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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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Lee HY, Lee SM, Kang SY, Kim K, Kim JH, Ryu G, Min JY, Park KH, Park SY, Sung M, Lee Y, Yang EA, Jee HM, Ha EK, Shin YS, Chung EH, Choi SH, Koh YI, Kim ST, Nahm DH, Park JW, Shim JY, An YM, Han DH, Han MY, Lee YW, Choi JH. KAAACI Guidelines for Allergen Immunotherapy. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2023; 15:725-756. [PMID: 37957792 PMCID: PMC10643862 DOI: 10.4168/aair.2023.15.6.725] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/16/2023] [Accepted: 10/07/2023] [Indexed: 11/15/2023]
Abstract
Allergen immunotherapy (AIT) is a causative treatment for various allergic diseases such as allergic rhinitis, allergic asthma, and bee venom allergy that induces tolerance to offending allergens. The need for uniform practice guidelines in AIT is continuously growing because of the increasing discovery of potential candidates for AIT and evolving interest in new therapeutic approaches. This guideline is an updated version of the Korean Academy of Asthma Allergy and Clinical Immunology recommendations for AIT published in 2010. This updated guideline proposes an expert opinion by allergy, pediatrics, and otorhinolaryngology specialists with an extensive literature review. The guideline deals with basic knowledge and methodological aspects of AIT, including mechanisms, clinical efficacy, patient selection, allergens extract selection, schedule and doses, management of adverse reactions, efficacy measurements, and special consideration in pediatrics. The guidelines for sublingual immunotherapy will be covered in detail in a separate article.
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Affiliation(s)
- Hwa Young Lee
- Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Min Lee
- Division of Pulmonology and Allergy, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Sung-Yoon Kang
- Division of Pulmonology and Allergy, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Kyunghoon Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ju Hee Kim
- Department of Pediatrics, Kyung Hee University Medical Center, Seoul, Korea
| | - Gwanghui Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Young Min
- Department of Otorhinolaryngology-Head & Neck Surgery, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Kyung Hee Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - So-Young Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Myongsoon Sung
- Department of Pediatrics, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Youngsoo Lee
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Eun-Ae Yang
- Department of Pediatrics, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Hye Mi Jee
- Department of Pediatrics, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam, Korea
| | - Eun Kyo Ha
- Department of Pediatrics, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Yoo Seob Shin
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Eun Hee Chung
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun Hee Choi
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Young-Il Koh
- Department of Allergy and Clinical Immunology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Seon Tae Kim
- Department of Otolaryngology-Head & Neck Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Dong-Ho Nahm
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Jung Won Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Yeon Shim
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - Doo Hee Han
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Man Yong Han
- Department of Pediatrics, CHA University School of Medicine, CHA Bundang Medical Center, Seongnam, Korea
| | - Yong Won Lee
- Division of Allergy & Clinical Immunology, Department of Internal Medicine, Center for Health Policy Research, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Incheon, Korea.
| | - Jeong-Hee Choi
- Department of Pulmonology and Allergy, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea.
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Abu El-Enin MA, Rabie Shehab El-Din EM, Abdelwahab HW, Abd El-Maksoud A, Abd El-Aziz AM, Shaaban MI, Attia AN, Aboukamar WA, Mohei-Aldin S, Belal F. Preparation of chemically stable allergen-specific sublingual immunotherapy from Egyptian allergens. J Clin Lab Anal 2022; 36:e24261. [PMID: 35150027 PMCID: PMC8906013 DOI: 10.1002/jcla.24261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 12/20/2021] [Accepted: 01/17/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The term "allergen extracts" refers to solutions of proteins or glycoproteins extracted from source raw materials. OBJECTIVES This study was planned to prepare chemically stable sublingual immunotherapy from different allergens in Egypt. METHODS Allergen extraction from raw materials. The concentrated aqueous extract of each allergen was mixed with an equal volume of glycerol. The protein content of the preparations was determined using the modified Lowry assay method. The prepared allergens were stored for 9 months at 2-4°C. Samples were analyzed periodically (0, 3, 6, and 9 months of intervals) adopting the Lowry Assay method. Levels of specific IgE to Chenopodium album antigens were measured in patients' sera by ELISA. RESULTS The concentration of all prepared allergens, as indicated by the concentration of the protein content, was found to decrease exponentially with time, implying first-order kinetics of degradation. From the values of the slopes of the log plot for each allergen, the half-life time (t1/2 ) and (t1/4 ) values were calculated. The expiration date was considered as the time after which the allergen loses 25% of its potency. The obtained values of t1/4% vary according to the type of vaccine. The most stable one is that of Chenopodium album pollens (2.4 years) and the least stable is that of house dust Mites (9 months). The immunological characters of Chenopodium album extract were stable for at least 6 months. CONCLUSION Differences exist among allergen extracts made by multiple manufacturers. So, developments in studies on allergen preparation and characterization in a different locality are necessary.
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Affiliation(s)
- Mohammed A Abu El-Enin
- Department of Medicinal Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt.,Department of Medicinal Chemistry, Faculty of Pharmacy, National University of Science and Technology, Nasiria, Iraq
| | | | | | | | - Abeer M Abd El-Aziz
- Microbiology & Immunology Department, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
| | - Mona I Shaaban
- Microbiology & Immunology Department, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
| | - Ahmed Nader Attia
- Agronomy Department, Faculty of agriculture, Mansoura University, Mansoura, Egypt
| | - Wafaa A Aboukamar
- Department of medical parasitology, Faculty of medicine, Mansoura University, Mansoura, Egypt
| | - Sanaa Mohei-Aldin
- Microbiology & Immunology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Fathalla Belal
- Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
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Ariaee N, Varasteh A, Jabbari Azad F, Sankian M. Preparation allergenic pollen extracts; the points should be considered to make high-quality products. J Immunoassay Immunochem 2018; 40:26-39. [PMID: 30422060 DOI: 10.1080/15321819.2018.1543705] [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: 01/29/2023]
Abstract
Atopic diseases have an increasing trend worldwide during the last two decades. Determining the main cause of allergic diseases, allergens, is the first step in managing and improving the issue, usually is done by Skin Prick tests (SPTs). Having allergenic extract in high quality is desired to perform a reliable SPT. Several parameters of extracts are considered including composition, stability, potency, preservation conditions, and unit definition. In this review, these factors have been explained pointing to factors might have profitable points or harmful drawback in the quality of allergen extracts.
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Affiliation(s)
- Nazila Ariaee
- a Allergy Research Center , Mashhad University of Medical Sciences , Mashhad , Iran
| | - Abdolreza Varasteh
- a Allergy Research Center , Mashhad University of Medical Sciences , Mashhad , Iran
| | | | - Mojtaba Sankian
- b Immunology Research Center , Mashhad University of Medical Sciences , Mashhad , Iran
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Plunkett G. Update: stability of allergen extracts to establish expiration dating. Curr Opin Otolaryngol Head Neck Surg 2018; 24:261-9. [PMID: 27092907 DOI: 10.1097/moo.0000000000000248] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The article reviews studies pertaining to US manufactured allergen extract stability that contribute to guidance for expiration dating for bulk concentrates, diluted patient testing and treatment vials, and adjustments following elevated temperature excursions. RECENT FINDINGS Studies on allergen stability were completed to satisfy the Food and Drug Administration requirements supporting labeled expiration dating for standardized short ragweed, dust mites, cat, grass, and venom extracts and are not published. These studies demonstrated the stability enhancing parameters of 50% glycerin and support the Food and Drug Administration mandated expiration of nonstandardized extracts allowing glycerin extracts twice the dating of nonglycerin aqueous extracts. Patient vials are commonly given 6-12 months dating. There is adequate evidence that human serum albumin stabilizes low protein diluted vials. High protease allergens such as molds and insects compromised potency of pollens when mixed. Subsequent work continued to define the effects of diluents on extract dilutions, temperature excursions that occasionally occur with shipping or refrigerator malfunctions, and allergen compatibility. SUMMARY Potency has been determined for allergen dilutions with diluents typically used for allergen immunotherapy. These studies along with changes of potency under various storage conditions and mixing designed to improve our guidance on expiration dating of allergen extracts will be discussed.
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Bozek A, Pyrkosz K. Immunotherapy of mold allergy: A review. Hum Vaccin Immunother 2017; 13:2397-2401. [PMID: 28481693 PMCID: PMC5647975 DOI: 10.1080/21645515.2017.1314404] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 03/22/2017] [Accepted: 03/29/2017] [Indexed: 12/27/2022] Open
Abstract
Mold allergies are common, mainly target the respiratory tract and present as allergic rhinitis and/or bronchial asthma. Molds include a large group of different allergens that induce all types of allergic reactions. Allergen specific immunotherapies (AITs) to molds are common; however, at the present time, they are limited to Alternaria. This review presents not only the benefits but also the problems with such types of AIT based on the literature and our experience.
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Affiliation(s)
- A. Bozek
- Clinical Department of Internal Disease, Dermatology and Allergology, Medical University of Silesia, Katowice, Poland
| | - K. Pyrkosz
- Clinical Department of Internal Disease, Dermatology and Allergology, Medical University of Silesia, Katowice, Poland
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Mindaye ST, Spiric J, David NA, Rabin RL, Slater JE. Accurate quantification of 5 German cockroach (GCr) allergens in complex extracts using multiple reaction monitoring mass spectrometry (MRM MS). Clin Exp Allergy 2017; 47:1661-1670. [PMID: 28756650 DOI: 10.1111/cea.12986] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/21/2017] [Accepted: 07/24/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND German cockroach (GCr) allergen extracts are complex and heterogeneous products, and methods to better assess their potency and composition are needed for adequate studies of their safety and efficacy. OBJECTIVE AND METHODS The objective of this study was to develop an assay based on liquid chromatography and multiple reaction monitoring mass spectrometry (LC-MRM MS) for rapid, accurate, and reproducible quantification of 5 allergens (Bla g 1, Bla g 2, Bla g 3, Bla g 4, and Bla g 5) in crude GCr allergen extracts. RESULTS We first established a comprehensive peptide library of allergens from various commercial extracts as well as recombinant allergens. Peptide mapping was performed using high-resolution MS, and the peptide library was then used to identify prototypic and quantotypic peptides to proceed with MRM method development. Assay development included a systematic optimization of digestion conditions (buffer, digestion time, and trypsin concentration), chromatographic separation, and MS parameters. Robustness and suitability were assessed following ICH (Q2 [R1]) guidelines. The method is precise (RSD < 10%), linear over a wide range (r > 0.99, 0.01-1384 fmol/μL), and sensitive (LLOD and LLOQ <1 fmol/μL). Having established the parameters for LC-MRM MS, we quantified allergens from various commercial GCr extracts and showed considerable variability that may impact clinical efficacy. CONCLUSIONS AND CLINICAL RELEVANCE Our data demonstrate that the LC-MRM MS method is valuable for absolute quantification of allergens in GCr extracts and likely has broader applicability to other complex allergen extracts. Definitive quantification provides a new standard for labelling of allergen extracts, which will inform patient care, enable personalized therapy, and enhance the efficacy of immunotherapy for environmental and food allergies.
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Affiliation(s)
- S T Mindaye
- Laboratory of Immunobiochemistry, Division of Bacterial, Parasitic, and Allergenic Products, Office of Vaccines Research and Review, CBER/FDA, Silver Spring, MD, USA
| | - J Spiric
- Laboratory of Immunobiochemistry, Division of Bacterial, Parasitic, and Allergenic Products, Office of Vaccines Research and Review, CBER/FDA, Silver Spring, MD, USA
| | - N A David
- Laboratory of Immunobiochemistry, Division of Bacterial, Parasitic, and Allergenic Products, Office of Vaccines Research and Review, CBER/FDA, Silver Spring, MD, USA
| | - R L Rabin
- Laboratory of Immunobiochemistry, Division of Bacterial, Parasitic, and Allergenic Products, Office of Vaccines Research and Review, CBER/FDA, Silver Spring, MD, USA
| | - J E Slater
- Laboratory of Immunobiochemistry, Division of Bacterial, Parasitic, and Allergenic Products, Office of Vaccines Research and Review, CBER/FDA, Silver Spring, MD, USA
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Maina E, Pelst M, Hesta M, Cox E. Food-specific sublingual immunotherapy is well tolerated and safe in healthy dogs: a blind, randomized, placebo-controlled study. BMC Vet Res 2017; 13:25. [PMID: 28100257 PMCID: PMC5241990 DOI: 10.1186/s12917-017-0947-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 01/12/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Food allergies are increasing in prevalence but no treatment strategies are currently available to cure dogs with food allergy. Over the past decade, experimental food allergen-specific sublingual immunotherapy (FA-SLIT) has emerged as a potential treatment for food allergies in human medicine. However, FA-SLIT has not been investigated in dogs. Therefore, the objective of this study was to prospectively evaluate the safety, tolerability and dispenser sterility of FA-SLIT in healthy dogs before testing it in food allergic dogs. Eight experimental healthy beagle dogs, never orally exposed to peanut, were randomized in two groups to receive SLIT with peanut or placebo for 4 months. Subjects were monitored daily for local and systemic adverse effects. Blood samples for complete blood count and serum biochemistry, and urine for urinalysis were collected and the dogs' body weight was recorded at day 0, 35 and 119 of the SLIT treatment. Sera for the determination of peanut-specific IgG and IgE were collected at day 0, 35, 49, 70, 91, 105 and 119. Intradermal tests were performed before (day 0) and after (day 119) the experiment. The content of each dispenser used to administer treatment or placebo was tested for sterility after usage. In order to assess the presence or absence of sensitization, dogs were challenged 6 months after the end of the study with 2000 μg of peanut extract daily for 7 to 14 days. RESULTS All dogs completed the study. The treatment did not provoke either local or systemic side-effects. Peanut-specific IgG significantly increased in treatment group. Even though a significant increase in peanut-specific IgE was also seen, intradermal tests were negative in all dogs before and after the experiment, and the challenge test did not trigger any adverse reactions in the treated dogs, which shows the protocol did not cause sensitization to peanut, but nevertheless primed the immune system as indicated by the humoral immune response. All dispenser solutions were sterile. CONCLUSIONS Our results demonstrate that the used peanut-SLIT protocol is well tolerated and safe in healthy dogs. Further studies should evaluate tolerability, safety and efficacy in dogs with food allergy.
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Affiliation(s)
- E. Maina
- Laboratory of Immunology, Ghent University, Faculty of Veterinary Medicine, Merelbeke, Belgium
| | - M. Pelst
- Laboratory of Immunology, Ghent University, Faculty of Veterinary Medicine, Merelbeke, Belgium
| | - M. Hesta
- Laboratory of Animal Nutrition, Department of Animal Nutrition, Genetics, Breeding and Ethology., Ghent University, Faculty of Veterinary Medicine, Merelbeke, Belgium
| | - E. Cox
- Laboratory of Immunology, Ghent University, Faculty of Veterinary Medicine, Merelbeke, Belgium
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Shakya AK, Chowdhury MYE, Tao W, Gill HS. Mucosal vaccine delivery: Current state and a pediatric perspective. J Control Release 2016; 240:394-413. [PMID: 26860287 PMCID: PMC5381653 DOI: 10.1016/j.jconrel.2016.02.014] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/21/2016] [Accepted: 02/05/2016] [Indexed: 12/30/2022]
Abstract
Most childhood infections occur via the mucosal surfaces, however, parenterally delivered vaccines are unable to induce protective immunity at these surfaces. In contrast, delivery of vaccines via the mucosal routes can allow antigens to interact with the mucosa-associated lymphoid tissue (MALT) to induce both mucosal and systemic immunity. The induced mucosal immunity can neutralize the pathogen on the mucosal surface before it can cause infection. In addition to reinforcing the defense at mucosal surfaces, mucosal vaccination is also expected to be needle-free, which can eliminate pain and the fear of vaccination. Thus, mucosal vaccination is highly appealing, especially for the pediatric population. However, vaccine delivery across mucosal surfaces is challenging because of the different barriers that naturally exist at the various mucosal surfaces to keep the pathogens out. There have been significant developments in delivery systems for mucosal vaccination. In this review we provide an introduction to the MALT, highlight barriers to vaccine delivery at different mucosal surfaces, discuss different approaches that have been investigated for vaccine delivery across mucosal surfaces, and conclude with an assessment of perspectives for mucosal vaccination in the context of the pediatric population.
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Affiliation(s)
| | | | - Wenqian Tao
- Department of Chemical Engineering, Texas Tech University, Lubbock, TX 79409, USA
| | - Harvinder Singh Gill
- Department of Chemical Engineering, Texas Tech University, Lubbock, TX 79409, USA.
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Grier TJ, Converse LM, Rekkerth DJ, Renahan KE. Math-free guides for glycerin and allergens at variable subcutaneous injection volumes: How's my dosing? Update. Ann Allergy Asthma Immunol 2016; 116:455-60. [PMID: 27017565 DOI: 10.1016/j.anai.2016.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/03/2016] [Accepted: 02/24/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Current summaries of effective maintenance dose ranges for subcutaneous immunotherapy (SCIT) are based on administration of 0.5-mL volumes. Extract formulations delivering equivalent dose ranges for practices using different injection volumes have not been reported, and calculation of the final glycerin concentrations in these solutions remains an inconvenient and repetitive process. OBJECTIVE To create math-free guides for allergen doses and glycerin concentrations that identify the extract concentrate volumes required to deliver doses within the ranges cited in the 2011 immunotherapy practice parameters for clinicians using 5.0-mL maintenance vials and injection volumes ranging from 0.2 to 1.0 mL. METHODS Algebraic calculations were performed to determine the specific combinations of extract concentrate strengths, volumes of these products in patient vaccines, and injection volumes needed for administration of target allergen doses spanning the current SCIT practice parameter recommendations. RESULTS For each product or group (nonstandardized extracts), tables were constructed to define the allergen doses provided by various combinations of extract concentrate volumes and injection volumes. The values within the effective dose ranges for each product were highlighted to facilitate comparisons of specific conditions relevant to allergy specialists. Glycerin tables were also created to permit convenient assessments of the final concentrations of this stabilizer in patient prescriptions. CONCLUSION SCIT dosing and glycerin tables are useful tools to assist allergists with practice decisions that involve variable patient formulas and injection volumes and can help identify suitable conditions for treatment of patients presenting with diverse allergen sensitivities and specificity profiles.
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Affiliation(s)
- Thomas J Grier
- Medical and Scientific Affairs, Stallergenes Greer, Lenoir, North Carolina.
| | - Lorie M Converse
- Medical and Scientific Affairs, Stallergenes Greer, Lenoir, North Carolina
| | - Donna J Rekkerth
- Medical and Scientific Affairs, Stallergenes Greer, Lenoir, North Carolina
| | - Kevin E Renahan
- Medical and Scientific Affairs, Stallergenes Greer, Lenoir, North Carolina
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Clinical Evaluation and Management of Patients with Suspected Fungus Sensitivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:405-14. [PMID: 26755100 DOI: 10.1016/j.jaip.2015.10.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 09/25/2015] [Accepted: 10/15/2015] [Indexed: 11/21/2022]
Abstract
Fungus-sensitized patients usually present with symptoms that are similar to symptoms presented by those who are sensitized to other aeroallergens. Therefore, diagnosis and management should follow the same pathways used for patients with allergic conditions in general. The physician should consider that a relationship between fungal exposure and symptoms is not necessarily caused by an IgE-mediated mechanism, even when specific fungal IgE is detected. Until recently, IgE-mediated allergy has been documented only for a limited number of fungi. We propose a series of questions to be used to identify symptoms that occur in situations with high fungal exposure and a limited skin-prick-test panel (Alternaria, Cladosporium, Penicillium, Aspergillus, Candida) that can be amplified only in cases of high suspicion of other fungal exposure (eg, postfloods). We also review in vitro testing for fungi-specific IgE. Treatment includes environmental control, medical management, and, when appropriate, specific immunotherapy. Low-quality evidence exists supporting the use of subcutaneous immunotherapy for Alternaria to treat allergic rhinitis and asthma, and very low quality evidence supports the use of subcutaneous immunotherapy for Cladosporium and sublingual immunotherapy for Alternaria. As is the case for many allergens, evidence for immunotherapy with other fungal extracts is lacking. The so-called toxic mold syndrome is also briefly discussed.
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Grier TJ, Hall DM, Duncan EA, Gada SM. Allergen stabilities and compatibilities in immunotherapy mixtures that contain cat, dog, dust mite, and cockroach extracts. Ann Allergy Asthma Immunol 2015; 115:496-502. [PMID: 26522255 DOI: 10.1016/j.anai.2015.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/01/2015] [Accepted: 10/02/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Indoor allergen mixtures that contain cat, dog, dust mite, and cockroach extracts are commonly used in allergy clinics for subcutaneous immunotherapy, but product-specific stabilities and mixing compatibilities in these complex patient formulas have not been determined. OBJECTIVES To assess the recoveries of cat, dog epithelia, dog dander, dust mite Dermatophagoides farinae, and cockroach mix allergen activities in 5 component mixtures and 1:10 (vol/vol) dilutions stored for up to 12 months. METHODS Concentrated stock mixtures, 10-fold dilutions of these mixtures in human serum albumin-saline diluent, and analogous single-extract controls were analyzed for major allergen concentrations (cat Fel d 1, dog dander Can f 1) and multiallergen IgE-binding potencies (dog epithelia, D farinae, cockroach mix) after storage for 3, 6, 9, and 12 months at 2°C to 8°C. RESULTS The selected immunoassays were specific for individual target extracts in the 5-component mixtures and exhibited analytical sensitivities sufficient for evaluation of both the concentrated and diluted indoor allergen formulas. All control samples except diluted cockroach extract had near-complete stabilities during refrigerated storage. Mixtures that contained cat, dog epithelia, dog dander, and D farinae extracts exhibited favorable mixing compatibilities in 1:1 (vol/vol) concentrates (47.5% glycerin) and 1:10 (vol/vol) dilutions (4.75% glycerin), relative to corresponding control sample reactivities. Cockroach allergens in both 1:1 (vol/vol) and 1:10 (vol/vol) concentrations were stabilized significantly by mixing with the other 4 indoor allergen extracts. CONCLUSION Extracts in mixtures that contained 5 common sources of indoor allergens possess favorable stabilities and mixing compatibilities and support the practice of combining these products in the same patient treatment formulations for subcutaneous immunotherapy.
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Affiliation(s)
- Thomas J Grier
- Research and Development Laboratory, Greer Laboratories Inc, Lenoir, North Carolina.
| | - Dawn M Hall
- Research and Development Laboratory, Greer Laboratories Inc, Lenoir, North Carolina
| | - Elizabeth A Duncan
- Research and Development Laboratory, Greer Laboratories Inc, Lenoir, North Carolina
| | - Satyen M Gada
- Walter Reed National Military Medical Center, Bethesda, Maryland
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Schaffer FM, Garner LM, Ebeling M, Adelglass JM, Hulsey TC, Naples AR. The efficacy assessment of a self-administered immunotherapy protocol. Int Forum Allergy Rhinol 2015; 6:148-55. [PMID: 26467843 PMCID: PMC4860610 DOI: 10.1002/alr.21653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 06/26/2015] [Accepted: 08/18/2015] [Indexed: 01/19/2023]
Abstract
Background We previously reported the safety of a self‐administered subcutaneous immunotherapy (SCIT) protocol. Here we report the results of the retrospective efficacy trial of the United Allergy Service (UAS) self‐administered SCIT protocol. We hypothesized that by utilizing a slow SCIT buildup phase, designed to attain recommended allergen concentrations on a cumulative basis, efficacious outcomes and clinical relevance would be achieved. Methods We enrolled 60 SCIT patients and 56 control patients. The study contrasted baseline and treatment period combined symptom plus medication scores (CSMS) as the primary outcome measure and rhinoconjunctivitis quality of life questionnaire (RQLQ) scores as the secondary study outcome measure. Changes in pollen counts were also examined with regard to effects on these efficacy parameters. Results The treatment group showed significantly improved CSMS (standardized mean difference [SMD]: −1.57; 95% confidence interval [CI], −1.97 to −1.18; p < 0.001) and RQLQ (SMD: −0.91; 95% CI, −1.23 to −0.59; p < 0.001). These treatment group outcome measures were respectively improved by 33% and 29% compared to baseline and greater than 40% in comparison to the control group (p < 0.0001). Significant results were also shown when examining these outcome measures with regards to either monotherapy or poly‐allergen SCIT. Furthermore, a comparison to recent meta‐analyses of SCIT studies showed equivalent efficacy and clinical relevance. Assessment of pollen counts during the baseline and treatment periods further corroborated the efficacy of the UAS SCIT protocol. Conclusion These efficacy results, and our previous safety results, show that a carefully designed and implemented self‐administered SCIT protocol is efficacious and safe.
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Affiliation(s)
- Frederick M Schaffer
- United Allergy Services (UAS), San Antonio, TX.,Division of Pediatric Pulmonary, Allergy and Immunology, Medical University of South Carolina, Charleston, SC
| | | | - Myla Ebeling
- Division of Pediatric Epidemiology, Medical University of South Carolina, Charleston, SC
| | | | - Thomas C Hulsey
- Division of Pediatric Epidemiology, Medical University of South Carolina, Charleston, SC
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Daigle BJ, Rekkerth DJ. Practical recommendations for mixing allergy immunotherapy extracts. ALLERGY & RHINOLOGY 2015; 6:1-7. [PMID: 25860164 PMCID: PMC4388870 DOI: 10.2500/ar.2015.6.0111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Critical aspects of formulating allergy immunotherapy vaccines include the selection, total number, and proportions of each allergen component in therapeutic mixtures. The immunotherapy prescription, determined by a medical provider, details the dosing and schedule for treatment as well as the specific composition of the treatment vials. Allergen extracts are composed of many components such as proteins, glycoproteins, and proteases. Some components in allergen extracts are cross-reactive, meaning that treatment with an extract from one species may confer partial protection against a triggering allergen from another species. Conversely, some allergen extracts are incompatible with other extracts when combined in a mixture for treatment, resulting in lowered therapeutic potential for the patient. Therefore, knowledge of allergen extract cross-reactivities and incompatibilities guides the preparation of subcutaneous immunotherapy prescriptions. In a clinical setting, an understanding of what can and can not be mixed is one critical element in improving treatment outcomes.
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Schaffer FM, Naples AR, Ebeling M, Hulsey TC, Garner LM. The safety of self-administered allergen immunotherapy during the buildup and maintenance phases. Int Forum Allergy Rhinol 2015; 5:149-56. [PMID: 25476041 PMCID: PMC4465093 DOI: 10.1002/alr.21443] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 09/30/2014] [Accepted: 10/05/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Self-administered allergen immunotherapy is considered controversial. We believe the implementation of a self-administration protocol characterized by patient preselection and a slow buildup phase is safe. METHODS We analyzed 23,614 patient records and associated immunotherapy injections for systemic reactions (SR) during a 1-year period (2011 to 2012). SRs were graded in accordance with the World Allergy Organization (WAO) criteria. RESULTS Thirty-seven SRs were reported for 23,614 patients who self-administered 2,021,600 injections yielding an annual SR rate of 0.16% (per patient) or 0.002% (per injection). Only 9 of 4643 pediatric (0.19%) and 28 of 18,971 adult patients (0.15%) experienced 1 or more SRs. No deaths (grade V SR) occurred. From 2009 through early 2014, over 90,000 patients received more than 10 million injections in accordance with the United Allergy Services (UAS) protocol without fatalities. CONCLUSION We believe this safety profile is due to a preselection of patients to exclude those with a high risk for adverse reactions and a slow immunotherapy buildup phase. In contrast, previous studies documented office-based SRs ranging from approximately 3% to greater than 14%. Thus, the UAS home-immunotherapy SR rate is significantly lower than office-based immunotherapy SR rates (p < 0.0001). The enhanced safety of this protocol results in a decreased frequency and severity of SRs. This safety report, derived from analyses of one of the largest patient cohorts studied, corroborates and expands the observations of previous studies of self-administered subcutaneous immunotherapy in a low-risk patient population by assessing self-administered allergen immunotherapy during the buildup and maintenance phases.
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Affiliation(s)
- Frederick M. Schaffer
- United Allergy Services (UAS), San Antonio, TX
- Division of Pediatric Pulmonary, Allergy and Immunology, Medical University of South Carolina, Charleston, SC
| | | | - Myla Ebeling
- Division of Pediatric Epidemiology, Medical University of South Carolina, Charleston, SC
| | - Thomas C. Hulsey
- Division of Pediatric Epidemiology, Medical University of South Carolina, Charleston, SC
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Mixing compatibilities of Aspergillus and American cockroach allergens with other high-protease fungal and insect extracts. Ann Allergy Asthma Immunol 2015; 114:233-9. [PMID: 25578248 DOI: 10.1016/j.anai.2014.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 11/24/2014] [Accepted: 11/26/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Recent studies have shown that Alternaria and German cockroach allergens can be degraded by endogenous proteases from other insect and fungal extracts when combined for immunotherapy, but data supporting the compatibilities of other high-protease products in comparable mixtures have not been reported. OBJECTIVE To assess the stabilities and compatibilities of Aspergillus fumigatus and American cockroach allergens after mixing with protease-rich extracts from other insects or fungi at concentrations similar to those recommended for subcutaneous immunotherapy. METHODS Mixtures containing A fumigatus, American cockroach, and other fungal or insect extracts were evaluated by quantitative (enzyme-linked immunosorbent assays) and qualitative (immunoblotting) methods. Test mixtures and control samples at 10% to 50% glycerin concentrations were analyzed after storage for up to 12 months at 2°C to 8°C. RESULTS Moderate to high recoveries of Aspergillus extract activities were retained in control samples and extract mixtures under all conditions examined. American cockroach extract controls were partly degraded at 10% to 25% glycerin, and cockroach allergen compatibilities were decreased significantly in mixtures with several fungal extracts at 25% glycerin. Mixing with other insects did not compromise the stability of American cockroach allergens at 25% to 50% glycerin. CONCLUSION Aspergillus extracts exhibited favorable stabilities after mixing with other high-protease products. American cockroach extract potencies were unstable in less than 50% glycerin, even in the absence of other protease-containing allergens, and were destabilized in mixtures with several fungal extracts. Addition of fungal and insect extracts to separate treatment vials or preparation of fungal-insect mixtures at elevated glycerin concentrations might be necessary to produce compatible patient formulations for allergen immunotherapy injections.
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Portnoy J, Miller JD, Williams PB, Chew GL, Miller JD, Zaitoun F, Phipatanakul W, Kennedy K, Barnes C, Grimes C, Larenas-Linnemann D, Sublett J, Bernstein D, Blessing-Moore J, Khan D, Lang D, Nicklas R, Oppenheimer J, Randolph C, Schuller D, Spector S, Tilles SA, Wallace D. Environmental assessment and exposure control of dust mites: a practice parameter. Ann Allergy Asthma Immunol 2013; 111:465-507. [PMID: 24267359 PMCID: PMC5156485 DOI: 10.1016/j.anai.2013.09.018] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 09/20/2013] [Indexed: 12/15/2022]
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Esch RE, Plunkett GA. Immunotherapy preparation guidelines, rules, and regulation. Curr Allergy Asthma Rep 2013; 13:406-13. [PMID: 23722699 DOI: 10.1007/s11882-013-0358-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Allergen immunotherapy has been used to treat allergic diseases for more than 100 years. In the U.S., the preparation of diagnostic and therapeutic extracts requires the cooperation of the extract manufacturer, who provides the individual allergen concentrates, and the practicing physician who formulates, dilutes, and administers the final patient-specific treatment extract. The guidelines, rules, and regulations for these activities have been established and continue to be developed as progress is made. The molecular characterization and standardization of allergenic extracts has allowed for improvements in defining the potency of these products. In turn, these advances have led to improved dosing regimens and formulation practices. This review will describe in detail some of these interactions and will identify issues that require more attention.
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Affiliation(s)
- Robert E Esch
- Greer Laboratories, 639 Nuway Circle, Lenoir, NC 28645, USA.
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Allergen immunotherapy extract treatment set preparation: making a safer and higher quality product for patients. Curr Allergy Asthma Rep 2013; 13:399-405. [PMID: 23881510 DOI: 10.1007/s11882-013-0362-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The best possible allergen immunotherapy clinical outcomes require the provision of high quality and safe allergen immunotherapy extract preparations. Evolving national guidelines and regulatory bodies have devoted special attention to the safe compounding of sterile products, including allergen extracts. It is incumbent upon allergists preparing extract treatment sets for patients to be familiar with and adopt training, procedures and safety measures that lead to standardized high quality products. Preparers and supervisors must maintain ongoing competency in aseptic technique and prescribing principles, such as probable effective dose ranges, allergen cross-reactivity, and separation of high protease-containing extracts from susceptible extracts. Accordingly, knowledge and application of vial labeling, diluent selection, standard operating procedures, mixing log documentation, and mixing condition principles are a necessity. Although there have been no instances of infectious complications from allergen immunotherapy in a century of clinical practice, continued vigilance in the use of measures that ensure extract sterility is paramount. A review of allergen immunotherapy preparation recommendations and best practices based on published national guidelines is presented. Further study of preparation measures and prescribing principles will continue to advance the practice of allergen immunotherapy and offer opportunities for refinement of current recommendations.
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Bahceciler NN, Galip N, Cobanoglu N. Multiallergen-specific immunotherapy in polysensitized patients: where are we? Immunotherapy 2013; 5:183-90. [PMID: 23413909 DOI: 10.2217/imt.12.161] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Allergen-specific immunotherapy administered by the subcutaneous route was introduced a century ago and has been shown to be effective in the management of allergic rhinitis and asthma. More recently, the sublingual administration of allergen extracts has become popular, especially in European countries, and has also demonstrated efficacy in respiratory allergic diseases. Both modes of allergen administration during immunotherapy have been shown not only to reduce symptoms and the need for medication, but also to prevent the development of additional sensitivities in monosensitized patients, as well as asthma development in patients with allergic rhinitis, with a long-lasting effect after the completion of several years of treatment. Almost all of the well-designed and double-blinded, placebo-controlled studies evaluated treatment with single-allergen extracts. Therefore, most meta-analyses published to date evaluated immunotherapy with single allergen or extracts containing several cross-reactive allergens. As a result, in general, multiallergen immunotherapy in polysensitized patients (mixture of noncross-reactive allergens) is not recommended owing to lack of evidence. Although some guidelines have recommended against the use of multiallergen mixtures, allergists commonly use mixtures to which the patient is sensitive with the rationale that effective immunotherapy should include all major sensitivities. Literature on this subject is scarce in spite of the widespread use worldwide. Here, this issue will be extensively discussed based on currently available literature and future perspectives will also be explored.
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Affiliation(s)
- Nerin Nadir Bahceciler
- Near East University, Faculty of Medicine, Division of Pediatric Allergy & Clinical Immunology, Nicosia, North Cyprus.
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Grier TJ, LeFevre DM, Duncan EA, Esch RE, Coyne TC. Allergen stabilities and compatibilities in mixtures of high-protease fungal and insect extracts. Ann Allergy Asthma Immunol 2012; 108:439-47. [PMID: 22626598 DOI: 10.1016/j.anai.2012.04.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 04/11/2012] [Accepted: 04/17/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND Current practice guidelines state that protease-rich fungal and insect extracts can be combined when preparing immunotherapy vaccines, but data supporting the stability of allergens in these mixtures have not been reported. OBJECTIVE To determine the stabilities and compatibilities of Alternaria alternata and German cockroach allergens in mixtures with other high-protease fungal and insect (cockroach, imported fire ant) extracts at final extract concentrations consistent with injection dose targets for maintenance immunotherapy. METHODS Mixtures containing Alternaria, German cockroach, and other fungal and insect extracts frequently included in immunotherapy vaccines were analyzed by a combination of quantitative analyses (enzyme-linked immunosorbent assays for multiallergen immunoglobulin E [IgE]-binding potency, major Alternaria allergen Alt a 1, and major German cockroach allergens Bla g 1 and Bla g 2) and qualitative methods (immunoblotting). Mixtures and analogous single-extract controls containing 10 to 50% glycerin were evaluated after storage for up to 12 months at 2°C to 8°C. RESULTS Mixtures of extracts within the same phylogenetic groups (fungal-fungal, insect-insect) retained favorable Alternaria and German cockroach allergen levels and activities under most conditions examined. For several cross-taxonomic (fungal-insect) extract combinations at 10 to 25% glycerin concentrations, different immunochemical test methods measuring single (major) or multiple allergens yielded threefold to 10-fold variations in allergen recoveries. CONCLUSION Allergen compatibilities can be compromised in some fungal-insect extract mixtures, contrary to current immunotherapy practice parameter recommendations. Separation of these products into different treatment vials may be required to produce stable mixtures for subcutaneous immunotherapy. Data from assay methodologies with distinct binding specificities provide a critical assessment of allergen activities in high-protease extract mixtures.
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Affiliation(s)
- Thomas J Grier
- Research and Development Laboratory, Greer Laboratories Inc., Lenoir, NC 28645, USA.
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Portnoy J, Kennedy K, Sublett J, Phipatanakul W, Matsui E, Barnes C, Grimes C, Miller JD, Seltzer JM, Williams PB, Bernstein JA, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J. Environmental assessment and exposure control: a practice parameter--furry animals. Ann Allergy Asthma Immunol 2012; 108:223.e1-15. [PMID: 22469456 DOI: 10.1016/j.anai.2012.02.015] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 02/21/2012] [Indexed: 12/20/2022]
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Portnoy J, Kennedy K, Sublett J, Phipatanakul W, Matsui E, Barnes C, Grimes C, Miller JD, Seltzer JM, Williams PB, Bernstein JA, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J. Environmental assessment and exposure control: a practice parameter--furry animals. Ann Allergy Asthma Immunol 2012. [PMID: 22469456 DOI: 10.1016/j.anai.2012.02.015.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2022]
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Gada S, Haymore B, McCoy L, Kosisky S, Nelson M. Frequency of mold and pollen mixing in allergen immunotherapy prescriptions within a large health care system, 1990-2010. J Allergy Clin Immunol 2011; 129:1151-3. [PMID: 22154380 DOI: 10.1016/j.jaci.2011.10.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2011] [Revised: 10/05/2011] [Accepted: 10/20/2011] [Indexed: 10/14/2022]
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Walker SM, Durham SR, Till SJ, Roberts G, Corrigan CJ, Leech SC, Krishna MT, Rajakulasingham RK, Williams A, Chantrell J, Dixon L, Frew AJ, Nasser SM. Immunotherapy for allergic rhinitis. Clin Exp Allergy 2011; 41:1177-200. [DOI: 10.1111/j.1365-2222.2011.03794.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
Stability studies with a few well-characterized allergen extracts have yielded useful information about the shelf-life of these products stored under various conditions. The development of validated stability-indicating tests and their clinical verification remains a fundamental challenge for extending this information to cover more products. This challenge becomes even greater for evaluations of more complex, multiextract mixtures that are used in clinical practice. Thus, the current approach for developing guidelines for extract expiration dating practices must rely on extrapolations of data obtained from a few well-controlled studies.
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Affiliation(s)
- Robert E Esch
- Research and Development, Greer Laboratories, Inc, 639 Nuway Circle, Lenoir, NC 28645, USA.
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Cox L, Esch RE, Corbett M, Hankin C, Nelson M, Plunkett G. Allergen immunotherapy practice in the United States: guidelines, measures, and outcomes. Ann Allergy Asthma Immunol 2011; 107:289-99; quiz 300. [PMID: 21962088 DOI: 10.1016/j.anai.2011.06.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 06/08/2011] [Accepted: 06/18/2011] [Indexed: 11/16/2022]
Abstract
To discuss recent issues pertinent to allergen immunotherapy practice in the United States. Allergen extract preparation guidelines, updated allergen immunotherapy practice parameter (AIPP) guidelines, and evolving trends in how immunotherapy outcomes will be measured and assessed. Allergen extract preparation guidelines have been established by 2 entities: the US Pharmacopeia and an American Academy of Allergy, Asthma, and Immunology/American College of Allergy, Asthma, and Immunology/Joint Council of Allergy, Asthma, and Immunology Joint Task Force. Minor differences exist between these guidelines, but both focus on aseptic techniques and require that compounding personnel pass a written examination and annual media fill test. The AIPP third update provides new dosing recommendations for Bermuda grass, imported fire ant, and nonstandardized extracts distinguishing between pollen (0.5 mL of a 1:100 or 1:200 vol/vol) and mold/fungi or cockroach (highest tolerated dose) extracts. Because of limited and sometimes conflicting data on high and low proteolytic-containing extract compatibility, the AIPP continues to recommend against mixing these together. Although the AIPP does not specifically recommend a specific diluent, recent evidence suggests normal saline may not be as effective a stabilizer for extract dilutions as glycerin or human serum albumin. Currently, immunotherapy efficacy is determined with subjective assessments that rely on patient reporting, but this may change as health care reform evolves. It will likely become more important for US allergy/immunology practices to demonstrate immunotherapy comparative-effectiveness and report quality measures. Recent comparative-effectiveness studies have demonstrated the cost-effectiveness of immunotherapy compared with symptomatic drug treatment.
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Affiliation(s)
- Linda Cox
- Nova Southeastern University, Ft Lauderdale, Florida, USA.
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Cox L, Nelson H, Lockey R, Calabria C, Chacko T, Finegold I, Nelson M, Weber R, Bernstein DI, Blessing-Moore J, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles S, Wallace D. Allergen immunotherapy: A practice parameter third update. J Allergy Clin Immunol 2011; 127:S1-55. [DOI: 10.1016/j.jaci.2010.09.034] [Citation(s) in RCA: 597] [Impact Index Per Article: 45.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Accepted: 09/23/2010] [Indexed: 10/18/2022]
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Grier TJ, LeFevre DM, Duncan EA, Esch RE. Stability and mixing compatibility of dog epithelia and dog dander allergens. Ann Allergy Asthma Immunol 2009; 103:411-7. [PMID: 19927540 DOI: 10.1016/s1081-1206(10)60361-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Little information or data are available concerning the stability and compatibility of dog epithelia and dog dander allergens. OBJECTIVE To determine the immunochemical reactivities of commercial, nonstandardized dog epithelia and dog dander extracts after exposures to various temperatures or after mixing with high-protease fungal and cockroach extracts at concentrations recommended for maintenance immunotherapy (IT) injections. METHODS Quantitative enzyme-linked immunosorbent assay and qualitative (immunoblot) analyses were performed to compare specific compositional changes with total or individual allergen activities. Assays for dog allergens Can f 1 and Can f 3 (albumin) used specific mouse or rabbit antibodies. Multiallergen enzyme-linked immunosorbent assay inhibition and immunoblot methods were conducted using a human serum pool with high levels of IgE to dog allergens. RESULTS Dog allergen recoveries ranged from 22% to 134% after short exposures to moderate or extreme temperatures and from 28% to 118% after mixing with fungal or insect extracts and storage for up to 15 months at 2 degrees C to 8 degrees C. Recoveries in dog dander extracts varied up to 2.5-fold with different test methods. Immunoblots revealed partial degradation of dog albumin molecules to discrete fragments that retained antibody-binding activities. In most cases, recoveries improved at elevated glycerin concentrations. CONCLUSIONS Dog allergens in epithelia and dander extracts exhibited favorable temperature stabilities. Compatibilities with fungal or insect extracts may be compromised or at risk in some combinations. These data support current IT practice parameter recommendations of separating high-protease extracts from other products if possible; they also demonstrate that dog extracts possess allergen stabilities suitable for many IT formulations.
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Affiliation(s)
- Thomas J Grier
- Research and Development Laboratory, Greer Laboratories, Inc, Lenoir, North Carolina 28645, USA.
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Letz AG, Calabria CW. T-cell epitopes of aeroallergens. Ann Allergy Asthma Immunol 2009; 102:445-51; quiz 452-4, 499. [PMID: 19558001 DOI: 10.1016/s1081-1206(10)60115-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To describe the current knowledge of the T-cell epitopes of common aeroallergens, how they were discovered, and implications for future therapy. DATA SOURCES PubMed search of English-language articles without date limits pertaining to T-cell epitopes of aeroallergens included on a standard skin test panel. STUDY SELECTION A total of 127 articles were screened based on the results of the PubMed search and cross-indexed as needed. The highest quality and most clinically relevant articles were included for discussion. RESULTS Of the 47 allergen extracts included on the standard skin test panel at our instittition, T-cell epitopes have been described for 13. Immunodominant epitopes have been used for peptide immunotherapy trials. CONCLUSIONS T-cell epitopes have been characterized for a minority of common aeroallergens. However, knowledge is rapidly expanding and can lay the groundwork for therapies that specifically target T cells.
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Affiliation(s)
- Adrian G Letz
- Wilford Hall Medical Center, Lackland AFB, San Antonio, Texas, USA.
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Srivastava D, Arora N, Singh BP. Current immunological approaches for management of allergic rhinitis and bronchial asthma. Inflamm Res 2009; 58:523-36. [PMID: 19333724 DOI: 10.1007/s00011-009-0033-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Revised: 02/18/2009] [Accepted: 03/12/2009] [Indexed: 01/15/2023] Open
Abstract
A large population world over is affected with allergic diseases and asthma. Pharmacotherapy for allergic diseases and asthma is effective in controlling symptoms but on discontinuation of medication, symptoms reoccur. In contrast, immunotherapy modifies and corrects the underlying pathological immune responses in an antigen-specific manner. Immunotherapy shows an increase in IgG (blocking antibody) that competes with IgE for allergen, inhibiting the release of inflammatory mediators. Recent studies suggest that immunotherapy acts by modifying CD4+ T-cell responses either by immune deviation, T-cell anergy and/or both. Current immunological approaches for management of allergies and asthma involve immunization with native allergen, modified allergen, peptides/cDNA of allergen, anti-IgE, adjuvants coupled allergen, including immunostimulatory DNA sequences, cytokines, and bacterial products. These approaches modulate the immune response and are intended to give long-term benefit.
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Affiliation(s)
- Deepsikha Srivastava
- Allergy and Immunology Section, Institute of Genomics and Integrative Biology (CSIR), Delhi University Campus, Mall Road, Delhi, 110007, India
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Rans TS, Hrabak TM, Whisman BA, Grier TJ, LeFevre DM, Kwon PO, Tankersley MS. Compatibility of imported fire ant whole body extract with cat, ragweed, Dermatophagoides pteronyssinus, and timothy grass allergens. Ann Allergy Asthma Immunol 2009; 102:57-61. [PMID: 19205287 DOI: 10.1016/s1081-1206(10)60109-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recommendations regarding the administration of imported fire ant whole body extract (IFA WBE) combined with aeroallergens or environmental allergens in a single immunotherapy injection are lacking. OBJECTIVE To evaluate the degradative effect of IFA WBE on cat, ragweed, Dermatophagoides pteronyssinus, and timothy grass allergens. METHODS Imported fire ant whole body extract was combined with extracts of cat, ragweed, D pteronyssinus, and timothy grass. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) was performed on each sample after storage for 0, 1, 3, and 6 months at 4 degrees C. In addition, cat and ragweed combinations were evaluated by radial immunodiffusion (RID); D pteronyssinus by enzyme-linked immunosorbent assay (ELISA) inhibition; and timothy grass by ELISA inhibition and Western blot. RESULTS Imported fire ant whole body extract combined with timothy grass demonstrated degradation of timothy grass allergens by SDS-PAGE, ELISA inhibition, and Western blot results. Cat and ragweed allergens were stable after mixing with IFA WBE, based on SDS-PAGE and RID analyses. Stability of D pteronyssinus allergens with IFA WBE was evident from SDS-PAGE and ELISA inhibition data. CONCLUSIONS Imported fire ant whole body extract combined with timothy grass resulted in significant and rapid timothy protein degradation. Imported fire ant whole body extract mixed with cat, ragweed, or D pteronyssinus revealed aeroallergen stability, yielding the possibility of combining these extracts in a single immunotherapy injection. Compatibilities of IFA WBE with other common aeroallergens remain undetermined and thus are not recommended for single-injection immunotherapy formulations.
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Affiliation(s)
- Tonya S Rans
- Department of Allergy and Immunology, Wilford Hall Medical Center, San Antonio, Texas 78236, USA.
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Hamilton RG. Diagnostic tests for human allergic disease. ACTA ACUST UNITED AC 2008; 2:1123-35. [PMID: 23496423 DOI: 10.1517/17530059.2.10.1123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The diagnosis of human allergic disease begins with a thorough clinical history and physical examination. Once a temporal relationship has been identified between a patient's history of allergic symptoms and a defined allergen exposure, confirmatory analyses for IgE antibody involving skin or blood testing are performed to verify sensitization. Debate continues over the relative diagnostic utility of the in vivo and in vitro measures of IgE antibody. OBJECTIVE This overview examines the strengths and limitations of primary diagnostic confirmatory methods for in vivo detection (skin test, provocation test) and in vitro quantification of IgE antibody. METHODS A literature review was performed to examine diagnostic performance characteristics and variables that influence the accuracy of IgE antibody assays. DISCUSSION The clinical history and both in vivo and in vitro measures of IgE antibody are subject to variability and potential patient, clinician and technician-related bias. As such, in the absence of an absolute clinical history-based gold standard for defining the presence of allergic disease, the relative diagnostic performance (sensitivity, specificity) of in vivo versus in vitro assays of IgE antibody cannot be effectively determined. The review examines which allergic disease states and allergen specificities allow both groups of IgE antibody assays to produce comparable qualitative data for assessing the state of allergic sensitization. Skin testing has experienced few recent technological innovations, whereas an explosion has occurred in the improved performance (analytical sensitivity and specificity) of in vitro assays and enhanced quality of reagents for IgE antibody quantification. This review discusses the impact of point of care-testing assays, microarrays, the use of native and recombinant allergen molecules, automation, and disease prediction algorithms and the 2008 Clinical and Laboratory Standards Institute Guideline on IgE antibody methods, on the diagnosis of human allergic disease.
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Affiliation(s)
- Robert G Hamilton
- Professor of Medicine and Pathology, Johns Hopkins University School of Medicine and Director, Johns Hopkins Dermatology, Allergy and Clinical Immunology Reference Laboratory
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Esch RE. Allergen immunotherapy: What can and cannot be mixed? J Allergy Clin Immunol 2008; 122:659-60. [DOI: 10.1016/j.jaci.2008.07.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Revised: 07/23/2008] [Accepted: 07/24/2008] [Indexed: 10/21/2022]
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Stability of allergen extracts used in skin testing and immunotherapy. Curr Opin Otolaryngol Head Neck Surg 2008; 16:285-91. [PMID: 18475087 DOI: 10.1097/moo.0b013e3282ff62b0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The present article reviews allergen extract stability applied to US manufactured products. Methods used to measure potency of extract concentrates, patient prescription dilute extracts, and mixes containing degrading enzymes will be discussed. RECENT FINDINGS Information about the allergen extract active ingredient components contributing to potency is increasing. Pertinent stability issues include the type of diluent used for extraction and mixing. Fifty percent glycerin greatly extends the time over which extracts remain potent, including in mixes with fungal and insect extracts known to contain protein-degrading enzymes. Diluents that contain additional protein content such as human serum albumin increase stability of dilute solutions. Many of the most rigorous studies on allergen stability have been performed by allergenic extract manufacturers in support of Food and Drug Administration approved dating for standardized products and are not published. SUMMARY Studies addressing how antigens in extracts change under various storage conditions have provided general guidance for expiration dating, but the diversity of extracts and testing methods have been less than complete. Additional findings that are increasing our knowledge of extract shelf life will be discussed.
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Current World Literature. Curr Opin Otolaryngol Head Neck Surg 2008; 16:292-5. [DOI: 10.1097/moo.0b013e3283041256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Allergen immunotherapy: a practice parameter second update. J Allergy Clin Immunol 2007; 120:S25-85. [PMID: 17765078 DOI: 10.1016/j.jaci.2007.06.019] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Revised: 05/25/2007] [Accepted: 06/14/2007] [Indexed: 11/18/2022]
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