualitative analysis. The extract was also characterised for its physical properties. The preformulation study for the extract and excipients of the tablet was performed using FT-IR spectroscopy and Differential scanning calorimetry. The tablet powder blends were characterised for pre-compression properties. The SLIT tablets were developed by direct compression and the post-compression evaluation was performed. Results The results of the quantitative and qualitative analysis of extract confirmed the presence of peanut proteins in the extract. The preformulation studies using FT-IR spectroscopy and Differential Scanning Calorimetry revealed that there is no significant interaction between the CPE and excipients. The pre-compression characterisation showed that the powder blends had good flowproperties. Three doses of SLIT tablets were formulated with each dose containing four batches and the tablet of each dose was optimized by studying the effect of varying concentrations of super disintegrants on disintegration time and dissolution rate. The post compression characterization of the tablets was performed and the optimized batch of the three doses with the concentration of 5% crospovidone and 2% croscarmellose sodium showed less wetting time and high-water absorption ratio, shorter disintegration time of 14secs and maximum drug release of >90% within 2-3 min. Conclusion The results indicated the suitability of formulated SLIT tablets for peanut induced allergic asthma.
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Affiliation(s)
- K.N. Aswathy
- Department of Pharmaceutics, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, AIMS Health Sciences Campus, Kochi 682041, Kerala, India
| | | | - C.K. Saritha
- Department of Pharmaceutics, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, AIMS Health Sciences Campus, Kochi 682041, Kerala, India
| | - Litha Thomas
- Department of Pharmaceutics, Krupanidhi College of Pharmacy, Bangalore 560035, Karnataka, India
| | - Nithya Haridas
- Department of Respiratory Medicine, AIMS Health Science Campus, Amrita Vishwa Vidyapeetham, Kochi, 682041, Kerala, India
| | - Vidya Viswanad
- Department of Pharmaceutics, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, AIMS Health Sciences Campus, Kochi 682041, Kerala, India
| | - Ram Kumar Sahu
- Department of Pharmaceutical Science, Assam University (A Central University), Silchar 788011, India
| | - Santosh Fattepur
- School of Pharmacy, Management and Science University, Seksyen 13, 40100 Shah Alam, Selangor, Malaysia
| | - Abdulhakeem S. Alamri
- Department of Clinical Laboratory Sciences, The Faculty of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
- Centre of Biomedical Sciences Research (CBSR), Deanship of Scientific Research, Taif University, Saudi Arabia
| | - Walaa F. Alsanie
- Department of Clinical Laboratory Sciences, The Faculty of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
- Centre of Biomedical Sciences Research (CBSR), Deanship of Scientific Research, Taif University, Saudi Arabia
| | - Majid Alhomrani
- Department of Clinical Laboratory Sciences, The Faculty of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
- Centre of Biomedical Sciences Research (CBSR), Deanship of Scientific Research, Taif University, Saudi Arabia
| | - Nagaraja Sreeharsha
- Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsa 31982, Saudi Arabia
- Department of Pharmaceutics, Vidya Siri College of Pharmacy, Off Sarjapura Road, Bangalore 560035, India
| | - Md. Khalid Anwer
- Department of Pharmaceutics, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Alkharj 11942, Saudi Arabia
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Yamamoto T, Ohashi-Doi K, Matsuhara H, Verhoog L, Lindholm M, Lawton S, Lund K. Allergen Release Profiles of Fast-Dissolving Freeze-Dried Orodispersible Sublingual Allergy Immunotherapy Tablets. Curr Ther Res Clin Exp 2022; 96:100678. [PMID: 35813554 PMCID: PMC9260442 DOI: 10.1016/j.curtheres.2022.100678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background Sublingual allergy immunotherapy tablets (SLIT-tablets) provide a well-tolerated and clinically efficacious treatment for allergic disease such as allergic rhinitis and allergic asthma. In SLIT, uptake of allergen by immune-competent cells in the oral mucosa activates the immune system and leads to tolerance toward the sensitizing allergen. The ability to deliver the full allergen content into solution within the recommended sublingual holding time is therefore an essential quality of SLIT-tablets that must be supported by the tablet formulation for all relevant allergen sources. SLIT-tablets based on a fast-dissolving orodispersible freeze-dried formulation (Zydis) are currently available for 5 of the most prevalent allergens: tree (birch and related species from the birch-homologous group), grass, ragweed, Japanese cedar, and house dust mite. Objectives The purpose of this study was to examine the allergen release properties of three freeze-dried SLIT-tablets containing tree, ragweed, and Japanese cedar extracts, respectively. The correlation between SLIT-tablet allergen release and the level of allergen-specific T-cell activation was examined for the tree SLIT-tablet. Methods Allergen release kinetics and tablet disintegration times for the 3 freeze-dried SLIT-tablets were examined. For all 3 tablets, the magnitude of solubilized major allergen relative to time in solution was compared to external controls to achieve a measure of the total allergen release. Additional assessments of allergen release occurring after the initial timepoint (15 or 30 seconds in solution) were done independently of external controls by linear regression analyses. For the tree SLIT-tablet, the immunological potency of the released major allergen was assessed at each experimental timepoint by a Bet v-specific T-cell activation assay. Results All 3 SLIT-tablets disintegrated within 1 second after contact with assay buffer without any detectible residue. Complete release of major allergens (Bet v 1, Amb a 1, and Cry j 1, respectively) was seen at the earliest experimental time points (15 or 30 seconds). For the tree SLIT-tablet, full T-cell activation was achieved at 30 seconds (earliest experimental time point). Conclusions The freeze-dried SLIT-tablet formulation consistently provides rapid and complete release of allergen from a wide range of species in a standardized in vitro assay. Full release of the SLIT-tablet allergen content within the sublingual holding time is a prerequisite for maximal exposure of allergens to the sublingual mucosa immune system. The freeze-dried SLIT-tablet formulation examined here supports short sublingual holding times and furthermore offers a convenient administration form of allergy immunotherapy.
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Affiliation(s)
| | | | | | | | | | | | - Kaare Lund
- Papermill Medical, Copenhagen, Denmark
- Address correspondence to: Kaare Lund, PhD, Papermill Medical, Ole Maaløes Vej 3, 2200 Copenhagen N, Denmark.
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8
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Strategies and formulations of freeze-dried tablets for controlled drug delivery. Int J Pharm 2021; 597:120373. [PMID: 33577912 DOI: 10.1016/j.ijpharm.2021.120373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/24/2021] [Accepted: 02/05/2021] [Indexed: 11/21/2022]
Abstract
The freeze-drying process has been particularly attractive for preparing tablets for controlled drug release. Although traditional methods, such as granulation or direct compression methods, have been used in various studies to produce tablets with controlled release, freeze-drying processes have been utilized in certain circumstances due to their distinct advantages. However, overall, further development of these strategies, which started with early studies on orally disintegrating tablets, is still necessary. In this review, the incorporation of different formulations into freeze-dried tablets will be discussed. Moreover, the use of excipients, freeze-drying conditions, formulation reconstitution and tablet structure for optimizing the performance of freeze-dried tablets will be reported, including strategies with nanoformulations and natural materials. Generally, this discussion with potential approaches will benefit further development of freeze-dried tablets containing drugs in the pharmaceutical industry.
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Calderon MA, Waserman S, Bernstein DI, Demoly P, Douglass J, Gagnon R, Katelaris CH, Kim H, Nelson HS, Okamoto Y, Okubo K, Virchow JC, DuBuske L, Casale TB, Canonica GW, Nolte H. Clinical Practice of Allergen Immunotherapy for Allergic Rhinoconjunctivitis and Asthma: An Expert Panel Report. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2920-2936.e1. [PMID: 32422372 DOI: 10.1016/j.jaip.2020.04.071] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/13/2020] [Accepted: 04/20/2020] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Moisés A Calderon
- Section of Allergy and Clinical Immunology, Imperial College London-NHLI, London, United Kingdom.
| | - Susan Waserman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David I Bernstein
- Division of Allergy, Rheumatology and Immunology, Department of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Pascal Demoly
- Department of Pulmonology, University Hospital of Montpellier, & IPLESP, Sorbonne Université - Inserm, Paris, France
| | - Jo Douglass
- The Royal Melbourne Hospital & The University of Melbourne, Melbourne, VIC, Australia
| | - Remi Gagnon
- Clinique Spécialisée en Allergie de la Capitale, Québec, QC, Canada
| | - Constance H Katelaris
- Campbelltown Hospital and the School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Harold Kim
- Division of Clinical Immunology and Allergy, Western University, London, ON, Canada; Division of Clinical Immunology & Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Harold S Nelson
- Department of Medicine, National Jewish Health, Denver, Colo
| | - Yoshitaka Okamoto
- Department of Otorhinolaryngology, Chiba University Hospital, Chiba, Japan
| | - Kimihiro Okubo
- Department of Otolaryngology, Nippon Medical School, Nippon, Japan
| | - J Christian Virchow
- Department of Pneumology/Intensive Care Medicine, University of Rostock, Rostock, Germany
| | - Lawrence DuBuske
- Department of Medicine, Division of Allergy and Immunology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Thomas B Casale
- Division of Allergy/Immunology, University of South Florida, Tampa, Fla
| | - G Walter Canonica
- Personalized Medicine Clinic Asthma & Allergy, Humanitas Clinical and Research Center, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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Halken S, Roberts G, Valovirta E, Nolte H, Hulstrøm V, Blaiss MS. Safety of Timothy Grass Sublingual Immunotherapy Tablet in Children: Pooled Analyses of Clinical Trials. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1387-1393.e2. [PMID: 31954191 DOI: 10.1016/j.jaip.2020.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 12/10/2019] [Accepted: 01/06/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Timothy grass sublingual immunotherapy (SLIT) tablets are indicated for children with allergic rhinitis with or without conjunctivitis. OBJECTIVE To use pooled analyses to assess the short- and long-term tolerability and safety of timothy grass SLIT-tablet in children. METHODS Data from 9 double-blinded, randomized European or North American trials that included children with allergic rhinitis with or without conjunctivitis treated up to 3 years with once-daily timothy grass SLIT-tablet or placebo were pooled. RESULTS In all, 1818 (timothy grass SLIT-tablet, n = 923; placebo, n = 895) subjects were included in the analysis. The frequency of treatment-emergent adverse events (AEs) was 86% in the SLIT-tablet group and 83% in the placebo group, and the frequency of treatment-related AEs (TRAEs) was 59% and 23%, respectively. Most (98%) TRAEs were mild to moderate in severity. The 2 most common TRAEs with SLIT-tablet were oral pruritus (33%) and throat irritation (19%), which had a median onset of 1 day and recurrence of 14.5 and 5 days, respectively. In all, 8% of subjects in the SLIT-tablet group and 2% in the placebo group discontinued because of AEs. There were 7 serious AEs assessed as related to SLIT-tablet, 1 systemic allergic reaction (severe with a drop in blood pressure), 3 epinephrine administrations, no eosinophilic esophagitis events, and no serious airway obstructions. The safety profile was similar in subjects across geographic regions and with and without asthma. CONCLUSIONS Pooled data indicate that short- and long-term timothy grass SLIT-tablet is well tolerated in children, regardless of geographic region. AEs were generally local, mild, and transient allergic reactions.
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Affiliation(s)
- Susanne Halken
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Graham Roberts
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport Isle of Wight, United Kingdom; NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; University of Southampton, Southampton, United Kingdom
| | - Erkka Valovirta
- Department of Lung Disease and Clinical Allergology, University of Turku and Terveystalo Allergy Clinic, Turku, Finland
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11
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Tankersley M, Han JK, Nolte H. Clinical aspects of sublingual immunotherapy tablets and drops. Ann Allergy Asthma Immunol 2020; 124:573-582. [PMID: 31923544 DOI: 10.1016/j.anai.2019.12.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/17/2019] [Accepted: 12/27/2019] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Mike Tankersley
- Departments of Medicine, Pediatrics and Otolaryngology, University of Tennessee Health Science Center, Memphis, Tennessee; The Tankersley Clinic, Memphis, Tennessee.
| | - Joseph K Han
- Department of Otolaryngology, Division of Rhinology and Endoscopic Sinus-Skull Base Surgery, Division of Allergy, Eastern Virginia Medical School, Norfolk, Virginia
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Canonica GW, Devillier P, Casale T, Demoly P, Bos C, Karagiannis E, Passalacqua G, Wahn U, Mascarell L. Clinical efficacy of sublingual immunotherapy tablets for allergic rhinitis is unlikely to be derived from in vitro allergen-release data. Expert Rev Clin Immunol 2019; 15:921-928. [PMID: 31403823 DOI: 10.1080/1744666x.2019.1649597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Allergen bioavailability underpins the efficacy and safety of SLIT tablets. Three product-related factors are likely to influence this: tablet potency, formulation and sublingual holding time. Areas covered: Tablet formulation determines the rate and extent of solubilized allergen release. Using validated in vitro dissolution assays, the two licensed grass pollen SLIT tablets are shown to release ≥85% of their total allergenic activity within several minutes. Sublingual holding time affects the contact duration between solubilized allergens and sublingual tissue. Maximal uptake of allergens by sublingual tissue requires ~5 minutes, with little uptake occurring within the first minute. A higher potency tablet with longer sublingual holding time would provide higher bioavailability, while faster rates of allergen release in vitro are unlikely to translate to a greater increase in bioavailability. Differences in dissolution times cannot serve as a surrogate of in vivo bioavailability, and are not related to differences in efficacy at the marketed tablet dosages. Rapid in vitro dissolution is likely not a key requirement for inducing a potent immune response. Expert opinion: In vitro dissolution cannot predict the clinical efficacy of SLIT tablets but could be important in immune tolerance and safety. In addition, a discontinuous administration regimen may have benefits for adherence and cost without compromising efficacy.
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Affiliation(s)
- Giorgio Walter Canonica
- Department of Internal Medicine, Humanitas University and Research Hospital ICH , Milan , Italy
| | - Philippe Devillier
- UPRES EA220, Foch Hospital, University Versailles Saint-Quentin, University Paris-Saclay , Suresnes , France
| | - Thomas Casale
- Department of Internal Medicine, University of South Florida , Tampa , FL , USA
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, University Hospital of Montpellier, Montpellier and INSERM UMRS 1136, Equipe - EPAR - IPLESP, Sorbonne Université, Hôpital Arnaud de Villeneuve , Paris , France
| | - Catherine Bos
- Department of Internal Medicine, Stallergenes Greer , Antony , France
| | | | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, University of Genoa , Genoa , Italy
| | - Ulrich Wahn
- Department of Paediatric Pneumology and Immunology, Charité Medical University , Berlin , Germany
| | - Laurent Mascarell
- Department of Internal Medicine, Stallergenes Greer , Antony , France
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Barber D, Rico P, Blanco C, Fernandez-Rivas M, Ibañez MD, Escribese MM. GRAZAX®: a sublingual immunotherapy vaccine for Hay fever treatment: from concept to commercialization. Hum Vaccin Immunother 2019; 15:2887-2895. [PMID: 31157592 PMCID: PMC6930101 DOI: 10.1080/21645515.2019.1622976] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/24/2019] [Accepted: 05/15/2019] [Indexed: 12/18/2022] Open
Abstract
Allergen immunotherapy has been used for more than 100 y, but only recently underlying immunological mechanisms have started to be understood. New Allergy vaccines are now considered to be full pharmaceutical products, that should comply with general as well as specific pharmaceutical legal framework. GRAZAX® is the first global allergy vaccine developed in compliance with the new legal environment and is thus a reference for developing new allergy vaccines. Here, we provide a rationale description of GRAZAX®, providing a sequential description of its pharmaceutical and clinical development. With more than 25 clinical trials, involving more than 8000 patients, including as well three 5-y prospective clinical trials, GRAZAX® is a key product to understand the unique position of allergen-specific immunotherapy as a disease-modifying intervention.
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Affiliation(s)
- Domingo Barber
- School of Medicine, Institute for Applied Molecular Medicine (IMMA), Universidad CEU San Pablo, Madrid, Spain
| | - Pilar Rico
- School of Medicine, Institute for Applied Molecular Medicine (IMMA), Universidad CEU San Pablo, Madrid, Spain
| | - Carlos Blanco
- Allergy Department, Hospital Universitario de la Princesa, Madrid, Spain
| | | | - Maria Dolores Ibañez
- Allergy Department, Hospital Infantil Universitario Niño Jesús. IIS-La Princesa. Fibhnjs, Madrid, Spain
| | - Maria M. Escribese
- School of Medicine, Institute for Applied Molecular Medicine (IMMA), Universidad CEU San Pablo, Madrid, Spain
- School of Medicine, Department of Basic Medical Sciences, Universidad CEU San Pablo, Madrid, Spain
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