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Mühlmeier G, Polk ML, Tisch M, Cuevas M. [Allergen immunotherapy for rare allergens]. HNO 2024; 72:626-632. [PMID: 38639764 DOI: 10.1007/s00106-024-01469-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Abstract
Among allergies to aeroallergens, approximately 20% are allotted to the so-called rare allergens. These include ash pollen, weed pollen, storage mites, molds, and animal allergens. The prevalences of allergies to these allergens are lower, but affected patients also suffer considerably from their "rare" allergy. Hence, these allergies should neither be overseen nor completely forgotten in daily practice. Especially mold, mite, and animal allergens often induce asthma, so that the significance of allergen-specific immunotherapy (AIT) should not be neglected in causal therapy. This work summarizes the current state of knowledge on the groups of rare aeroallergens in terms of characteristics, prevalences, and data on AIT. It is based on a systematic literature search performed in the MEDLINE (PubMed®) and Google Scholar databases. AIT preparations for rare allergens are classified as individual formulations and are not subject to the German Therapy Allergen Ordinance. Due to the low case numbers, the levels of evidence for these formulations are not as high as those for dust mites, grass, or birch pollen, but exhibit good efficacy in practical experience.
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Affiliation(s)
- Guido Mühlmeier
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.
| | - Marie-Luise Polk
- Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus Klinik und Poliklinik für Hals‑, Nasen- und Ohrenheilkunde, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Matthias Tisch
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
| | - Mandy Cuevas
- Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus Klinik und Poliklinik für Hals‑, Nasen- und Ohrenheilkunde, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
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2
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Van der Borght K, Brimnes J, Haspeslagh E, Brand S, Neyt K, Gupta S, Knudsen NPH, Hammad H, Andersen PS, Lambrecht BN. Sublingual allergen immunotherapy prevents house dust mite inhalant type 2 immunity through dendritic cell-mediated induction of Foxp3 + regulatory T cells. Mucosal Immunol 2024; 17:618-632. [PMID: 38570140 DOI: 10.1016/j.mucimm.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 03/03/2024] [Accepted: 03/22/2024] [Indexed: 04/05/2024]
Abstract
Sublingual allergen immunotherapy (SLIT) is an emerging treatment option for allergic asthma and a potential disease-modifying strategy for asthma prevention. The key cellular events leading to such long-term tolerance remain to be fully elucidated. We administered prophylactic SLIT in a mouse model of house dust mite (HDM)-driven allergic asthma. HDM extract was sublingually administered over 3 weeks followed by intratracheal sensitization and intranasal challenges with HDM. Prophylactic SLIT prevented allergic airway inflammation and hyperreactivity with a low lab-to-lab variation. The HDM-specific T helper (Th)2 (cluster of differentiation 4 Th) response was shifted by SLIT toward a regulatory and Th17 response in the lung and mediastinal lymph node. By using Derp1-specific cluster of differentiation 4+ T cells (1-DER), we found that SLIT blocked 1-DER T cell recruitment to the mediastinal lymph node and dampened IL-4 secretion following intratracheal HDM sensitization. Sublingually administered Derp1 protein activated 1-DER T cells in the cervical lymph node via chemokine receptor7+ migratory dendritic cells (DC). DCs migrating from the oral submucosa to the cervical lymph node after SLIT-induced Foxp3+ regulatory T cells. When mice were sensitized with HDM, prior prophylactic SLIT increased Derp1 specific regulatory T cells (Tregs) and lowered Th2 recruitment in the lung. By using Foxp3-diphtheria toxin receptor mice, Tregs were found to contribute to the immunoregulatory prophylactic effect of SLIT on type 2 immunity. These findings in a mouse model suggest that DC-mediated functional Treg induction in oral mucosa draining lymph nodes is one of the driving mechanisms behind the disease-modifying effect of prophylactic SLIT.
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Affiliation(s)
- Katrien Van der Borght
- Laboratory of Immunoregulation and Mucosal Immunology, VIB-UGent Center for Inflammation Research, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Jens Brimnes
- Immunology Department, In vivo Biology Team, ALK Abelló A/S, Hørsholm, Denmark
| | - Eline Haspeslagh
- Laboratory of Immunoregulation and Mucosal Immunology, VIB-UGent Center for Inflammation Research, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Stephanie Brand
- Immunology Department, In vivo Biology Team, ALK Abelló A/S, Hørsholm, Denmark
| | - Katrijn Neyt
- Laboratory of Immunoregulation and Mucosal Immunology, VIB-UGent Center for Inflammation Research, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Shashank Gupta
- Immunology Department, In vivo Biology Team, ALK Abelló A/S, Hørsholm, Denmark
| | | | - Hamida Hammad
- Laboratory of Immunoregulation and Mucosal Immunology, VIB-UGent Center for Inflammation Research, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Peter S Andersen
- Immunology Department, In vivo Biology Team, ALK Abelló A/S, Hørsholm, Denmark
| | - Bart N Lambrecht
- Laboratory of Immunoregulation and Mucosal Immunology, VIB-UGent Center for Inflammation Research, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Department of Pulmonary Medicine, Erasmus MC, Rotterdam, The Netherlands.
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3
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Stranzl T, Bernstein DI, Matsuoka T, Durham S, Maekawa Y, Sejer Andersen P, Nolte J, Hulstrom V, Nolte H. Consistent efficacy and safety of sublingual immunotherapy tablets across allergens and geographic regions. Allergy Asthma Proc 2024; 45:232-239. [PMID: 38760164 DOI: 10.2500/aap.2024.45.240020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
Background: The clinical development program of the SQ grass, ragweed, tree, and house dust mite (HDM) sublingual immunotherapy (SLIT)-tablets for allergic rhinitis/conjunctivitis (AR/C) included clinical trials conducted in North America, Europe, and Japan. Objective: Data from these trials were analyzed to assess efficacy, immunologic mechanisms, and safety outcomes across allergens and geographic regions. Methods: Thirteen phase III, double-blind, placebo controlled trials in the subjects with AR/C were conducted in North America, Europe (including Russia), and Japan (N = 7763 analyzed). Trials were generally similar with respect to medical practice, target population, eligibility criteria, and efficacy and safety monitoring. Data were analyzed for the approved doses in North America and Europe. Four statistical models were used to enhance comparison of the efficacy end points among the trials. Results: The SLIT-tablets demonstrated consistent efficacy across allergens and regions, regardless of the statistical analysis used. Relative improvement in the primary efficacy end point compared with placebo by using the predefined protocol analysis ranged from 17.9% to 32.8%, 17.5% to 19.3%, 20.6% to 38.3%, and 39.6% with the grass, HDM, ragweed, and tree SLIT-tablets, respectively. The kinetics of specific immunoglobulin E (IgE) and IgG4 responses were similar among the allergens and regions. Local application-site reactions were the most common adverse events for all allergens and in all regions. Most treatment-related adverse events for all allergens and in all regions were mild in severity. The rate of systemic allergic reactions was similar across regions (0%-0.54%). Conclusion: Confirmatory phase III trials for SLIT-tablets in the treatment of AR/C showed consistent efficacy, immunologic, and safety outcomes across allergens and geographic regions.
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Affiliation(s)
| | - David I Bernstein
- Division of Immunology and Allergy, University of Cincinnati College of Medicine and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Tomokazu Matsuoka
- Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Graduate Faculty of Interdisciplinary Research, University of Yamanashi, Yamanashi, Japan
| | - Stephen Durham
- Section for Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | | | - Josephine Nolte
- Center of Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark, and
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Olivieri B, Günaydın FE, Corren J, Senna G, Durham SR. The combination of allergen immunotherapy and biologics for inhalant allergies: Exploring the synergy. Ann Allergy Asthma Immunol 2024:S1081-1206(24)00365-X. [PMID: 38897405 DOI: 10.1016/j.anai.2024.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 06/10/2024] [Accepted: 06/11/2024] [Indexed: 06/21/2024]
Abstract
The development of monoclonal antibodies that selectively target IgE and type 2 immunity has opened new possibilities in the treatment of allergies. Although they have been used mainly as single therapies found to have efficacy in the management of asthma and other T2-mediated diseases, there is a growing interest in using these monoclonal antibodies in combination with allergen immunotherapy (AIT). AIT has transformed the treatment of allergic diseases by aiming to modify the underlying immune response to allergens rather than just providing temporary symptom relief. Despite the proven efficacy and safety of AIT, unmet needs call for further research and innovation. Combination strategies involving biologics and AIT exhibit potential in improving short-term efficacy, reducing adverse events, and increasing immunologic tolerance. Anti-IgE emerges as the most promising therapeutic strategy, not only enhancing AIT's safety and tolerability but also providing additional evidence of efficacy compared with AIT alone. Anti-interleukin-4 receptor offers a reduction in adverse effects and an improved immunologic profile when combined with AIT; however, its impact on short-term efficacy seems limited. The combination of cat dander subcutaneous immunotherapy with anti-thymic stromal lymphopoietin was synergistic with enhanced efficacy and altered immune responses that persisted for 1 year after discontinuation compared with AIT alone. Long-term studies are needed to evaluate the sustained benefits and safety profiles of combination strategies.
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Affiliation(s)
- Bianca Olivieri
- Asthma, Allergy and Clinical Immunology Section, University Hospital of Verona, Verona, Italy
| | - Fatma Esra Günaydın
- Department of Immunology and Allergy Diseases, Ordu University Education and Training Hospital, Ordu, Turkey
| | - Jonathan Corren
- Division of Allergy and Clinical Immunology, Department of Medicine and Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gianenrico Senna
- Asthma, Allergy and Clinical Immunology Section, University Hospital of Verona, Verona, Italy; Department of Medicine, University of Verona, Verona, Italy
| | - Stephen R Durham
- Allergy and Clinical Immunology, Section Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
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5
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Blaiss MS, Durham SR, Bernstein D, Stranzl T, Lindholm M, Nolte H, Andersen KF, Roberts G. Sublingual Tablet Immunotherapy Improves Quality of Life in Adults With Allergic Rhinoconjunctivitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1520-1529.e5. [PMID: 38307205 DOI: 10.1016/j.jaip.2024.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 12/11/2023] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Allergic rhinitis with or without conjunctivitis can negatively impact many aspects of quality of life (QoL). The efficacy and safety of standardized quality (SQ) sublingual immunotherapy (SLIT) tablets have been confirmed across large clinical trials in adults with grass, tree, ragweed, and house dust mite (HDM) allergic rhinitis with or without conjunctivitis. OBJECTIVE This pooled analysis investigates whether the reduction in symptom burden found across the clinical trials is supported by improvements in QoL. METHODS A total of 11 phase II/III randomized placebo-controlled trials across the SQ grass, tree, ragweed, and HDM SLIT tablets (grass: N = 3179; ragweed: N = 767; tree: N = 634; HDM: N = 2221) were included. QoL was assessed using the standardized Rhinitis Quality of Life Questionnaire (RQLQ), with the exception of 3 grass trials, which used the nonstandardized version. The overall RQLQ scores were expressed as a mean of 7 domains. In the pooled analysis, treatment was used as fixed effect; and the trial, and the interaction between region/country and trial as random effects. RESULTS The pooled analysis showed consistent and statistically significant improvements in overall RQLQ scores across all 4 SQ SLIT tablets versus placebo (pooled estimate [95% CI], P value-grass: -0.20 [-0.28 to -0.12], P < .001; tree: -0.42 [-0.58 to -0.26], P < .001; ragweed: -0.36 [-0.55 to -0.17], P < .001; HDM: -0.28 [-0.39 to -0.17], P < .001). Furthermore, significant improvements versus placebo for all 4 SQ SLIT tablets were seen across the 7 individual domains. CONCLUSIONS The proven efficacy of SQ SLIT tablets to reduce symptoms across 4 of the most common respiratory allergens is supported by concurrent significant improvements in RQLQ scores overall and for all 7 domains.
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Affiliation(s)
| | - Stephen R Durham
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital London, London, United Kingdom
| | - David Bernstein
- Division of Immunology and Allergy, University of Cincinnati College of Medicine and Bernstein Clinical Research Center, Cincinnati, Ohio
| | | | | | | | | | - 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 Faculty of Medicine and University Hospital Southampton, Southampton, United Kingdom
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Creticos PS, Gunaydin FE, Nolte H, Damask C, Durham SR. Allergen Immunotherapy: The Evidence Supporting the Efficacy and Safety of Subcutaneous Immunotherapy and Sublingual Forms of Immunotherapy for Allergic Rhinitis/Conjunctivitis and Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1415-1427. [PMID: 38685477 DOI: 10.1016/j.jaip.2024.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/23/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
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.
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Affiliation(s)
- Peter Socrates Creticos
- Johns Hopkins Division of Allergy & Clinical Immunology, Baltimore, Md; Creticos Research Group, Crownsville, MD.
| | - Fatma E Gunaydin
- Department of Immunology & Allergy, Ordu University Education & Research Hospital, Ordu, Türkiye
| | | | - Cecilia Damask
- Department of Otolaryngology, Central Florida College of Medicine, Orlando, Fla
| | - Stephen R Durham
- Allergy & Clinical Immunology, Division of Respiratory Science, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, United Kingdom
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Zemelka-Wiacek M, Agache I, Akdis CA, Akdis M, Casale TB, Dramburg S, Jahnz-Różyk K, Kosowska A, Matricardi PM, Pfaar O, Shamji MH, Jutel M. Hot topics in allergen immunotherapy, 2023: Current status and future perspective. Allergy 2024; 79:823-842. [PMID: 37984449 DOI: 10.1111/all.15945] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/10/2023] [Accepted: 11/04/2023] [Indexed: 11/22/2023]
Abstract
The importance of allergen immunotherapy (AIT) is multifaceted, encompassing both clinical and quality-of-life improvements and cost-effectiveness in the long term. Key mechanisms of allergen tolerance induced by AIT include changes in memory type allergen-specific T- and B-cell responses towards a regulatory phenotype with decreased Type 2 responses, suppression of allergen-specific IgE and increased IgG1 and IgG4, decreased mast cell and eosinophil numbers in allergic tissues and increased activation thresholds. The potential of novel patient enrolment strategies for AIT is taking into account recent advances in biomarkers discoveries, molecular allergy diagnostics and mobile health applications contributing to a personalized approach enhancement that can increase AIT efficacy and compliance. Artificial intelligence can help manage and interpret complex and heterogeneous data, including big data from omics and non-omics research, potentially predict disease subtypes, identify biomarkers and monitor patient responses to AIT. Novel AIT preparations, such as synthetic compounds, innovative carrier systems and adjuvants, are also of great promise. Advances in clinical trial models, including adaptive, complex and hybrid designs as well as real-world evidence, allow more flexibility and cost reduction. The analyses of AIT cost-effectiveness show a clear long-term advantage compared to pharmacotherapy. Important research questions, such as defining clinical endpoints, biomarkers of patient selection and efficacy, mechanisms and the modulation of the placebo effect and alternatives to conventional field trials, including allergen exposure chamber studies are still to be elucidated. This review demonstrates that AIT is still in its growth phase and shows immense development prospects.
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Affiliation(s)
| | - Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University Zurich, Davos, Switzerland
| | - Mübeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University Zurich, Davos, Switzerland
| | - Thomas B Casale
- Departments of Medicine and Pediatrics and Division of Allergy and Immunology, Joy McCann Culverhouse Clinical Research Center, University of South Florida, Tampa, Florida, USA
| | - Stephanie Dramburg
- Department of Pediatric Respiratory Care, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Karina Jahnz-Różyk
- Department of Internal Diseases, Pneumonology, Allergology and Clinical Immunology, Military Institute of Medicine-National Research Institute, Warsaw, Poland
| | - Anna Kosowska
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
- ALL-MED Medical Research Institute, Wroclaw, Poland
| | - Paolo M Matricardi
- Department of Pediatric Respiratory Care, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Pfaar
- Section of Rhinology and Allergy, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Mohamed H Shamji
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
- ALL-MED Medical Research Institute, Wroclaw, Poland
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Gurgel RK, Baroody FM, Damask CC, Mims JW, Ishman SL, Baker DP, Contrera KJ, Farid FS, Fornadley JA, Gardner DD, Henry LR, Kim J, Levy JM, Reger CM, Ritz HJ, Stachler RJ, Valdez TA, Reyes J, Dhepyasuwan N. Clinical Practice Guideline: Immunotherapy for Inhalant Allergy. Otolaryngol Head Neck Surg 2024; 170 Suppl 1:S1-S42. [PMID: 38408152 DOI: 10.1002/ohn.648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care. PURPOSE The purpose of this clinical practice guideline (CPG) is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce the risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS The GDG made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitizations, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions (LRs) to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The GDG offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.
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Affiliation(s)
| | - Fuad M Baroody
- The University of Chicago Medicine, Chicago, Illinois, USA
| | | | - James Whit Mims
- Wake Forest Baptist Health, Winston Salem, North Carolina, USA
| | | | - Dole P Baker
- Anderson ENT & Facial Plastics, Anderson, South Carolina, USA
| | | | | | - John A Fornadley
- Associated Otolaryngologists of PA, Inc, Hershey, Pennsylvania, USA
| | | | | | - Jean Kim
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua M Levy
- National Institute on Deafness and Other Communication Disorders, Bethesda, Maryland, USA
| | - Christine M Reger
- Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | - Joe Reyes
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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9
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Simard ML, Novak N, Drolet JP, Joly MC, Nolte H, Wuestenberg E, Gagnon R. Tolerability of sublingual versus vestibular allergy immunotherapy tablet administration: A randomized pilot study. Clin Exp Allergy 2024; 54:120-129. [PMID: 37990117 DOI: 10.1111/cea.14427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/08/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Local application site reactions are common with sublingual allergy immunotherapy (AIT)-tablets for the treatment of allergic rhinitis/conjunctivitis (AR/C) and occasionally lead to treatment discontinuation. Because of the lower mast cell density in the vestibular mucosa than the sublingual area, vestibular AIT-tablet administration may result in fewer adverse events (AEs). This pilot study evaluated the tolerability of the vestibular administration route of AIT-tablets compared with the sublingual route in adult subjects with AR/C. METHODS Adults (n = 164) aged 18-65 years with AR/C treated with daily birch pollen, grass pollen, ragweed pollen or house dust mite AIT in tablet form were randomized 1:1 to vestibular or sublingual administration for 28 days, followed by 28 days of sublingual administration only. The primary endpoint was the severity (mild, moderate, severe) of local treatment-related adverse events (TRAEs) during the first 28 days of treatment. RESULTS During the first 28 days, the percentage of subjects in the vestibular and sublingual groups reporting mild TRAEs were 55.6% versus 50.6%, respectively; moderate TRAEs were 27.2% versus 30.1%; and severe TRAEs were 12.3% versus 6.0% (p = .16). In the vestibular group, 95.1% of the subjects experienced at least one TRAE during the first period versus 81.9% in the sublingual group (p = .01) and discontinuation rates due to AEs were higher (12.3% vs. 3.6%). CONCLUSION The frequencies of subjects experiencing severe TRAEs, at least one TRAE, and discontinuations due to AEs at the initiation of AIT-tablets were numerically higher with vestibular administration than sublingual administration. Sublingual administration should remain the standard of care for subjects treated with AIT-tablets for AR/C.
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Affiliation(s)
- Marie-Lee Simard
- Clinique Spécialisée en Allergie de la Capitale, Québec, Québec, Canada
| | - Natalija Novak
- Clinic and Polyclinic for Dermatology and Allergology, University Hospital Bonn, Bonn, Germany
| | | | - Marie-Claude Joly
- Clinique Spécialisée en Allergie de la Capitale, Québec, Québec, Canada
| | | | - Eike Wuestenberg
- ALK-Abelló A/S, Hørsholm, Denmark
- Department of Otorhinolaryngology Head and Neck Surgery, Faculty of Medicine (and University Hospital) Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Rémi Gagnon
- Clinique Spécialisée en Allergie de la Capitale, Québec, Québec, Canada
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10
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Nelson HS, Sowers T, Plunkett G, Nolte H, Rance K. The Art of Dosing for Subcutaneous Immunotherapy in North America. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:13-22. [PMID: 37385447 DOI: 10.1016/j.jaip.2023.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 05/18/2023] [Accepted: 06/13/2023] [Indexed: 07/01/2023]
Abstract
Subcutaneous immunotherapy (SCIT) is a long-established treatment option for allergic rhinoconjunctivitis. Proper dosing of the allergens is critical for the efficacy and safety of SCIT. Of the hundreds of liquid allergen extracts in the United States, effective and well-tolerated SCIT dosing has only been established for a small number. Thus, SCIT dosing remains largely empiric and continues to be, by necessity, an art. To highlight the complexity of SCIT dosing, this review summarizes the historical and current landscape of U.S. allergen extracts, differences among U.S. and European allergen extracts, allergen selection for SCIT, considerations for compounding of allergen extract mixtures, and recommended dosing. As of 2021, 18 standardized allergen extracts are available in the United States; all other extracts remain unstandardized without characterization of allergen content or potency. U.S. allergen extracts differ from European extracts in formulation and potency characterization. There is no standardized methodology for SCIT allergen selection, and interpretation of allergen sensitization is not straightforward. Compounding of SCIT mixtures requires consideration of potential dilution effects, allergen cross-reactivity, proteolytic activity, and additives. Probable effective dose ranges for SCIT are recommended in U.S. allergy immunotherapy practice parameters, although there are few studies using U.S. extracts supporting these doses as therapeutic. In contrast, optimized doses of sublingual immunotherapy tablets have been confirmed in North American phase 3 trials. The SCIT dosing for each patient remains an art that requires clinical experience and consideration of polysensitization, tolerability, compounding of allergen extract mixtures, and the range of recommended doses within the context of extract potency variability.
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Affiliation(s)
- Harold S Nelson
- Department of Medicine, National Jewish Health, Denver, Colo
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11
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Nelson HS. The Art of Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1-10. [PMID: 37898175 DOI: 10.1016/j.jaip.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 10/30/2023]
Abstract
Selection of a patient with rhinitis/conjunctivitis or asthma for allergy immunotherapy (AIT) requires several decisions. First, does the patient's sensitization, pattern of exposure to an allergen, and degree of exposure to that allergen reasonably suggest a causal relationship? Does the level and duration of symptoms warrant the cost and inconvenience of immunotherapy, or is the patient motivated by the disease-modifying potential of AIT? If AIT is selected, is the choice to be greater safety and convenience with sublingual immunotherapy (SLIT) tablets, but with treatment probably limited to 2 or 3 allergens, or for subcutaneous immunotherapy where multiple allergen therapy is the rule and efficacy may be somewhat greater, at least initially, or does the physician go off-label into the unknowns of liquid SLIT? Are there extracts of sufficient potency to achieve likely effective doses? How does the physician deal with large local or systemic reactions, with gaps in treatment, with pollen seasons, and the use of premedication or cautionary prescription of epinephrine autoinjectors? How can adherence to AIT be improved? These and other questions are addressed in this paper.
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Affiliation(s)
- Harold S Nelson
- Department of Medicine, Division of Allergy/Immunology, National Jewish Health, Denver, Colo.
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12
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Nelson HS, Bernstein DI, Biedermann T, Nolte H. Sublingual immunotherapy tablets in monosensitized and polysensitized adults with allergic rhinoconjunctivitis. Allergy Asthma Proc 2024; 45:33-36. [PMID: 38151733 DOI: 10.2500/aap.2024.45.230068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Background: Most patients with allergic rhinitis/conjunctivitis (AR/C) are sensitized to more than one allergen. An ongoing question is the efficacy of single-allergen immunotherapy in patients who are polysensitized. Objective: To evaluate the efficacy and safety of grass, ragweed, tree, and house-dust mite (HDM) sublingual immunotherapy (SLIT) tablets in adults with AR/C who are mono- or polysensitized. Methods: Data from adults (ages ≥ 18 years) with AR/C who participated in phase III double-blind, placebo controlled field trials (four grass, two ragweed, two HDM, one tree) were included in the post hoc analyses. Efficacy was assessed by the total combined score (TCS) (sum of AR/C daily symptom and medication scores) during the entire pollen season for grass and tree trials, and peak pollen season for ragweed trials versus placebo. Efficacy for the HDM SLIT-tablet was assessed by the total combined rhinitis score (TCRS) (sum of rhinitis daily symptom and medication scores) during the last 8 weeks of treatment versus placebo. Results: For the grass SLIT-tablet, TCS improved by 20% (mean difference 1.33 [95% confidence interval {CI}, 0.44-2.22]) in the subjects who were monosensitized (n = 442) and 20% (mean difference 1.28 [95% CI, 0.90-1.67]) in the subjects who were polysensitized (n = 1857). For the ragweed SLIT-tablet, TCS improved by 19% (mean difference 1.72 [95% CI, -0.20 to 3.63]) in the subjects who were monosensitized (n = 115) and 27% (mean difference 2.27 [95% CI, 1.28-3.27]) in the subjects who were polysensitized (n = 528). For the tree SLIT-tablet, TCS improved by 54% (mean difference 4.65 [95% CI, 2.48-6.82]) in the subjects who were monosensitized (n = 138) and 34% (mean difference 2.51 [95% CI, 1.34-3.69]) in the subjects who were polysensitized (n = 437). For the HDM SLIT-tablet, TCRS improved by 20% (mean difference 1.24 [95% CI, 0.48-1.99]) in the subjects who were monosensitized (n = 468) and 17% (mean difference 0.85 [95% CI, 0.43-1.28]) in the subjects who were polysensitized (n = 1294). The overall safety profile was not qualitatively different between the subjects who were monosensitized and the subjects who were polysensitized. Conclusion: Grass, ragweed, tree, or HDM SLIT-tablet treatment is effective for the specific allergen in question in adults with AR/C and who are monosensitized or polysensitized. Targeting one relevant allergen with SLIT-tablets induces a clinical effect for that allergen in patients who were polysensitized.
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Affiliation(s)
- Harold S Nelson
- From the Department of Medicine, National Jewish Health, Denver, Colorado
| | - David I Bernstein
- Division of Immunology and Allergy, University of Cincinnati College of Medicine and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Tilo Biedermann
- Department of Dermatology and Allergology, Technical University of Munich, Munich, Germany, and
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de Kam PJ, Zielen S, Bernstein JA, Berger U, Berger M, Cuevas M, Cypcar D, Fuhr-Horst A, Greisner WA, Jandl M, Laßmann S, Worm M, Matz J, Sher E, Smith C, Steven GC, Mösges R, Shamji MH, DuBuske L, Borghese F, Oluwayi K, Zwingers T, Seybold M, Armfield O, Heath MD, Hewings SJ, Kramer MF, Skinner MA. Short-course subcutaneous treatment with PQ Grass strongly improves symptom and medication scores in grass allergy. Allergy 2023; 78:2756-2766. [PMID: 37366581 DOI: 10.1111/all.15788] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/05/2023] [Accepted: 06/04/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND A modified grass allergen subcutaneous immunotherapy (SCIT) product with MicroCrystalline Tyrosine and monophosphoryl lipid-A as an adjuvant system (Grass MATA MPL [PQ Grass]) is being developed as short-course treatment of grass-pollen allergic rhinitis (SAR) and/or rhinoconjunctivitis. We sought to evaluate the combined symptom and medication score (CSMS) of the optimized cumulative dose of 27,600 standardized units (SU) PQ Grass in a field setting prior to embarking on a pivotal Phase III trial. METHODS In this exploratory, randomized, double-blind, placebo-controlled trial subjects were enrolled across 14 sites (Germany and the United States of America). Six pre-seasonal subcutaneous injections of PQ Grass (using conventional or extended regimens) or placebo were administered to 119 subjects (aged 18-65 years) with moderate-to-severe SAR with or without asthma that was well-controlled. The primary efficacy endpoint was CSMS during peak grass pollen season (GPS). Secondary endpoints included Rhinoconjunctivitis Quality of Life Questionnaire standardized (RQLQ-S) and allergen-specific IgG4 response. RESULTS The mean CSMS compared to placebo was 33.1% (p = .0325) and 39.5% (p = .0112) for the conventional and extended regimens, respectively. An increase in IgG4 was shown for both regimens (p < .01) as well as an improvement in total RQLQ-S for the extended regimen (mean change -0.72, p = .02). Both regimens were well-tolerated. CONCLUSIONS This trial demonstrated a clinically relevant and statistically significant efficacy response to PQ Grass. Unprecedented effect sizes were reached for grass allergy of up to ≈40% compared to placebo for CSMS after only six PQ Grass injections. Both PQ Grass regimens were considered equally safe and well-tolerated. Based on enhanced efficacy profile extended regime will be progressed to the pivotal Phase III trial.
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Affiliation(s)
| | - S Zielen
- Children and Adolescents Department, Allergology, Pulmonology & Cystic Fibrosis, Goethe University, Frankfurt, Germany
| | - J A Bernstein
- Bernstein Clinical Research Center, LLC, Cincinnati, Ohio, USA
| | - U Berger
- Aerobiology and Pollen Research Unit, Department of Oto-Rhino-Laryngology, Medical University Vienna, Vienna, Austria
| | - M Berger
- Department of Otorhinolaryngology, Wiener Gesundheitsverbund, Hospital Hietzing, Vienna, Austria
| | - M Cuevas
- Clinic and Polyclinic of Otorhinolaryngology, University Clinic Carl Gustav Carus, Dresden, Germany
| | - D Cypcar
- Allergy Partners of Western North Carolina, Asheville, North Carolina, USA
| | - A Fuhr-Horst
- ENT Research- Institut für klinische Studien, Essen, Germany
| | - W A Greisner
- Bluegrass Allergy Research, Lexington, Kentucky, USA
| | - M Jandl
- Hamburger Institut für Therapieforschung GmbH, Hamburg, Germany
| | - S Laßmann
- Studienzentrum Dr. Sabine Laßmann, Saalfeld, Germany
| | - M Worm
- Department of Dermatology and Allergy-Charite Campus Mitte, Universitätsmedizin Berlin, Berlin, Germany
| | - J Matz
- Chesapeake Clinical Research, Inc, White Marsh, Maryland, USA
| | - E Sher
- Allergy Partners of New Jersey, Ocean Township, New Jersey, USA
| | - C Smith
- Certified Research Associates, Cortland, New York, USA
| | - G C Steven
- Allergy Asthma & Sinus Center, S.C., Greenfield, Wisconsin, USA
| | - R Mösges
- IMSB (Institute of Computational Biology and Medical Statistics), University at Cologne, Cologne, Germany
- ClinCompetence, Cologne, Germany
| | - M H Shamji
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, Imperial College London, London, UK
- Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, UK
| | - L DuBuske
- Division of Allergy and Immunology, Department of Internal Medicine, George Washington University Hospital, Washington, DC, USA
| | | | - K Oluwayi
- Allergy Therapeutics PLC, Worthing, UK
| | | | - M Seybold
- Allergy Therapeutics PLC, Worthing, UK
| | | | - M D Heath
- Allergy Therapeutics PLC, Worthing, UK
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14
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Wise SK, Damask C, Roland LT, Ebert C, Levy JM, Lin S, Luong A, Rodriguez K, Sedaghat AR, Toskala E, Villwock J, Abdullah B, Akdis C, Alt JA, Ansotegui IJ, Azar A, Baroody F, Benninger MS, Bernstein J, Brook C, Campbell R, Casale T, Chaaban MR, Chew FT, Chambliss J, Cianferoni A, Custovic A, Davis EM, DelGaudio JM, Ellis AK, Flanagan C, Fokkens WJ, Franzese C, Greenhawt M, Gill A, Halderman A, Hohlfeld JM, Incorvaia C, Joe SA, Joshi S, Kuruvilla ME, Kim J, Klein AM, Krouse HJ, Kuan EC, Lang D, Larenas-Linnemann D, Laury AM, Lechner M, Lee SE, Lee VS, Loftus P, Marcus S, Marzouk H, Mattos J, McCoul E, Melen E, Mims JW, Mullol J, Nayak JV, Oppenheimer J, Orlandi RR, Phillips K, Platt M, Ramanathan M, Raymond M, Rhee CS, Reitsma S, Ryan M, Sastre J, Schlosser RJ, Schuman TA, Shaker MS, Sheikh A, Smith KA, Soyka MB, Takashima M, Tang M, Tantilipikorn P, Taw MB, Tversky J, Tyler MA, Veling MC, Wallace D, Wang DY, White A, Zhang L. International consensus statement on allergy and rhinology: Allergic rhinitis - 2023. Int Forum Allergy Rhinol 2023; 13:293-859. [PMID: 36878860 DOI: 10.1002/alr.23090] [Citation(s) in RCA: 79] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/11/2022] [Accepted: 09/13/2022] [Indexed: 03/08/2023]
Abstract
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.
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Affiliation(s)
- Sarah K Wise
- Otolaryngology-HNS, Emory University, Atlanta, Georgia, USA
| | - Cecelia Damask
- Otolaryngology-HNS, Private Practice, University of Central Florida, Lake Mary, Florida, USA
| | - Lauren T Roland
- Otolaryngology-HNS, Washington University, St. Louis, Missouri, USA
| | - Charles Ebert
- Otolaryngology-HNS, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Joshua M Levy
- Otolaryngology-HNS, Emory University, Atlanta, Georgia, USA
| | - Sandra Lin
- Otolaryngology-HNS, University of Wisconsin, Madison, Wisconsin, USA
| | - Amber Luong
- Otolaryngology-HNS, McGovern Medical School of the University of Texas, Houston, Texas, USA
| | - Kenneth Rodriguez
- Otolaryngology-HNS, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ahmad R Sedaghat
- Otolaryngology-HNS, University of Cincinnati, Cincinnati, Ohio, USA
| | - Elina Toskala
- Otolaryngology-HNS, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Baharudin Abdullah
- Otolaryngology-HNS, Universiti Sains Malaysia, Kubang, Kerian, Kelantan, Malaysia
| | - Cezmi Akdis
- Immunology, Infectious Diseases, Swiss Institute of Allergy and Asthma Research, Davos, Switzerland
| | - Jeremiah A Alt
- Otolaryngology-HNS, University of Utah, Salt Lake City, Utah, USA
| | | | - Antoine Azar
- Allergy/Immunology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Fuad Baroody
- Otolaryngology-HNS, University of Chicago, Chicago, Illinois, USA
| | | | | | - Christopher Brook
- Otolaryngology-HNS, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Raewyn Campbell
- Otolaryngology-HNS, Macquarie University, Sydney, NSW, Australia
| | - Thomas Casale
- Allergy/Immunology, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Mohamad R Chaaban
- Otolaryngology-HNS, Cleveland Clinic, Case Western Reserve University, Cleveland, Ohio, USA
| | - Fook Tim Chew
- Allergy/Immunology, Genetics, National University of Singapore, Singapore, Singapore
| | - Jeffrey Chambliss
- Allergy/Immunology, University of Texas Southwestern, Dallas, Texas, USA
| | - Antonella Cianferoni
- Allergy/Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | | | - Anne K Ellis
- Allergy/Immunology, Queens University, Kingston, ON, Canada
| | | | - Wytske J Fokkens
- Otorhinolaryngology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | | | - Matthew Greenhawt
- Allergy/Immunology, Pediatrics, University of Colorado, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Amarbir Gill
- Otolaryngology-HNS, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashleigh Halderman
- Otolaryngology-HNS, University of Texas Southwestern, Dallas, Texas, USA
| | - Jens M Hohlfeld
- Respiratory Medicine, Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, Hannover Medical School, German Center for Lung Research, Hannover, Germany
| | | | - Stephanie A Joe
- Otolaryngology-HNS, University of Illinois Chicago, Chicago, Illinois, USA
| | - Shyam Joshi
- Allergy/Immunology, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Jean Kim
- Otolaryngology-HNS, Johns Hopkins University, Baltimore, Maryland, USA
| | - Adam M Klein
- Otolaryngology-HNS, Emory University, Atlanta, Georgia, USA
| | - Helene J Krouse
- Otorhinolaryngology Nursing, University of Texas Rio Grande Valley, Edinburg, Texas, USA
| | - Edward C Kuan
- Otolaryngology-HNS, University of California Irvine, Orange, California, USA
| | - David Lang
- Allergy/Immunology, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Matt Lechner
- Otolaryngology-HNS, University College London, Barts Health NHS Trust, London, UK
| | - Stella E Lee
- Otolaryngology-HNS, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Victoria S Lee
- Otolaryngology-HNS, University of Illinois Chicago, Chicago, Illinois, USA
| | - Patricia Loftus
- Otolaryngology-HNS, University of California San Francisco, San Francisco, California, USA
| | - Sonya Marcus
- Otolaryngology-HNS, Stony Brook University, Stony Brook, New York, USA
| | - Haidy Marzouk
- Otolaryngology-HNS, State University of New York Upstate, Syracuse, New York, USA
| | - Jose Mattos
- Otolaryngology-HNS, University of Virginia, Charlottesville, Virginia, USA
| | - Edward McCoul
- Otolaryngology-HNS, Ochsner Clinic, New Orleans, Louisiana, USA
| | - Erik Melen
- Pediatric Allergy, Karolinska Institutet, Stockholm, Sweden
| | - James W Mims
- Otolaryngology-HNS, Wake Forest University, Winston Salem, North Carolina, USA
| | - Joaquim Mullol
- Otorhinolaryngology, Hospital Clinic Barcelona, Barcelona, Spain
| | - Jayakar V Nayak
- Otolaryngology-HNS, Stanford University, Palo Alto, California, USA
| | - John Oppenheimer
- Allergy/Immunology, Rutgers, State University of New Jersey, Newark, New Jersey, USA
| | | | - Katie Phillips
- Otolaryngology-HNS, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael Platt
- Otolaryngology-HNS, Boston University, Boston, Massachusetts, USA
| | | | | | - Chae-Seo Rhee
- Rhinology/Allergy, Seoul National University Hospital and College of Medicine, Seoul, Korea
| | - Sietze Reitsma
- Otolaryngology-HNS, University of Amsterdam, Amsterdam, Netherlands
| | - Matthew Ryan
- Otolaryngology-HNS, University of Texas Southwestern, Dallas, Texas, USA
| | - Joaquin Sastre
- Allergy, Fundacion Jiminez Diaz, University Autonoma de Madrid, Madrid, Spain
| | - Rodney J Schlosser
- Otolaryngology-HNS, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Theodore A Schuman
- Otolaryngology-HNS, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Marcus S Shaker
- Allergy/Immunology, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Aziz Sheikh
- Primary Care, University of Edinburgh, Edinburgh, Scotland
| | - Kristine A Smith
- Otolaryngology-HNS, University of Utah, Salt Lake City, Utah, USA
| | - Michael B Soyka
- Otolaryngology-HNS, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Masayoshi Takashima
- Otolaryngology-HNS, Houston Methodist Academic Institute, Houston, Texas, USA
| | - Monica Tang
- Allergy/Immunology, University of California San Francisco, San Francisco, California, USA
| | | | - Malcolm B Taw
- Integrative East-West Medicine, University of California Los Angeles, Westlake Village, California, USA
| | - Jody Tversky
- Allergy/Immunology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Matthew A Tyler
- Otolaryngology-HNS, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maria C Veling
- Otolaryngology-HNS, University of Texas Southwestern, Dallas, Texas, USA
| | - Dana Wallace
- Allergy/Immunology, Nova Southeastern University, Ft. Lauderdale, Florida, USA
| | - De Yun Wang
- Otolaryngology-HNS, National University of Singapore, Singapore, Singapore
| | - Andrew White
- Allergy/Immunology, Scripps Clinic, San Diego, California, USA
| | - Luo Zhang
- Otolaryngology-HNS, Beijing Tongren Hospital, Beijing, China
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Abstract
Allergen immunotherapy is a form of therapeutic vaccination for established IgE-mediated hypersensitivity to common allergen sources such as pollens, house dust mites and the venom of stinging insects. The classical protocol, introduced in 1911, involves repeated subcutaneous injection of increasing amounts of allergen extract, followed by maintenance injections over a period of 3 years, achieving a form of allergen-specific tolerance that provides clinical benefit for years after its discontinuation. More recently, administration through the sublingual route has emerged as an effective, safe alternative. Oral immunotherapy for peanut allergy induces effective ‘desensitization’ but not long-term tolerance. Research and clinical trials over the past few decades have elucidated the mechanisms underlying immunotherapy-induced tolerance, involving a reduction of allergen-specific T helper 2 (TH2) cells, an induction of regulatory T and B cells, and production of IgG and IgA ‘blocking’ antibodies. To better harness these mechanisms, novel strategies are being explored to achieve safer, effective, more convenient regimens and more durable long-term tolerance; these include alternative routes for current immunotherapy approaches, novel adjuvants, use of recombinant allergens (including hypoallergenic variants) and combination of allergens with immune modifiers or monoclonal antibodies targeting the TH2 cell pathway. Durham and Shamji review the history and future of allergen immunotherapy for established IgE-mediated hypersensitivity to common allergens. They describe the mechanisms of immunotherapy-induced tolerance and the new strategies being explored to achieve safer, more effective, long-term tolerance.
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Abstract
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.
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Affiliation(s)
- Lawrence DuBuske
- From the Department of Internal Medicine, George Washington University Hospital, Washington, D.C.; and
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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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18
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Bonertz A, Tripathi A, Zimmer J, Reeb C, Kaul S, Bridgewater J, Rabin RL, Slater JE, Vieths S. A regulator’s view on AIT clinical trials in the United States and Europe: Why successful studies fail to support licensure. J Allergy Clin Immunol 2022; 149:812-818. [DOI: 10.1016/j.jaci.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 10/19/2022]
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19
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Ellis AK, Connors L, Francoeur MJ, Mack DP. Rupatadine to prevent local allergic reactions to sublingual allergy immunotherapy: a case series. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2021; 17:125. [PMID: 34863283 PMCID: PMC8643187 DOI: 10.1186/s13223-021-00630-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/18/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Sublingual immunotherapy tablets (SLIT-T) are an effective treatment for allergic rhinitis (AR), but some patients experience local allergic reactions (LAR) in the first few weeks of treatment that can lead to treatment discontinuation. Although oral antihistamines are recommended for the treatment and pretreatment of LAR associated with SLIT-T, there are no clinical trial data to support this recommendation. Rupatadine is an H1 antihistamine that also inhibits platelet activating factor activity. The objective of this case series is to describe real-world clinical situations in which rupatadine was used to treat or mitigate SLIT-T-related LAR. CASE PRESENTATIONS Five cases are presented by the managing allergist and off-label use of rupatadine is their expert opinion only. Patients in all 5 cases were treated with a SLIT-T (e.g. ragweed, tree, grass, or house dust mites) for the management of allergic rhinitis and experienced bothersome LAR with the first SLIT-T administration. In 3 cases, rupatadine 10 mg was administered for the immediate treatment of LAR (either in-office with the first SLIT-T dose or for subsequent LAR experienced at home) and the symptoms resolved. In 3 cases, pretreatment with other second-generation H1 antihistamines was unable to prevent LAR and the patients discontinued the SLIT-T. In these 3 cases, switching to pretreatment with rupatadine allowed the patients to restart and tolerate SLIT-T treatment with minimal or no LAR. In these patients with an established history of LAR, proactive pretreatment with rupatadine in subsequent seasons or with initiation of a different SLIT-T mitigated the previously experienced LARs. CONCLUSIONS In the cases presented, treatment with rupatadine resolved LAR associated with SLIT-T treatment and rupatadine pretreatment appeared to mitigate subsequent LAR. Rupatadine may be an option to treat or improve the tolerability of the SLIT-T, potentially improving early treatment persistence.
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Affiliation(s)
- Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, 76 Stuart St, Kingston, ON, K7L 2V7, Canada.
| | - Lori Connors
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Marie-Josee Francoeur
- Division of Pediatric Allergy, University of Sherbrooke CISSS Montérégie Centre, Clinique des spécialistes Santé Dix 30, Elna Tiny Tots, Montréal, QC, Canada
| | - Douglas P Mack
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Halton Pediatric Allergy, Burlington, ON, Canada
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Barber D, Diaz‐Perales A, Escribese MM, Kleine‐Tebbe J, Matricardi PM, Ollert M, Santos AF, Sastre J. Molecular allergology and its impact in specific allergy diagnosis and therapy. Allergy 2021; 76:3642-3658. [PMID: 34057744 DOI: 10.1111/all.14969] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/19/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023]
Abstract
Progressive knowledge of allergenic structures resulted in a broad availability of allergenic molecules for diagnosis. Component-resolved diagnosis allowed a better understanding of patient sensitization patterns, facilitating allergen immunotherapy decisions. In parallel to the discovery of allergenic molecules, there was a progressive development of a regulation framework that affected both in vitro diagnostics and Allergen Immunotherapy products. With a progressive understanding of underlying mechanisms associated to Allergen immunotherapy and an increasing experience of application of molecular diagnosis in daily life, we focus in analyzing the evidences of the value provided by molecular allergology in daily clinical practice, with a focus on Allergen Immunotherapy decisions.
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Affiliation(s)
- Domingo Barber
- Departamento de Ciencias Médicas Básicas Facultad de Medicina IMMA, Universidad San Pablo CEU, CEU Universities Madrid Spain
- ARADyAL‐RD16/0006/0015 RD16/0006/0003 Thematic Network and Cooperative Research Centers ISCIII Madrid Spain
| | - Araceli Diaz‐Perales
- ARADyAL‐RD16/0006/0015 RD16/0006/0003 Thematic Network and Cooperative Research Centers ISCIII Madrid Spain
- Center for Plant Biotechnology and Genomic Universidad Politécnica de Madrid Pozuelo de Alarcon Spain
| | - Maria M. Escribese
- Departamento de Ciencias Médicas Básicas Facultad de Medicina IMMA, Universidad San Pablo CEU, CEU Universities Madrid Spain
- ARADyAL‐RD16/0006/0015 RD16/0006/0003 Thematic Network and Cooperative Research Centers ISCIII Madrid Spain
| | | | - Paolo M. Matricardi
- Department of Pediatric Pneumology and Immunology Charitè Medical University of Berlin Berlin Germany
| | - Markus Ollert
- Department of Infection and Immunity Luxembourg Institute of Health Esch‐sur‐Alzette Luxembourg
- Department of Dermatology and Allergy Centre Odense University Hospital Odense Denmark
| | - Alexandra F. Santos
- Department of Women and Children's Health (Pediatric Allergy School of Life Course Sciences Faculty of Life Sciences and Medicine King's College London London UK
- Peter Gorer Department of Immunobiology School of Immunology and Microbial Sciences King's College London London UK
- Asthma UK Centre in Allergic Mechanisms of Asthma London UK
- Children's Allergy Service Guy's and St Thomas' Hospital London UK
| | - Joaquin Sastre
- Fundación Jiménez Diaz AllergyDepartment Universidad Autonomade Madrid, CIBERES, Instituto de Salud Carlos III Madrid Spain
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Ellis AK, Gagnon R, Bernstein DI, Nolte H. Randomized controlled trial of ragweed sublingual immunotherapy tablet in the subpopulation of Canadian children and adolescents with allergic rhinoconjunctivitis. Allergy Asthma Clin Immunol 2021; 17:127. [PMID: 34886880 PMCID: PMC8656080 DOI: 10.1186/s13223-021-00626-2] [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: 07/20/2021] [Accepted: 11/15/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Post hoc analyses of randomized placebo-controlled trials have demonstrated efficacy and tolerability of the ragweed sublingual immunotherapy (SLIT)-tablet in Canadian adults with ragweed pollen-induced allergic rhinitis/conjunctivitis (AR/C). This post hoc analysis evaluated the efficacy and tolerability of the ragweed SLIT-tablet in the subpopulation of Canadian children and adolescents with AR/C in a previously described randomized, double-blind, placebo-controlled trial.
Methods
The trial (NCT02478398) was conducted in North American and European children/adolescents ages 5–17 years with ragweed pollen-induced AR/C with or without asthma (FEV1 ≥ 80% predicted). Participants were randomized to daily ragweed SLIT-tablet (12 Amb a 1-U) or placebo for up to 28 weeks. The primary endpoint was the average total combined score (TCS; sum of rhinoconjunctivitis daily symptom score [DSS] and daily medication score [DMS]) during peak ragweed pollen season (RPS). Key secondary endpoints were TCS during the entire RPS, and DSS and DMS during peak RPS. Post hoc analyses of the primary and key secondary endpoints were conducted in the subpopulation of Canadian participants.
Results
Of the 1025 randomized participants, 246 (SLIT-tablet, n = 116; placebo, n = 130) were in the Canadian subpopulation. In the total study population, relative TCS (95% CI) improvement with ragweed SLIT-tablet versus placebo was − 38.3% (− 46.0%, − 29.7%; least square [LS] mean difference, − 2.73; P < 0.001) during peak RPS. In the Canadian subpopulation, relative TCS improvements with ragweed SLIT-tablet versus placebo were − 40.8% (− 54.5%, − 20.2%; LS mean difference, − 1.59; P = 0.001) during peak RPS and − 36.6% (− 50.2%, − 16.5%; LS mean difference, − 1.36; P = 0.002) during the entire RPS. DSS and DMS during peak RPS in the Canadian subpopulation improved with SLIT-tablet versus placebo by − 30.6% (− 45.2%, − 7.7%; LS mean difference, − 0.94; P = 0.010) and − 77.2% (− 97.5%, − 44.2%; LS mean difference, − 0.66; P = 0.003), respectively. No events of anaphylaxis, airway compromise, intramuscular epinephrine administration, eosinophilic esophagitis, or severe treatment-related systemic allergic reactions were reported in the overall population or Canadian subpopulation.
Conclusion
Efficacy and safety of the ragweed SLIT-tablet in Canadian children/adolescents with ragweed pollen-induced AR/C was consistent with the total study population. The ragweed SLIT-tablet resulted in clinically meaningful improvement in symptoms, decreased symptom-relieving medication use, and was well tolerated in Canadian children/adolescents.
Trial registration: clinicaltrials.gov, NCT02478398. Registered June 23, 2015, https://clinicaltrials.gov/ct2/show/NCT02478398?term=NCT02478398&draw=2&rank=1
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22
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Nelson HS. How important is proper dosing for subcutaneous and sublingual allergy immunotherapy? Allergy Asthma Proc 2021; 42:368-377. [PMID: 34474706 DOI: 10.2500/aap.2021.42.210061] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Results of surveys report that allergists use a wide range of doses for allergy immunotherapy; however, results of randomized, double-blind, placebo controlled studies suggest that the range of the optimum effective dosing is relatively narrow. Objective: To review studies that established effective or less than fully effective doses for allergy immunotherapy. Methods: Studies were reviewed that established effective and ineffective subcutaneous and sublingual immunotherapy doses. Only those studies that expressed dosing in terms of the content of a major allergen in the maintenance doses were included in defining effective and ineffective doses. Results: Studies were identified that showed effective doses for subcutaneous injection, established in randomized, double-blind, placebo controlled trials, for short ragweed, timothy grass, house-dust mites, cat and dog dander, birch, and Alternaria. For short ragweed, timothy grass, Dermatophagoides pteronyssinus, and cat and dog dander, less-effective doses were determined, along with effective doses; the less-effective doses were only one-fifth to one-tenth less in allergen content than were the effective doses. Effective doses of cockroach and all fungal extracts except Alternaria have not been established. Information is available on the mean major allergen content of U.S. standardized and a few nonstandardized extracts, which allows the information on effective and ineffective dosing to be used in prescribing subcutaneous allergy immunotherapy. With sublingual allergy immunotherapy, all the approved tablets had multidose studies that determined the optimal dose. For the U.S. liquid extracts, to my knowledge, there are no studies to define effective doses except for ragweed. Conclusions: Although a wide range of doses are prescribed by U.S. allergists, analysis of available data suggests that effective doses fall within a narrow range and that use of doses one-fifth or one-tenth of the effective doses may sacrifice most or all of the potential efficacy of the treatment.
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23
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Ellis AK, DeVeaux M, Steacy L, Ramesh D, Suprun M, Langdon S, Wang CQ, Adams D, Thiele J, Walker T, Perlee LT, O'Brien MP. Environmental exposure unit simulates natural seasonal birch pollen exposures while maximizing change in allergic symptoms. Ann Allergy Asthma Immunol 2021; 127:488-495.e5. [PMID: 34186172 DOI: 10.1016/j.anai.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/07/2021] [Accepted: 06/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Birch pollen is a prevalent aeroallergen during the springtime allergy season. In field studies, variable allergen exposure and environmental factors can affect data quality while environmental exposure units (EEUs) deliver controlled, standardized, and reproducible allergen exposures. OBJECTIVE To inform study design for EEU trials evaluating antiallergic therapies. METHODS In this prospective study, 76 participants with birch allergy experienced 3 exposures to birch pollen: (1) an out-of-season EEU challenge (two 3-hour sessions on consecutive days); (2) a natural seasonal exposure; and (3) an in-season EEU challenge (3-hour exposure for 2 weeks after birch pollen season initiation). RESULTS The total nasal symptom score, total ocular symptom score, and total symptom score (TSS = total nasal symptom score plus total ocular symptom score) were assessed every 30 minutes and daily during EEU and natural exposures. A high association between TSSs and day 2 of the out-of-season and in-season EEU challenges was noted, with a good association between the maximum TSS during the natural and in-season EEU challenges, and natural season and day 2 of the out-of-season EEU challenge (P < .001 for all). Participants had higher maximum change from the baseline TSS during day 2 of the out-of-season EEU challenge (12.4) vs the following: (1) first day (9.8); (2) in-season EEU challenge (8.4); and (3) natural seasonal exposure (7.6) (P < .001 for all). CONCLUSION A strong association was seen between the presence of allergy symptoms and exposure to birch pollen in the EEU (maximum change in symptom scores during day 2) and in the field. A hybrid trial design may be useful to demonstrate the clinical efficacy of novel antiallergic therapies requiring fewer participants and shorter timelines and expediting treatment availability.
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Affiliation(s)
- Anne K Ellis
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada; Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada.
| | | | - Lisa Steacy
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Divya Ramesh
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Maria Suprun
- Department of Pediatrics, Allergy, and Immunology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shaun Langdon
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Claire Q Wang
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Daniel Adams
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Jenny Thiele
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Terry Walker
- Allergy Research Unit, Kingston General Health Research Institute, Kingston, Ontario, Canada
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Tie K, Miller C, Zanation AM, Ebert CS. Subcutaneous Versus Sublingual Immunotherapy for Adults with Allergic Rhinitis: A Systematic Review with Meta-Analyses. Laryngoscope 2021; 132:499-508. [PMID: 33929726 DOI: 10.1002/lary.29586] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine whether subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT) better improves patient outcomes and quality of life for adults with allergic rhinitis or rhinoconjunctivitis (AR/C) with or without mild to moderate asthma. METHODS Systematic review methodology was based on the Cochrane Collaboration handbook and Preferred Reporting Items for Systematic Reviews and Meta-analyses. Four databases (PubMed, Cochrane Library, EMBASE, and Web of Science) were queried from inception to July 30, 2020. Two independent reviewers screened potentially relevant studies and assessed risk of bias. Outcomes of interest were symptom score (SS), medication score (MS), combined symptom medication score (CSMS), and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ). Meta-analyses with an adjusted indirect comparison were conducted in RevMan 5.4.1. RESULTS Seven SCIT versus SLIT randomized controlled trials (RCTs) demonstrated no significant differences for any outcomes, but insufficient data precluded direct meta-analysis. For the adjusted indirect comparison, 46 RCTs over 39 studies were included for SCIT versus placebo (n = 13) and SLIT versus placebo (n = 33). Statistically significant results favoring SCIT were found for SS (standardized mean difference [SMD] = 0.40; 95% confidence interval [CI] = 0.31-0.49), MS (SMD = 0.26; 95% CI = 0.14-0.39), CSMS (SMD = 0.42; 95% CI = 0.17-0.67), and RQLQ (MD = 0.24; 95% CI = 0.04-0.44). Statistically significant results favoring SLIT were found for SS (SMD = 0.42; 95% CI = 0.32-0.53), MS (SMD = 0.40; 95% CI = 0.28-0.53), CSMS (SMD = 0.37; 95% CI = 0.29-0.45), and RQLQ (MD = 0.32; 95% CI = 0.20-0.43). No significant differences were found between SCIT and SLIT for SS (SMD = -0.02; 95% CI = -0.15 to 0.11), MS (SMD = -0.14; 95% CI = -0.31 to 0.03), CSMS (SMD = 0.05; 95% CI = -0.21 to 0.31), or RQLQ (MD = -0.08; 95% CI = -0.31 to 0.15). CONCLUSION SCIT and SLIT are comparably effective treatments for adults with AR/C. More RCTs analyzing SCIT versus SLIT are needed to directly compare the two. Laryngoscope, 2021.
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Affiliation(s)
- Kevin Tie
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, U.S.A
| | - Craig Miller
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, U.S.A
| | - Adam M Zanation
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, U.S.A
| | - Charles S Ebert
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, U.S.A
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Pfaar O, Agache I, Bergmann K, Bindslev‐Jensen C, Bousquet J, Creticos PS, Devillier P, Durham SR, Hellings P, Kaul S, Kleine‐Tebbe J, Klimek L, Jacobsen L, Jutel M, Muraro A, Papadopoulos NG, Rief W, Scadding GK, Schedlowski M, Shamji MH, Sturm G, Ree R, Vidal C, Vieths S, Wedi B, Gerth van Wijk R, Frew AJ. Placebo effects in allergen immunotherapy-An EAACI Task Force Position Paper. Allergy 2021; 76:629-647. [PMID: 32324902 DOI: 10.1111/all.14331] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/18/2020] [Indexed: 12/12/2022]
Abstract
The placebo (Latin "I will please") effect commonly occurs in clinical trials. The psychological and physiological factors associated with patients' expectations about a treatment's positive and negative effects have yet to be well characterized, although a functional prefrontal cortex and intense bidirectional communication between the central nervous system and the immune system appear to be prerequisites for a placebo effect. The use of placebo raises certain ethical issues, especially if patients in a placebo group are denied an effective treatment for a long period of time. The placebo effect appears to be relatively large (up to 77%, relative to pretreatment scores) in controlled clinical trials of allergen immunotherapy (AIT), such as the pivotal, double-blind, placebo-controlled (DBPC) randomized clinical trials currently required by regulatory authorities worldwide. The European Academy of Allergy and Clinical Immunology (EAACI) therefore initiated a Task Force, in order to better understand the placebo effect in AIT and its specific role in comorbidities, blinding issues, adherence, measurement time points, variability and the natural course of the disease. In this Position Paper, the EAACI Task Force highlights several important topics regarding the placebo effect in AIT such as a) regulatory aspects, b) neuroimmunological and psychological mechanisms, c) placebo effect sizes in AIT trials, d) methodological limitations in AIT trial design and e) potential solutions in future AIT trial design. In conclusion, this Position Paper aims to examine the methodological problem of placebo in AIT from different aspects and also to highlight unmet needs and possible solutions for future trials.
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Affiliation(s)
- Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital Marburg Philipps‐Universität Marburg Marburg Germany
| | | | - Karl‐Christian Bergmann
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin Berlin Germany
- Berlin Institute of Health Allergy‐Centre‐Charité Berlin Germany
| | - Carsten Bindslev‐Jensen
- Department of Dermatology and Allergy Centre Odense University Hospital Odense Research Center for Anaphylaxis (ORCA) Odense Denmark
| | - Jean Bousquet
- MACVIA‐France Montpellier France
- University Hospital Montpellier Montpellier France
| | - Peter S. Creticos
- Division of Allergy & Clinical Immunology Johns Hopkins University School of Medicine Baltimore MD USA
- Creticos Research Group Crownsville MD USA
| | - Philippe Devillier
- Department of Airway Diseases, Exhalomics, Hôpital Foch Université Paris‐Saclay Suresnes France
| | - Stephen R. Durham
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
| | - Peter Hellings
- Department of Otorhinolaryngology University Hospitals of Leuven Leuven Belgium
- Department of Otorhinolaryngology Academic Medical Center University of Amsterdam Amsterdam The Netherlands
- Department of Neuroscience University of Ghent Ghent Belgium
| | - Susanne Kaul
- Paul‐Ehrlich‐Institut Federal Institute for Vaccines and Biomedicines Langen Germany
| | - Jörg Kleine‐Tebbe
- Allergy & Asthma Center Westend Outpatient Clinic and Clinical Research Center Berlin Germany
| | - Ludger Klimek
- Center for Rhinology and Allergology Wiesbaden Germany
| | - Lars Jacobsen
- ALC, Allergy Learning and Consulting Copenhagen Denmark
| | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- All‐Med Medical Research Institute Wroclaw Poland
| | - Antonella Muraro
- Food Allergy Referral Centre Padua University Hospital Padua Padua Italy
| | - Nikolaos G. Papadopoulos
- Division of Infection Immunity & Respiratory Medicine University of Manchester Manchester UK
- Allergy Department 2nd Pediatric Clinic University of Athens Athens Greece
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy Philipps‐University of Marburg Marburg Germany
| | | | - Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology University Clinic Essen Essen Germany
| | - Mohamed H. Shamji
- National Heart and Lung Institute Imperial College London London UK
- NIHR Biomedical Research Centre Imperial College London London UK
| | - Gunter Sturm
- Department of Dermatology and Venereology Medical University of Graz Graz Austria
- Allergy Outpatient Clinic Reumannplatz Vienna Austria
| | - Ronald Ree
- Departments of Experimental Immunology and of Otorhinolaryngology Amsterdam University Medical Centers Amsterdam The Netherlands
| | - Carmen Vidal
- Department of Allergy and Faculty of Medicine University of Santiago de Compostela Santiago Spain
| | - Stefan Vieths
- Paul‐Ehrlich‐Institut Federal Institute for Vaccines and Biomedicines Langen Germany
| | - Bettina Wedi
- Department of Dermatology and Allergy Hannover Medical School Comprehensive Allergy Center Hannover Germany
| | - Roy Gerth van Wijk
- Section of Allergology Department of Internal Medicine Erasmus MC Rotterdam the Netherlands
| | - Anthony J. Frew
- Department of Respiratory Medicine Royal Sussex County Hospital University of Sussex and University of Brighton Brighton UK
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Nolte H, Waserman S, Ellis AK, Biedermann T, Würtzen PA. Treatment Effect of the Tree Pollen SLIT-Tablet on Allergic Rhinoconjunctivitis During Oak Pollen Season. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1871-1878. [PMID: 33548518 DOI: 10.1016/j.jaip.2021.01.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/21/2020] [Accepted: 01/20/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Birch, alder, hazel, and oak are members of the birch homologous group based on cross-reactivity toward the birch pollen allergen Betula verrucosa 1. Theoretically, allergy to these tree pollens may be treated by immunotherapy with one representative allergen extract. OBJECTIVE To evaluate post hoc whether treatment of birch pollen-induced allergic rhinoconjunctivitis with a standardized tree sublingual immunotherapy (SLIT)-tablet containing birch pollen extract reduces symptoms and symptom-relieving medication use during the oak pollen season (OPS). METHODS In a randomized, multinational, double-blind trial (EudraCT-2015-004821-15), 634 participants (ages 12-65 years) received daily tree SLIT-tablet (12 SQ-Bet) or placebo before and during tree pollen season (alder/hazel plus birch pollen season [BPS]). Symptom-relieving medication was allowed. The primary end point was the average total combined score (sum of rhinoconjunctivitis daily symptom score and daily medication score) during BPS. Outcomes during the OPS (excluding overlapping BPS days) were analyzed post hoc. RESULTS Relative improvements in average total combined score, daily symptom score, and daily medication score with the tree SLIT-tablet versus placebo during the OPS were 25%, 22%, and 32%, respectively (all P < .001). Significant correlations were observed between birch and oak serum immunoglobulin E (sIgE) at baseline (r = 0.86) and between birch and oak IgG4 after treatment (r = 0.72). Oak sIgE and IgG4 kinetics in response to tree SLIT-tablet treatment were similar to birch. CONCLUSIONS The tree SLIT-tablet leads to significant improvement of rhinoconjunctivitis outcomes during the OPS, supporting the clinical relevance of immunological cross-reactivity toward birch and oak allergens.
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Affiliation(s)
| | - Susan Waserman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Tilo Biedermann
- Department of Dermatology and Allergology, Technical University of Munich, Munich, Germany
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Cavaliere C, Incorvaia C, Begvarfaj E, Orlando MP, Turchetta R, Musacchio A, Ralli M, Ciofalo A, Greco A, de Vincentiis M, Masieri S. The safety of sublingual immunotherapy, can the rare systemic reactions be prevented? Expert Opin Drug Saf 2021; 20:259-264. [PMID: 33427529 DOI: 10.1080/14740338.2021.1874917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Carlo Cavaliere
- Department of Oral and Maxillo-Facial Sciences, Sapienza University, Rome, Italy
| | | | - Elona Begvarfaj
- Integrated Activity Head Neck Department, Federico II University, Naples, Italy
| | | | | | | | - Massimo Ralli
- Department of Sense Organs, Sapienza University, Rome, Italy
| | - Andrea Ciofalo
- Department of Sense Organs, Sapienza University, Rome, Italy
| | - Antonio Greco
- Department of Sense Organs, Sapienza University, Rome, Italy
| | - Marco de Vincentiis
- Department of Oral and Maxillo-Facial Sciences, Sapienza University, Rome, Italy
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28
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Bisyuk Y, DuBuske I, DuBuske LM. Efficacy of sublingual immunotherapy tablets in dust mite and pollen allergy. Allergy Asthma Proc 2021; 42:36-42. [PMID: 33404387 DOI: 10.2500/aap.2021.42.200109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The latest evidence on the mechanisms, efficacy, and safety of sublingual immunotherapy (SLIT) was reviewed. Interleukin (IL) 35 and IL-35-producing regulatory T cells were assessed as new biomarkers for SLIT responsiveness. A detailed analysis of clinical studies, including timothy grass pollen, 5-grass pollen, ragweed, and house-dust mite SLIT tablets, was provided, including a comparative analysis of efficacy and safety of SLIT versus subcutaneous immunotherapy.
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Affiliation(s)
- Yuriy Bisyuk
- From the Department of Clinical Laboratory Immunology and Allergy, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
| | - Ilona DuBuske
- Immunology Research Institute of New England, Gardner, Massachusetts
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Bernstein DI, Würtzen PA, DuBuske L, Blaiss MS, Ellis AK, Weber RW, Nolte H. Allergy to oak pollen in North America. Allergy Asthma Proc 2021; 42:43-54. [PMID: 33404388 DOI: 10.2500/aap.2021.42.200089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Oak pollen is an important allergen in North America. The genus Quercus (oak) belongs to the family Fagaceae under the order Fagales. Objective: The objective of this article was to narratively review the oak pollen season, clinical and epidemiologic aspects of allergy to oak pollen, oak taxonomy, and oak allergen cross-reactivity, with a focus on the North American perspective. Methods: A PubMed literature review (no limits) was conducted. Publications related to oak pollen, oak-related allergic rhinitis with or without conjunctivitis, and oak-related allergic asthma were selected for review. Results: Oak species are common throughout the United States and contribute up to 50% to overall atmospheric pollen loads. Mean peak oak pollen counts can reach >2000 grains/m³. The start of the oak pollen season generally corresponds to the seasonal shift from winter to spring based on latitude and elevation, and may begin as early as mid February. The duration of the season can last > 100 days and, in general, is longer at lower latitudes. In the United States, ∼30% of individuals with allergy are sensitized to oak. The oak pollen season correlates with increased allergic rhinitis symptom-relieving medication use and asthma-related emergency department visits or hospitalizations. Oak falls within the birch homologous group. Extensive immunologic cross-reactivity has been demonstrated between oak pollen and birch pollen allergens, and, more specifically, their major allergens Que a 1 and Bet v 1. The cross-reactivity between oak and birch has implications for allergy immunotherapy (AIT) because guidelines suggest selecting one representative allergen within a homologous group for AIT, a principle that would apply to oak. Conclusion: Allergy to oak pollen is common in North America and has a substantial clinical impact. Oak pollen allergens are cross-reactive with birch pollen allergens, which may have implications for AIT.
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Affiliation(s)
- David I. Bernstein
- From the Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Lawrence DuBuske
- Division of Allergy and Immunology, Department of Medicine, The George Washington University School of Medicine and Health Sciences, Washington, D.C
| | | | - Anne K. Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Richard W. Weber
- Department of Medicine, National Jewish Health, Denver, Colorado; and
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Würtzen PA, Grønager PM, Lund G, Gupta S, Andersen PS, Biedermann T, Ipsen H. Simplified AIT for allergy to several tree pollens-Arguments from the immune outcome analyses following treatment with SQ tree SLIT-tablet. Clin Exp Allergy 2020; 51:284-295. [PMID: 33207015 PMCID: PMC7984359 DOI: 10.1111/cea.13788] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 11/02/2020] [Accepted: 11/11/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The SQ tree SLIT-tablet (containing birch extract) proved clinically significant effects during the pollen season for birch as well as alder/hazel. Immune outcomes of this treatment for allergens from multiple birch homologous trees need further investigation. We hypothesize that birch pollen extract AIT modulates a highly cross-reactive immune response and that this may be the basis for the observed clinical cross-protection. METHODS Blood samples were collected from 397 birch allergic patients during SQ tree SLIT-tablet or placebo treatment (1:1) for up to 40 weeks. Serum IgE and IgG4 specific to birch, and birch homologous tree pollens from alder, hazel, hornbeam, beech and chestnut were measured by ImmunoCAP. IgE-Blocking Factor (IgE-BF) for alder, birch and hazel during treatment was measured by Advia Centaur and blocking effects for birch and all these birch homologous tree pollens were further investigated by basophil activation (BAT). Antibody readouts were investigated in patient subsets. T-cell responses (proliferation) to allergen extracts and peptide pools (group 1 allergens) were investigated in T-cell lines from 29 untreated birch pollen-allergic individuals. RESULTS Significant Pearson correlations between serum IgE towards birch, alder, hazel, hornbeam and beech were observed (r-values > .86). T-cell reactivity was observed throughout the birch homologous group. Almost identical kinetics for changes in IgE towards birch, alder and hazel were observed during treatment and similar species-specific changes were seen for serum-IgG4 . IgG4 reactivity towards birch and alder, hazel, hornbeam and beech correlated significantly at end-of-treatment (r-values > .72). Treatment resulted in similar IgE-BF kinetics for alder, birch, and hazel and blocking of BAT for multiple trees in most actively treated patients investigated. CONCLUSIONS Systematic analyses of T-cell and antibody cross-reactivities before and during birch pollen extract AIT provide the immunological basis for the observed clinical effect of SQ tree SLIT-tablet treatment of tree pollen allergy induced by multiple trees in the birch homologous group.
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Affiliation(s)
| | | | | | | | | | - Tilo Biedermann
- Department of Dermatology and Allergology, Technical University of Munich, Munich, Germany.,Clinical Unit Allergology, Helmholtz Zentrum München, German Research Center for Environmental Health GmbH, Neuherberg, Germany
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Dick K, Briggs A, Brandi H. Application of a Mapping Function to Estimate Utilities for Ragweed Allergy Immunotherapy Trials. PHARMACOECONOMICS - OPEN 2020; 4:649-655. [PMID: 32152899 PMCID: PMC7688878 DOI: 10.1007/s41669-020-00205-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Ragweed pollen sensitivity is a common cause of allergic rhinitis (AR) worldwide. AR symptoms include itchy and runny eyes, sneezing, blocked nose, impaired sleep and social and emotional problems, which can have a significant impact on quality of life. OBJECTIVE The objective of this analysis was to estimate utilities for two pooled standardised quality (SQ) ragweed sublingual immunotherapy (SLIT) tablet trials by applying a previously developed mapping algorithm. This study validated the algorithm and extended its application to ragweed seasonal allergy trials. The mapping algorithm relates disease-specific quality-of-life scores to preference-based utilities that may be used to calculate quality-adjusted life-years (QALYs) in cost-effectiveness studies. METHODS A mapping algorithm based on a grass pollen allergy immunotherapy trial, GT-08 (EudraCT no. 2004-000083-27) was applied to pooled data from two ragweed pollen immunotherapy trials, P05233 (EudraCT 2008-003863-38) and P05234 (EudraCT 2008-003864-20) to generate EuroQoL 5-Dimensions, 3-Levels (EQ-5D-3L) utilities from Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) data. RESULTS The mean utility difference between the SQ ragweed SLIT tablet and placebo was 0.025 [95% confidence interval (CI) 0.011-0.038]. The SQ ragweed SLIT tablet showed an incremental quality-adjusted life-days (QALDs) benefit of 1.900 (95% CI 0.835-2.916) over 75 days. CONCLUSIONS Application of a previously developed mapping function allowed for the calculation of QALDs associated with the SQ ragweed SLIT tablet. The results showed a QALD benefit of the SQ ragweed SLIT tablet in P05233 and P05234 trials in the treatment of ragweed pollen-induced AR.
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Affiliation(s)
- Katherine Dick
- Health Economist, Avalon Health Economics, 26 Washington Street, Floor 2, Morristown, NJ, 07960, USA.
| | - Andrew Briggs
- Health Economist, Avalon Health Economics, 26 Washington Street, Floor 2, Morristown, NJ, 07960, USA
- London School of Hygiene and Tropical Medicine, London, UK
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32
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Trivedi A, Katelaris C. Presentation, diagnosis, and the role of subcutaneous and sublingual immunotherapy in the management of ocular allergy. Clin Exp Optom 2020; 104:334-349. [PMID: 32944983 DOI: 10.1111/cxo.13129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Allergic eye disease or ocular allergy is a debilitating condition with a significant impact on quality of life and productivity. As atopy continues to be on the rise, primary care providers are likely to encounter increasing numbers of patients with allergic eye disease. This review outlines the classification and pathophysiology of allergic eye disease and its clinical presentation. This paper does not detail traditional first-line therapies of allergic eye disease but describes the interdisciplinary management between the eye-care provider and allergist. It is recommended that patients with ongoing signs and symptoms of ocular allergy despite first-line therapies be referred for allergen immunotherapy, as it is highly effective for treatment of allergic eye disease. Through induction of immune tolerance, allergen immunotherapy is a disease-modifying therapy that can result in long-term improvement of ocular allergy. A thorough literature review was conducted on the efficacy and safety of allergen immunotherapy, including subcutaneous immunotherapy and sublingual immunotherapy, and its role in allergic eye disease.
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Affiliation(s)
- Amruta Trivedi
- Immunology Department, Campbelltown Hospital, Sydney, Australia.,Department of Medicine, Campbelltown Hospital, Sydney, Australia
| | - Constance Katelaris
- Immunology Department, Campbelltown Hospital, Sydney, Australia.,Department of Medicine, Campbelltown Hospital, Sydney, Australia
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Hoffmann TM, Acar Şahin A, Aggelidis X, Arasi S, Barbalace A, Bourgoin A, Bregu B, Brighetti MA, Caeiro E, Caglayan Sozmen S, Caminiti L, Charpin D, Couto M, Delgado L, Di Rienzo Businco A, Dimier C, Dimou MV, Fonseca JA, Goksel O, Guvensen A, Hernandez D, Jang DT, Kalpaklioglu F, Lame B, Llusar R, Makris MP, Mazon A, Mesonjesi E, Nieto A, Öztürk A, Pahus L, Pajno GB, Panasiti I, Panetta V, Papadopoulos NG, Pellegrini E, Pelosi S, Pereira AM, Pereira M, Pinar M, Pfaar O, Potapova E, Priftanji A, Psarros F, Sackesen C, Sfika I, Suarez J, Thibaudon M, Travaglini A, Tripodi S, Verdier V, Villella V, Xepapadaki P, Yazici D, Matricardi PM, Dramburg S. "Whole" vs. "fragmented" approach to EAACI pollen season definitions: A multicenter study in six Southern European cities. Allergy 2020; 75:1659-1671. [PMID: 31833579 DOI: 10.1111/all.14153] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/08/2019] [Accepted: 10/29/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The adequate definition of pollen seasons is essential to facilitate a correct diagnosis, treatment choice, and outcome assessment in patients with seasonal allergic rhinitis. A position paper by the European Academy of Allergy and Clinical Immunology (EAACI) proposed season definitions for Northern and Middle Europe. OBJECTIVE To test the pollen season definitions proposed by EAACI in six Mediterranean cities for seven pollen taxa. METHODS As part of the @IT.2020 multi-center study, pollen counts for Poaceae, Oleaceae, Fagales, Cupressaceae, Urticaceae (Parietaria spp.), and Compositae (Ambrosia spp., Artemisia spp.) were collected from January 1 to December 31, 2018. Based on these data, pollen seasons were identified according to EAACI criteria. A unified monitoring period for patients in AIT trials was created and assessed for feasibility. RESULTS The analysis revealed a great heterogeneity between the different locations in terms of pattern and length of the examined pollen seasons. Further, we found a fragmentation of pollen seasons in several segments (max. 8) separated by periods of low pollen counts (intercurrent periods). Potential monitoring periods included often many recording days with low pollen exposure (max. 341 days). CONCLUSION The Mediterranean climate leads to challenging pollen exposure times. Monitoring periods for AIT trials based on existing definitions may include many intermittent days with low pollen concentrations. Therefore, it is necessary to find an adapted pollen season definition as individual solution for each pollen and geographical area.
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Affiliation(s)
- Tara Maria Hoffmann
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Aydan Acar Şahin
- Department of Biology Faculty of Science Ankara University Ankara Turkey
| | - Xenophon Aggelidis
- Allergy Unit 2 Department of Dermatology and Venereology National and Kapodistrian University of Athens University Hospital "Attikon" Athens Greece
| | - Stefania Arasi
- Pediatric Allergology Unit Department of Pediatric Medicine Bambino Gesù Children´s research Hospital (IRCCS) Rome Italy
| | - Andrea Barbalace
- Department of Pediatrics‐ Allergy Unit University of Messina Messina Italy
| | - Anne Bourgoin
- Department of Pneumonology and Allergy La Timone Hospital APHM Aix‐Marseille University Marseille France
- Hospital APHM Aix‐Marseille University Marseille France
| | - Blerina Bregu
- Department of Allergology and Clinical Immunology UHC Mother Teresa Medical University Tirana Tirana Albania
| | | | - Elsa Caeiro
- MED ‐ Mediterranean Institute for Agriculture, Environment and Development Institute for Advanced Studies and Research University of Évora Évora Portugal
- Portuguese Society of Allergology and Clinical Immunology Lisbon Portugal
| | - Sule Caglayan Sozmen
- Department of Pediatric Allergy and Immunology Okan University Faculty of Medicine Istanbul Turkey
| | - Lucia Caminiti
- Department of Pediatrics‐ Allergy Unit University of Messina Messina Italy
| | - Denis Charpin
- Department of Pneumonology and Allergy La Timone Hospital APHM Aix‐Marseille University Marseille France
- Hospital APHM Aix‐Marseille University Marseille France
| | - Mariana Couto
- Immunoallergology José de Mello Saúde Porto Portugal
| | - Luís Delgado
- Basic and Clinical Immunology Unit Department of Pathology Faculty of Medicine University of Porto Porto Portugal
- CINTESIS Center for Health Technology and Services Research Bologna Portugal
- Allergy Unit Instituto & Hospital CUF Porto Porto Portugal
| | | | - Claire Dimier
- Department of Pneumonology and Allergy La Timone Hospital APHM Aix‐Marseille University Marseille France
- Hospital APHM Aix‐Marseille University Marseille France
| | - Maria V. Dimou
- Allergy Department 2nd Pediatric Clinic Athens General Children's Hospital "P&A Kyriakou" University of Athens Athens Greece
| | - João A. Fonseca
- CINTESIS Center for Health Technology and Services Research Bologna Portugal
- Allergy Unit Instituto & Hospital CUF Porto Porto Portugal
- MEDCIDS‐Department of Community Medicine, Information, and Health Sciences Faculty of Medicine University of Porto Porto Portugal
| | - Ozlem Goksel
- Department of Pulmonary Medicine Division of Immunology, Allergy and Asthma Faculty of Medicine Ege University Izmir Turkey
| | - Aykut Guvensen
- Department of Biology Faculty of Science Ege University Izmir Turkey
| | - Dolores Hernandez
- Service of Allergy Hospital La Fe; Health Research Institute La Fe Valencia Spain
| | - Dah Tay Jang
- Pediatric Allergy and Pneumology Unit Children's Hospital La Fe; Health Research Institute La Fe Valencia Spain
| | - Fusun Kalpaklioglu
- Department of Chest Diseases Division of Immunology and Allergic Diseases Kırıkkale University School of Medicine Kırıkkale Turkey
| | - Blerta Lame
- Department of Allergology and Clinical Immunology UHC Mother Teresa Medical University Tirana Tirana Albania
| | - Ruth Llusar
- Pediatric Allergy and Pneumology Unit Children's Hospital La Fe; Health Research Institute La Fe Valencia Spain
| | - Michael P. Makris
- Allergy Unit 2 Department of Dermatology and Venereology National and Kapodistrian University of Athens University Hospital "Attikon" Athens Greece
| | - Angel Mazon
- Pediatric Allergy and Pneumology Unit Children's Hospital La Fe; Health Research Institute La Fe Valencia Spain
| | - Eris Mesonjesi
- Department of Allergology and Clinical Immunology UHC Mother Teresa Medical University Tirana Tirana Albania
| | - Antonio Nieto
- Pediatric Allergy and Pneumology Unit Children's Hospital La Fe; Health Research Institute La Fe Valencia Spain
| | - Ayse Öztürk
- Department of Allergy and Immunology Koç University Hospital Istanbul Turkey
| | - Laurie Pahus
- Department of Pneumonology and Allergy La Timone Hospital APHM Aix‐Marseille University Marseille France
- Hospital APHM Aix‐Marseille University Marseille France
| | | | - Ilenia Panasiti
- Department of Pediatrics‐ Allergy Unit University of Messina Messina Italy
| | - Valentina Panetta
- Biostatistics L'altrastatistica srl Consultancy & Training Rome Italy
- Division of Infection Immunity& Respiratory Medicine Royal Manchester Children's Hospital University of Manchester Manchester UK
| | - Nikolaos G. Papadopoulos
- MEDCIDS‐Department of Community Medicine, Information, and Health Sciences Faculty of Medicine University of Porto Porto Portugal
- Biostatistics L'altrastatistica srl Consultancy & Training Rome Italy
- Division of Infection Immunity& Respiratory Medicine Royal Manchester Children's Hospital University of Manchester Manchester UK
| | - Elisabetta Pellegrini
- Department of Reggio Calabria ARPACal‐ Regional Agency for Environmental Protection Messina Italy
| | | | - Ana Margarida Pereira
- CINTESIS Center for Health Technology and Services Research Bologna Portugal
- Allergy Unit Instituto & Hospital CUF Porto Porto Portugal
| | - Mariana Pereira
- CINTESIS Center for Health Technology and Services Research Bologna Portugal
- Allergy Unit Instituto & Hospital CUF Porto Porto Portugal
| | - Munevver Pinar
- Department of Biology Faculty of Science Ankara University Ankara Turkey
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital Marburg Phillipps‐Universität Marburg Germany
| | - Ekaterina Potapova
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Alfred Priftanji
- Department of Allergology and Clinical Immunology UHC Mother Teresa Medical University Tirana Tirana Albania
| | - Fotis Psarros
- Allergy Department Athens Naval Hospital Athens Greece
| | - Cansin Sackesen
- Division of Pediatric Allergy Koç University School of Medicine Istanbul Turkey
| | - Ifigenia Sfika
- Pediatric Allergy Unit Sandro Pertini Hospital Rome Italy
| | - Javier Suarez
- Department of Biology of Organisms and Systems Area of Botany University of Oviedo Oviedo Spain
| | | | - Alessandro Travaglini
- Department of Biology Tor Vergata University Rome Italy
- Italian Aerobiology Monitoring Network ‐ Italian Aerobiology Association Bologna Italy
| | - Salvatore Tripodi
- Pediatric Allergy Unit Sandro Pertini Hospital Rome Italy
- Allergology Service Policlinico Casilino Rome Italy
| | - Valentine Verdier
- Department of Pneumonology and Allergy La Timone Hospital APHM Aix‐Marseille University Marseille France
- Hospital APHM Aix‐Marseille University Marseille France
| | | | - Paraskevi Xepapadaki
- Allergy Department 2nd Pediatric Clinic National and Kapodistrian University of Athens Athens Greece
| | - Duygu Yazici
- Cellular and Molecular Medicine KUTTAM Graduate School of Health Sciences Koç University Istanbul Turkey
| | - Paolo M. Matricardi
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Stephanie Dramburg
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
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Kleine‐Tebbe J, Zuberbier T, Werfel T, Krüll M, Wagenmann M, Johansen N, Adler Würtzen P, Wolf H, Mücke V, Wüstenberg E, Biedermann T. Is allergy immunotherapy with birch sufficient to treat patients allergic to pollen of tree species of the birch homologous group? Allergy 2020; 75:1327-1336. [PMID: 31758559 DOI: 10.1111/all.14130] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 09/10/2019] [Accepted: 09/14/2019] [Indexed: 01/06/2023]
Abstract
Pollen from various Fagales tree species prolongs the season and makes tree pollen allergy a major health problem. Despite involving the same causative allergens, allergy immunotherapy (AIT) treatment habits differ significantly across different geographical regions. Diagnosis and treatment with AIT in patients allergic to tree pollen were discussed by a group of German medical experts who give practical recommendations based on the available data. Regulatory perspective: According to current guidelines on allergen products, birch pollen are the representative allergen source of the birch homologous group including several Fagales trees based on sequence and structural similarity of their allergen proteins. Immunological perspective: A high level of IgE cross-reactivity towards allergens from the birch homologous group has been observed in basic research and clinical trials. Clinical perspective: Clinical trial data show that the efficacy of birch pollen AIT is not only related to birch pollen allergy but extends to pollen from other trees, especially alder, hazel and oak. In order to optimize diagnosis and treatment of tree pollen allergy, the experts recommend to focus diagnosis and respective treatment with AIT primarily to birch as the representative allergen of the Fagales tree homologous group, but further diagnostics may be needed for some patients to determine adequate treatment.
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Affiliation(s)
| | - Torsten Zuberbier
- Charité Universitätsmedizin Berlin Freie Universität Berlin Humboldt Universität zu Berlin Berlin Germany
- Department of Dermatology and Allergy Berlin Institute of Health Berlin Germany
| | - Thomas Werfel
- Division of Immunodermatology and Allergy Research Department of Dermatology and Allergy Hannover Medical School Hannover Germany
| | - Matthias Krüll
- Institut für Allergie und Asthmaforschung Berlin (IAAB) GbR Berlin Germany
| | - Martin Wagenmann
- Department of Otorhinolaryngology & Head/Neck Surgery University Hospital Duesseldorf Heinrich Heine University Duesseldorf Germany
| | | | | | - Hendrik Wolf
- Medical Department ALK‐Abelló Arzneimittel GmbH Hamburg Germany
| | - Victoria Mücke
- Medical Department ALK‐Abelló Arzneimittel GmbH Hamburg Germany
| | - Eike Wüstenberg
- Medical Department ALK‐Abelló Arzneimittel GmbH Hamburg Germany
- Department of Otorhinolaryngology University of Dresden Dresden Germany
| | - Tilo Biedermann
- Department of Dermatology and Allergology Technical University of Munich Munich Germany
- Clinical Unit Allergology Helmholtz Zentrum München German Research Center for Environmental Health GmbH Neuherberg Germany
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Otsuka K, Otsuka H, Matsune S, Okubo K. Decreased numbers of metachromatic cells in nasal swabs in Japanese cedar pollinosis following sublingual immunotherapy. IMMUNITY INFLAMMATION AND DISEASE 2020; 8:333-341. [PMID: 32468704 PMCID: PMC7416035 DOI: 10.1002/iid3.314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/06/2020] [Accepted: 05/13/2020] [Indexed: 01/21/2023]
Abstract
Background and Objective Nasal symptoms were reduced following allergen‐specific sublingual immunotherapy (SLIT) for allergic rhinitis. The mechanisms underlying the effectiveness of SLIT for Japanese cedar pollinosis are poorly understood. We studied changes in the numbers of metachromatic cells, eosinophils, and neutrophils following SLIT for Japanese cedar pollinosis. Methods Nasal swabs were taken in the preseason (n = 32) and in pollinosis season (n = 49) from subjects given sublingual drop immunotherapy for an average duration of 1.5 years. The numbers of metachromatic cells (mast cells and basophils), eosinophils and neutrophils were determined and compared with those from untreated subjects in preseason (n = 65) and in season (n = 54). Results SLIT subjects had a significantly reduced frequency of moderate to most severe symptoms in comparison to untreated subjects in preseason (P < .001, the Mann‐Whitney U test), and (P < .00001) in season. Metachromatic cell counts in nasal swabs of SLIT subjects in preseason and in season were lower than those of untreated subjects (P = .014, the Mann‐Whitney U test) and (P = .00001) respectively. Eosinophil numbers in SLIT subjects were not significantly different than in untreated subjects in both preseason (P = .29) and in season (P = .09). However, when SLIT subjects in season were divided into those with greater than or equal to 1.5 years, or <1.5 years of SLIT duration, the degree of eosinophilia in those with SLIT greater than or equal to 1.5 years was significantly lower (P = .011) than in untreated patients, but not in those with SLIT less than 1.5 years (P = .9). There were no significant differences in neutrophil numbers in nasal swabs between untreated and SLIT subjects in preseason and in season. Conclusion One of mechanisms underlying the effectiveness of sublingual drop immunotherapy for Japanese cedar pollinosis is a reduction of the number of metachromatic cells in preseason and in season. Eosinophilia was also reduced in season in those given SLIT for greater than or equal to 1.5 years.
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Affiliation(s)
- Kuninori Otsuka
- Otsuka ENT Clinic, Yokohama, Kanagawa, Japan.,Otorhinolaryngology, Shin-yurigaoka General Hospital, Kawasaki, Kanagawa, Japan
| | - Hirokuni Otsuka
- Otsuka ENT Clinic, Yokohama, Kanagawa, Japan.,Otorhinolaryngology, Nippon Medical School, Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Shoji Matsune
- Otorhinolaryngology, Nippon Medical School, Musashikosugi Hospital, Kawasaki, Kanagawa, Japan
| | - Kimihiro Okubo
- Otorhinolaryngology and Head and Neck Surgery, Nippon Medical School, Tokyo, Japan
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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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Passalacqua G, Bagnasco D, Canonica GW. 30 years of sublingual immunotherapy. Allergy 2020; 75:1107-1120. [PMID: 31715001 DOI: 10.1111/all.14113] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/28/2019] [Accepted: 11/02/2019] [Indexed: 12/12/2022]
Abstract
Allergen Immunotherapy (AIT) was introduced in clinical practice on an empirical basis more than 100 years ago. Since the first attempts, AIT was administered subcutaneously. Indeed, other routes of administration were proposed and studied, in particular to improve the safety, but only the sublingual route (SLIT) achieved a credibility based on evidence and was then accepted as a viable "alternative" option to the subcutaneous route. SLIT was largely used in clinical trials and clinical practice in this last 30 years. Thus, a large amount of data is available, coming from either controlled trials and postmarketing surveillance studies. It is clear that SLIT is overall effective, but it is also clear that the efficacy is not "class-related," as derived from meta-analyses, but restricted to each specific product. The 30-year lasting use of SLIT allowed to clarify many clinical aspects, such as efficacy, safety, use in asthma, regimens of administration, and optimal doses. In parallel, the mechanisms of action of AIT were elucidated, and new indications were proposed (eg food allergy, atopic dermatitis). In addition, the introduction of molecular-based diagnosis, allowed to better refine the prescription of SLIT, based on specific sensitization profiles. The present article will describe the origin and evolution of SLIT for respiratory allergy, taking into account the clinical context that suggested this form of treatment, the recently developed aspects, the future perspectives and unmet needs, This is not, therefore, a systematic review, rather a narrative historical description of the past history, and a look forward to the future opportunities.
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Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases IRCCS Policlinico San Martino ‐University of Genoa Genoa Italy
| | - Diego Bagnasco
- Allergy and Respiratory Diseases IRCCS Policlinico San Martino ‐University of Genoa Genoa Italy
| | - Giorgio Walter Canonica
- Allergy and Respiratory Diseases IRCCS Policlinico San Martino ‐University of Genoa Genoa Italy
- Personalized Medicine Asthma & Allergy ‐ Humanitas Clinical and Research Center IRCCS Rozzano (MI) Italy
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Nolte H, Bernstein DI, Nelson HS, Ellis AK, Kleine-Tebbe J, Lu S. Efficacy and Safety of Ragweed SLIT-Tablet in Children with Allergic Rhinoconjunctivitis in a Randomized, Placebo-Controlled Trial. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2322-2331.e5. [PMID: 32304832 DOI: 10.1016/j.jaip.2020.03.041] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ragweed sublingual immunotherapy (SLIT) tablet reduces symptoms and symptom-relieving medication use in adults with allergic rhinitis with or without conjunctivitis (AR/C) but has not been evaluated in children. OBJECTIVE This international, multicenter, double-blind, placebo-controlled trial evaluated the efficacy and safety of ragweed SLIT-tablet in children with AR/C. METHODS Children (N = 1025; 77.7% polysensitized) aged 5 to 17 years with ragweed pollen-induced AR/C with or without asthma (FEV1 ≥80% predicted) were randomized 1:1 to daily ragweed SLIT-tablet (12 Amb a 1-Unit) or placebo for up to 28 weeks (NCT02478398). The primary end point was the average total combined score (TCS; sum of rhinoconjunctivitis daily symptom score [DSS] and daily medication score [DMS]) during peak ragweed pollen season (RPS). Key secondary end points were TCS during the entire RPS, and DSS and DMS during the peak RPS. RESULTS Relative TCS (95% CI) improvements with ragweed SLIT-tablet versus placebo were -38.3% (-46.0% to -29.7%; least square [LS] mean difference, -2.73; P < .001) during peak RPS and -32.4% (-40.7% to -23.3%; LS mean difference, -1.86; P < .001) during the entire RPS. DSS and DMS during peak RPS improved with SLIT-tablet versus placebo by -35.4% (-43.2% to -26.1%; LS mean difference, -1.40; P < .001) and -47.7% (-59.8% to -32.5%; LS mean difference, -1.84; P < .001), respectively. Asthma DSS, short-acting β-agonist use, and nocturnal awakenings during peak RPS improved with SLIT-tablet versus placebo by -30.7%, -68.1%, and -75.1%, respectively (all nominal P ≤ .02). No events of anaphylaxis, airway compromise, or severe treatment-related systemic allergic reactions were reported. CONCLUSIONS Ragweed SLIT-tablet significantly improved symptoms and decreased symptom-relieving medication use in children with ragweed pollen-induced AR/C and was well tolerated.
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Affiliation(s)
| | - David I Bernstein
- Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Harold S Nelson
- Department of Medicine, Allergy/Immunology Service, National Jewish Health, Denver, Colo
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Susan Lu
- Merck & Co., Inc., Kenilworth, NJ
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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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Würtzen PA, Hoof I, Christensen LH, Váczy Z, Henmar H, Salamanca G, Lundegaard C, Lund L, Kráľova T, Brooks EG, Andersen PS. Diverse and highly cross-reactive T-cell responses in ragweed allergic patients independent of geographical region. Allergy 2020; 75:137-147. [PMID: 31325327 DOI: 10.1111/all.13992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Ragweed frequently causes seasonal allergies in North America and Europe. In the United States, several related ragweed species with diverse geographical distribution cause allergic symptoms. Cross-reactivity towards related ragweed species of IgE and treatment-induced IgG4 has been demonstrated previously. However, less is known about the underlying T-cell cross-reactivity. METHODS The allergen content of ragweed extracts was determined by mass spectrometry and related to T-cell epitopes of Amb a allergens (group 1, 3, 4, 5, 8 and 11) in 20 American ragweed allergic patients determined by FluoroSpot and proliferation assays. T-cell responses to 50 frequently recognized Amb a-derived T-cell epitopes and homologous peptides from western ragweed (Amb p), giant ragweed (Amb t) and mugwort (Art v) were investigated in an additional 11 American and 14 Slovakian ragweed allergic donors. RESULTS Ragweed extracts contained all known allergens and isoallergens thereof. Donor T-cell responses were diverse and directed against all Amb a 1 isoallergens and to most minor allergens investigated. Similar response patterns were seen in American and Slovakia donors. Several epitopes were cross-reactive between isoallergens and ragweed species, some even including mugwort. T-cell cross-reactivity generally correlated with allergen sequence homology. CONCLUSION T-cell epitopes of multiple allergens/isoallergens are involved in the diverse T-cell responses in ragweed allergic individuals. T-cell lines were highly cross-reactive to epitopes of related ragweed species without any apparent geographical response bias. These data support that different ragweed species can be considered an allergen homology group with Amb a as the representative species regarding diagnosis as well as allergy immunotherapy.
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Affiliation(s)
| | - Ilka Hoof
- Global Research ALK Hørsholm Denmark
| | | | - Zuzana Váczy
- Louis Pasteur University Hospital Košice Slovak Republic
| | | | | | | | - Lise Lund
- Global Research ALK Hørsholm Denmark
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Pfaar O, Agache I, Blay F, Bonini S, Chaker AM, Durham SR, Gawlik R, Hellings PW, Jutel M, Kleine‐Tebbe J, Klimek L, Kopp MV, Nandy A, Rabin RL, Ree R, Renz H, Roberts G, Salapatek A, Schmidt‐Weber CB, Shamji MH, Sturm GJ, Virchow JC, Wahn U, Willers C, Zieglmayer P, Akdis CA. Perspectives in allergen immunotherapy: 2019 and beyond. Allergy 2019; 74 Suppl 108:3-25. [PMID: 31872476 DOI: 10.1111/all.14077] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/23/2019] [Indexed: 12/28/2022]
Abstract
The seventh "Future of the Allergists and Specific Immunotherapy (FASIT)" workshop held in 2019 provided a platform for global experts from academia, allergy clinics, regulatory authorities and industry to review current developments in the field of allergen immunotherapy (AIT). Key domains of the meeting included the following: (a) Biomarkers for AIT and allergic asthma; (b) visions for the future of AIT; (c) progress and data for AIT in asthma and the updates of GINA and EAACI Asthma Guidelines (separated for house dust mite SCIT, SLIT tablets and SLIT drops; patient populations) including a review of clinically relevant endpoints in AIT studies in asthma; (d) regulatory prerequisites such as the "Therapy Allergen Ordinance" in Germany; (e) optimization of trial design in AIT clinical research; (f) challenges planning and conducting phase III (field) studies and the future role of Allergen Exposure Chambers (AEC) in AIT product development from the regulatory point of view. We report a summary of panel discussions of all six domains and highlight unmet needs and possible solutions for the future.
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Affiliation(s)
- Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital Marburg Philipps‐Universität Marburg Marburg Germany
| | - Ioana Agache
- Faculty of Medicine Transylvania University Brasov Romania
| | - Frédéric Blay
- Pneumology Department New Civil Hospital Strasbourg‐Cedex France
| | - Sergio Bonini
- Institute of Translational Medicine Italian National Research Council Rome Italy
| | - Adam M. Chaker
- Department of Otolaryngology and Center of Allergy and Environment TUM School of Medicine Technical University of Munich Munich Germany
| | - Stephen R. Durham
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma London UK
| | - Radoslaw Gawlik
- Department of Internal Medicine, Allergology and Clinical Immunology Silesian University of Medicine Katowice Poland
| | - Peter W. Hellings
- Department of Otorhinolaryngology University Hospitals of Leuven Leuven Belgium
- Department of Otorhinolaryngology Academic Medical Center University of Amsterdam Amsterdam The Netherlands
- Department of Neuroscience University of Ghent Ghent Belgium
| | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- All‐Med Medical Research Institute Wroclaw Poland
| | - Jörg Kleine‐Tebbe
- Allergy & Asthma Center Westend Outpatient Clinic and Clinical Research Center Berlin Germany
| | - Ludger Klimek
- Center for Rhinology and Allergology Wiesbaden Germany
| | - Matthias V. Kopp
- Department of Pediatric Allergy and Pulmonology University of Luebeck Luebeck Germany
- Member of the Deutsches Zentrum für Lungenforschung (DZL) Airway Research Center North (ARCN) Luebeck Germany
| | - Andreas Nandy
- Research & Development Allergopharma GmbH & Co. KG Reinbek Germany
| | - Ronald L. Rabin
- Center for Biologics Evaluation and Research US Food and Drug Administration Silver Spring MD USA
| | - Ronald Ree
- Departments of Experimental Immunology and of Otorhinolaryngology Amsterdam University Medical Centers Amsterdam The Netherlands
| | - Harald Renz
- Department Laboratory Medicine and Pathobiochemistry Molecular Diagnostics University Giessen and Philipps‐Universität Marburg Marburg Germany
| | - Graham Roberts
- Paediatric Allergy and Respiratory Medicine University of Southampton Southampton UK
- David Hide Asthma and Allergy Centre St Mary’s Hospital Isle of Wight UK
| | | | - Carsten B. Schmidt‐Weber
- Center of Allergy and Environment (ZAUM) Technical University of Munich and Helmholtz Center Munich Munich Germany
- Member of the German Center for Lung Research (DZL) Lübeck Germany
| | - Mohamed H. Shamji
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma London UK
| | - Gunter J. Sturm
- Department of Dermatology and Venereology Medical University of Graz Graz Austria
- Allergy Outpatient Clinic Reumannplatz Vienna Austria
| | - J. Christian Virchow
- Department Pulmonology & Interdisciplinary Intensive Care Medicine Rostock University Medical Center Rostock Germany
| | - Ulrich Wahn
- Department for Pediatric Pneumology and Immunology Charité Medical University Berlin Germany
| | | | | | - Cezmi A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Zurich Switzerland
- Christine‐Kühne‐Center for Allergy Research and Education (CK‐CARE) Davos Switzerland
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Abstract
PURPOSE OF REVIEW The nasal allergen challenge (NAC) model can be a valuable diagnostic tool for allergic rhinitis. Alongside its clinical use, NACs can be used as primary and secondary endpoints in studies evaluating allergen immunotherapy (AIT) products for allergic rhinitis treatment. This review will discuss the technical aspects of the NAC model and provide a summary of recent studies using NACs to assess existing and new AIT treatments. RECENT FINDINGS Over the last 2 years, both titrated and single-dose nasal challenge protocols have been used to evaluate immunotherapies targeting grass, birch, house dust mite, and cat allergens. Early efficacy and dose-finding trials showed improvements in allergic symptoms and nasal tolerance to allergens after AIT treatment with standardized extracts or modified forms of whole allergen. NACs were also used in two proof-of-concept studies to illustrate the efficacy of intralymphatic immunotherapy with two concomitant allergens and subcutaneous immunotherapy with Fel d 1-specific IgG-blocking antibodies. SUMMARY Along with existing therapies, nasal challenges are useful in evaluating AIT treatments in the very early stages of clinical development. However, because of the variety in challenge techniques and symptom assessments available, special attention must be placed in the protocol design in order to compare the study results with existing NAC publications.
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Scadding GK, Kariyawasam HH, Scadding G, Mirakian R, Buckley RJ, Dixon T, Durham SR, Farooque S, Jones N, Leech S, Nasser SM, Powell R, Roberts G, Rotiroti G, Simpson A, Smith H, Clark AT. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy 2019; 47:856-889. [PMID: 30239057 DOI: 10.1111/cea.12953] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/01/2017] [Accepted: 05/04/2017] [Indexed: 12/12/2022]
Abstract
This is an updated guideline for the diagnosis and management of allergic and non-allergic rhinitis, first published in 2007. It was produced by the Standards of Care Committee of the British Society of Allergy and Clinical Immunology, using accredited methods. Allergic rhinitis is common and affects 10-15% of children and 26% of adults in the UK, it affects quality of life, school and work attendance, and is a risk factor for development of asthma. Allergic rhinitis is diagnosed by history and examination, supported by specific allergy tests. Topical nasal corticosteroids are the treatment of choice for moderate to severe disease. Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy. Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms. Treatment of rhinitis is associated with benefits for asthma. Non-allergic rhinitis also is a risk factor for the development of asthma and may be eosinophilic and steroid-responsive or neurogenic and non- inflammatory. Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidoisis. Infective rhinitis can be caused by viruses, and less commonly by bacteria, fungi and protozoa.
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Affiliation(s)
- G K Scadding
- The Royal National Throat Nose and Ear Hospital, London, UK
| | - H H Kariyawasam
- The Royal National Throat Nose and Ear Hospital, London, UK.,UCLH NHS Foundation Trust, London, UK
| | - G Scadding
- Department of Upper Respiratory Medicine, Imperial College NHLI, London, UK
| | - R Mirakian
- The Royal National Throat Nose and Ear Hospital, London, UK
| | - R J Buckley
- Vision and Eye Research Unit, Anglia Ruskin University, Cambridge, UK
| | - T Dixon
- Royal Liverpool and Broad green University Hospital NHS Trust, Liverpool, UK
| | - S R Durham
- Department of Upper Respiratory Medicine, Imperial College NHLI, London, UK
| | - S Farooque
- Chest and Allergy Department, St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - N Jones
- The Park Hospital, Nottingham, UK
| | - S Leech
- Department of Child Health, King's College Hospital, London, UK
| | - S M Nasser
- Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - R Powell
- Department of Clinical Immunology and Allergy, Nottingham University, Nottingham UK
| | - G Roberts
- Department of Child Health, University of Southampton Hospital, Southampton, UK
| | - G Rotiroti
- The Royal National Throat Nose and Ear Hospital, London, UK
| | - A Simpson
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, UK
| | - H Smith
- Division of Primary Care and Public Health, University of Sussex, Brighton, UK
| | - A T Clark
- Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
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Wheatley LM, Wood R, Nadeau K, Liu A, Zoratti E, Bacharier L, Brittain E, Calderon M, Casale T, Chipps B, Cox L, Creticos PS, Desai M, Dreborg S, Durham S, Gergen PJ, Gruchalla R, Nelson H, O'Hehir RE, Plaut M, Schwaninger JM, Tilles S, Vickery B, Wittenberg KM, Togias A. Mind the gaps: Clinical trial concepts to address unanswered questions in aeroallergen immunotherapy-An NIAID/AHRQ Workshop. J Allergy Clin Immunol 2019; 143:1711-1726. [PMID: 30731123 DOI: 10.1016/j.jaci.2019.01.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/08/2019] [Accepted: 01/22/2019] [Indexed: 11/21/2022]
Abstract
The Agency for Healthcare Research and Quality and the National Institute of Allergy and Infectious Diseases organized a workshop to develop trial concepts that could improve the use and effectiveness of aeroallergen immunotherapy (AAIT). Expert groups were formed to accomplish the following tasks: (1) propose a study design to compare the effectiveness and safety of subcutaneous versus sublingual AAIT; (2) propose a study design to compare the effectiveness and safety of AAIT by using 1 or a few allergens versus all or most allergens to which a patient is sensitized; (3) propose a study design to determine whether AAIT can alter the progression of childhood allergic airways disease; and (4) propose a study design to determine the optimal dose and duration of AAIT to achieve maximal effectiveness with acceptable safety. Study designs were presented by the workgroups, extensively discussed at the workshop, and revised for this report. The proposed trials would be of long duration and require large highly characterized patient populations. Scientific caveats and feasibility matters are discussed. These concepts are intended to help the development of clinical trials that can address some of the major questions related to the practice of AAIT for the management and prevention of allergic airways disease.
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Affiliation(s)
- Lisa M Wheatley
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Md.
| | | | | | - Andrew Liu
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | | | | | - Erica Brittain
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Md
| | | | | | - Bradley Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, Calif
| | - Linda Cox
- Nova Southeastern University, Fort Lauderdale, Fla
| | | | - Manisha Desai
- Quantitative Sciences Unit, Stanford University, Stanford, Calif
| | | | | | - Peter J Gergen
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Md
| | | | | | - Robyn E O'Hehir
- Alfred Hospital and Monash University Medical School, Melbourne, Australia
| | - Marshall Plaut
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Md
| | - Julie M Schwaninger
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Md
| | | | - Brian Vickery
- North Carolina Children's Hospital, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kim M Wittenberg
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Md
| | - Alkis Togias
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Md
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Lund K, Kito H, Skydtsgaard MB, Nakazawa H, Ohashi-Doi K, Lawton S. The Importance of Tablet Formulation on Allergen Release Kinetics and Efficiency: Comparison of Freeze-dried and Compressed Grass Pollen Sublingual Allergy Immunotherapy Tablet Formulations. Clin Ther 2019; 41:742-753. [DOI: 10.1016/j.clinthera.2019.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 01/25/2019] [Accepted: 02/10/2019] [Indexed: 12/20/2022]
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Biedermann T, Kuna P, Panzner P, Valovirta E, Andersson M, de Blay F, Thrane D, Jacobsen SH, Stage BS, Winther L. The SQ tree SLIT-tablet is highly effective and well tolerated: Results from a randomized, double-blind, placebo-controlled phase III trial. J Allergy Clin Immunol 2019; 143:1058-1066.e6. [PMID: 30654054 DOI: 10.1016/j.jaci.2018.12.1001] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/08/2018] [Accepted: 12/07/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The SQ tree sublingual immunotherapy (SLIT)-tablet (ALK-Abelló, Hørsholm, Denmark) is developed for treatment of tree pollen-induced allergic rhinoconjunctivitis (ARC). OBJECTIVE The aim of this pivotal phase III trial was to demonstrate the efficacy and safety of the SQ tree SLIT-tablet. METHODS This was a randomized, double-blind, placebo-controlled trial with 634 subjects (12-65 years) with moderate-to-severe ARC despite use of symptom-relieving medication. Eligible subjects were randomized 1:1 to active or placebo treatment. The primary end point was the average daily ARC total combined score (TCS) during the birch pollen season (BPS) analyzed for subjects with diary data during the BPS. Secondary end points included average daily symptom scores (DSS) during the BPS, average TCS and DSS during the tree pollen season (TPS), and average daily medication scores (DMS) in the BPS and TPS. RESULTS The primary and key secondary end points demonstrated statistically significant and clinically relevant effects of the SQ tree SLIT-tablet compared with placebo. For the BPS, absolute (relative) differences from placebo were 3.02 (40%) for TCS, 1.32 (37%) for DSS, and 1.58 (49%) for DMS (all P < .0001). For the TPS, absolute (relative) differences from placebo were 2.27 (37%) for TCS, 0.99 (33%) for DSS, and 1.20 (47%) for DMS (all P < .0001). Treatment was well tolerated. The most frequently reported treatment-related adverse events were mild or moderate local reactions related to sublingual administration. CONCLUSION The trial demonstrated the efficacy and safety of the SQ tree SLIT-tablet compared with placebo during the BPS and TPS in adolescents and adults with birch pollen-induced ARC (EudraCT 2015-004821-15).
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Affiliation(s)
- Tilo Biedermann
- Department of Dermatology and Allergology, Technical University of Munich, Munich, Germany.
| | - Piotr Kuna
- Division of Internal Medicine, Asthma and Allergy, Barlicki University Hospital, Medical University of Lodz, Lodz, Poland
| | - Petr Panzner
- Department of Immunology and Allergology, Faculty of Medicine in Pilsen, Charles University, Prague, Czech Republic
| | - Erkka Valovirta
- Department of Pulmonary Diseases and Clinical Allergology, University of Turku, Turku, Finland; Terveystalo Allergy Clinic, Turku, Finland
| | - Morgan Andersson
- Department of Otorhinolaryngology, Head and Neck Surgery, Skåne University Hospital, Lund, Sweden
| | - Frederic de Blay
- Federation of Translational Medicine Chest Disease Department, University Hospital of Strasbourg, University of Strasbourg, Strasbourg, France
| | - Dorthe Thrane
- Global Clinical Development, ALK-Abelló, Hørsholm, Denmark
| | | | | | - Lone Winther
- Allergy Clinic, Department of Dermato-Allergology, Gentofte Hospital, Copenhagen, Denmark
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Blanco C, Bazire R, Argiz L, Hernández-Peña J. Sublingual allergen immunotherapy for respiratory allergy: a systematic review. Drugs Context 2018; 7:212552. [PMID: 30416528 PMCID: PMC6220898 DOI: 10.7573/dic.212552] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 01/01/2023] Open
Abstract
The objective of the systematic review is to provide complete and updated information on efficacy and safety of sublingual immunotherapy (SLIT) formulations for the treatment of allergic respiratory diseases (ARDs). The literature search was conducted on PubMed database, involving double-blind, randomized clinical trials published between January 1992 and 2018, written in English, and performed in humans. The number of articles finally selected for review was 112. Data from the majority of properly controlled clinical trials demonstrate that SLIT is effective not only with short-term use (first year) but also with long-term use (up to the third year of active therapy), for treating ARDs in children and adults. Both continuous and discontinuous schemes of administration showed significant reductions in symptom and medication scores. Moreover, a SLIT-induced disease-modifying effect has been documented mainly with grass pollen extracts, since improvement is maintained during at least 2 years of follow-up after a 3-year treatment period. Additionally, allergen immunotherapy should also be considered a preventive strategy, especially for decreasing bronchial asthma incidence in children and adolescents with allergic rhinitis treated with SLIT. This therapy is also safe, producing only a few mainly local and mild-to-moderate adverse events, and usually self-limited in time. The registration and authorization of allergen SLIT preparations (grasses and house-dust mite tablets) as drugs by regulatory agencies, such as the United States Food and Drug Administration (FDA) and the European Medicines Agency (EMA), has represented a landmark in allergy immunotherapy research. Further long-term studies, specially designed with allergens other than grass pollen or house-dust mites, not only in allergic rhinoconjunctivitis but also on asthmatic subjects, as well as studies comparing different administration schedules and/or routes, are required in order to continue the progress in the modern development of this particularly promising therapy.
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Affiliation(s)
- Carlos Blanco
- Allergy Service, University Hospital La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
- RETIC ARADYAL RD16/0006/0015, Instituto de Salud Carlos III, Madrid, Spain
| | - Raphaelle Bazire
- Allergy Service, University Hospital La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
| | - Laura Argiz
- Allergy Service, University Hospital La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
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Nelson HS. Ragweed allergy immunotherapy tablet MK-3641 (Ragwitek®) for the treatment of allergic rhinitis. Expert Rev Clin Immunol 2018; 14:1003-1011. [PMID: 30345820 DOI: 10.1080/1744666x.2018.1538788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Allergic rhinitis (AR) is among the most common chronic conditions affecting both children and adults. It is the cause of significant morbidity from the symptoms and interference with sleep. It results in major impairment of performance both at school and at work. In the U.S. and certain parts of Europe, ragweed pollen is a major cause of seasonal AR. In 2014, the U.S. Food and Drug Administration (FDA) approved a sublingual ragweed tablet (MK-3641) for use in adults with ragweed-induced AR. Areas covered: This paper will review the impact of ragweed-induced AR and available treatments including subcutaneous immunotherapy and studies with MK-3641. The principal search method was PubMed. Expert commentary: One dosing finding, two 28-day safety and two 52-week safety and efficacy studies have been conducted with MK-3641. The 12-U (12μg Amb a 1) tablet was the most effective. Local application site reactions were common but usually not serious. Only one, non-serious systemic reaction was reported in four safety studies. MK-3641 is a safe and effective treatment for ragweed-pollen-induced AR when treatment is initiated ≥ 12 weeks prior to the onset of the ragweed pollen season.
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Affiliation(s)
- Harold S Nelson
- a Department of Medicine, Division of Allergy/Immunology , National Jewish Health , Denver , Colorado USA
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Blaiss MS, Steven GC, Bender B, Bukstein DA, Meltzer EO, Winders T. Shared decision making for the allergist. Ann Allergy Asthma Immunol 2018; 122:463-470. [PMID: 30201469 DOI: 10.1016/j.anai.2018.08.019] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/21/2018] [Accepted: 08/27/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Shared decision making (SDM) is becoming more commonly appreciated and used in medical practice as a way to empower patients who are facing treatment preference-sensitive conditions, such as allergic rhinitis, atopic dermatitis, food allergy, and persistent asthma. The purpose of this review is to educate the allergy health care provider about how SDM works and provide practical advice and allergist-specific SDM resources. DATA SOURCES PubMed and online patient decision aid resources. STUDY SELECTIONS Studies and reviews relevant to SDM and patient decision aids relevant to the allergy health care provider were selected for discussion. RESULTS There are ethical, practical, economic, and psychological imperatives for the implementation of quality SDM, particularly for chronic diseases. Many benefits and barriers of SDM have been identified and models have been developed to encourage implementation of quality SDM. For the allergy health care provider, SDM for asthma has been shown to improve adherence, outcomes, and patient satisfaction with care. Patient decision aids are useful tools for SDM and have recently been developed for allergen immunotherapy, severe asthma, and atopic dermatitis. CONCLUSION Effective SDM has been shown to improve adherence and lead to better outcomes. SDM should be universally implemented as a key component of patient-centered health care. Allergy health care providers should work with their patients to reach treatment decisions that align with their values and preferences.
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Affiliation(s)
- Michael S Blaiss
- Department of Pediatrics, Medical College of Georgia, Augusta, Georgia.
| | - Gary C Steven
- Allergy, Asthma & Sinus Center, Milwaukee, Wisconsin
| | - Bruce Bender
- National Jewish Health, Denver, and University of Colorado School of Medicine, Aurora, Colorado
| | | | - Eli O Meltzer
- Department of Pediatrics, University of California-San Diego School of Medicine, San Diego, California
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Abstract
Allergic rhinitis affects 20 to 30% of adults in both the United States and Europe and perhaps a somewhat higher percentage of children. In addition to nasal and ocular symptoms directly related to the allergic process, interference of these symptoms with sleep leads to daytime sleepiness and impaired quality of life. Patients miss work because of symptoms but an even greater problem is interference with work productivity, or presenteeism, which has been reported to be the biggest contributor to the total economic cost of allergic rhinitis. There has been increasing awareness that many patients with either seasonal or perennial symptoms but negative skin and in vitro tests for allergen sensitivity have local nasal allergy, diagnosable by the presence of allergen-specific IgE in their nasal secretions or a positive nasal allergen challenge or both. The pharmaceutical management of allergic rhinitis rests on symptomatic treatment with antihistamines that perhaps are more effectively administered intranasally than orally and intranasal corticosteroids. Allergen immunotherapy is very effective, even for local allergic rhinitis, and the shortcomings of subcutaneous immunotherapy of inconvenience and safety are reduced by the introduction of sublingual immunotherapy (SLIT). Use of the latter is currently somewhat limited by the lack of appropriate dosing information for SLIT liquids and the limited number of allergens for which SLIT tablets are available.
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Affiliation(s)
- Flavia C. L. Hoyte
- Department of Medicine, Division of Allergy/Immunology, National Jewish Health, Denver, CO, 80206, USA
| | - Harold S. Nelson
- Department of Medicine, Division of Allergy/Immunology, National Jewish Health, Denver, CO, 80206, USA
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