Update on sublingual immunotherapy

Effects of Sublingual Duster Mite Drops on Lung Function and Exhaled Nitric Oxide in Children with Multiple and Single Allergic Respiratory Diseases

Objective

To evaluate the efficiency of sublingual immunotherapy with Dermatophagoides Farinae Drops in children with single and multiple respiratory allergic diseases.

Methods

Seventy-one children with allergic respiratory diseases who had been treated with Dermatophagoides Farinae Drops for one year or more were divided into a single allergic group (12 cases) and multiple allergic group (59 cases). The rhinitis score, daytime and night symptom score of asthma, VAS score, drug score, pulmonary function, and FeNO level before and after treatment were evaluated and compared between the two groups.

Results

The rhinitis score, night symptom score, VAS score, and drug score in the single allergic group after treatment were significantly lower than those before treatment (p < 0.05), but there was no significant difference in the daytime symptom score before and after treatment (p > 0.05). The rhinitis score, VAS score, and drug score in the multiple allergic group after treatment were significantly lower than those before treatment (p < 0.05), but there was no significant difference in the scores of daytime symptoms and nighttime symptoms before and after treatment (p > 0.05). In both the single allergic group and multiple allergic group, the pulmonary function indexes of the patients were significantly improved after treatment, and the FeNO after treatment was significantly lower than that before treatment (p < 0.05). There was no significant difference in scores, pulmonary function, and FeNO between the two groups (p > 0.05).

Conclusion

Sublingual specific immunotherapy is effective in treating multiple and single allergic respiratory diseases in children.

Effects of sublingual-specific immunotherapy on pulmonary function and exhaled nitric oxide levels in asthmatic children with and without allergic rhinitis

BACKGROUND

Allergic asthma and allergic rhinitis are common chronic respiratory diseases in children. The prevalence rate of disease is increasing year by year. And avoid allergens, drug treatments and special immunotherapy (SIT) is the fundamental treatment for respiratory allergies diseases. But there are few comprehensive studies on the control level of asthma, improvement of lung function, and changes of exhaled nitric oxide (FeNO) after SLIT treatment in children with allergic asthma and rhinitis.

METHODS

In all, 71 child asthma patients who received sublingual-specific immune therapy for 1 year or more were divided into an asthmatic rhinitis group (31 cases) and an asthma-alone group (40 cases). The two groups of patients were compared before and after treatment in terms of rhinitis symptom scores, daytime and nighttime asthma symptom scores, visual analog scale (VAS) score, drug score, pulmonary function, and exhaled nitric oxide level (FeNO).

RESULTS

After treatment, daytime symptom scores, VAS scores, drug scores, and FeNO levels of the asthma-alone group were all lower than before treatment, and the lung function was significantly improved (P<0.05), while the difference in night symptom scores before and after treatment was not statistically significant (P>0.05). The lung function and FeNO level of children in the asthmatic rhinitis group were lower after treatment than before treatment, with statistically significant differences (P<0.05). The scores of rhinitis and VAS in the asthmatic rhinitis group were higher than those in the asthma-alone group, and the differences were statistically significant. There was no significant difference in other scores between the two groups. There was no significant difference in lung function and FeNO level between the two groups.

CONCLUSIONS

SLIT for children with or without allergic asthma or with or without rhinitis has a significant effect, but its effect on children with asthma combined with rhinitis is not superior to that of children with asthma alone.

Recent Advances in Polymeric Nanomedicines for Cancer Immunotherapy

Immunotherapy has emerged as a promising approach to treat cancer, since it facilitates eradication of cancer by enhancing innate and/or adaptive immunity without using cytotoxic drugs. Of the immunotherapeutic approaches, significant clinical potentials are shown in cancer vaccination, immune checkpoint therapy, and adoptive cell transfer. Nevertheless, conventional immunotherapies often involve immune-related adverse effects, such as liver dysfunction, hypophysitis, type I diabetes, and neuropathy. In an attempt to address these issues, polymeric nanomedicines are extensively investigated in recent years. In this review, recent advances in polymeric nanomedicines for cancer immunotherapy are highlighted and thoroughly discussed in terms of 1) antigen presentation, 2) activation of antigen-presenting cells and T cells, and 3) promotion of effector cells. Also, the future perspectives to develop ideal nanomedicines for cancer immunotherapy are provided.

Yiqi Wenyang Fang ameliorates allergic rhinitis through inhibiting inflammatory response and promoting the expression of Foxp3

Allergic rhinitis (AR) is an inflammatory disease with a hypersensitivity response to environmental stimulus. The aim of this study was to evaluate the effect of Yiqi Wenyang Fang (YWF) on AR and investigate the underlying mechanism. A total of 48 female Sprague-Dawley rats were randomly divided into six groups (normal control, model control, YWF at low dose, YWF at median dose, YWF at high dose, and loratadine). Rats were injected with antigen for sensitization. Then, rats in the YWF groups were treated with different dose of YWF for 28 days. Loratadine was used as a positive control. Number of sneezes, degree of runny nose, nasal rubbing movements, and tissue damage were scored. The protein and mRNA expression of Foxp3 were determined by western blot and real time-PCR analysis, respectively. Flow cytometry was used to detect the number of CD4⁺CD25⁺Foxp3⁺ Treg cells. The content of interleukin (IL)-10, transforming growth factor β1 (TGF-β1), IL-13, and IL-4 in the serum were detected by enzyme-linked immunosorbent assay (ELISA). Scores of symptoms were significantly reduced and nasal mucosa damage was alleviated after YWF administration. YWF increased the expression of Foxp3, IL-10, TGF-β1, and number of CD4⁺CD25⁺Foxp3⁺ Treg cells which were reduced by antigen injection. The expression levels of IL-13 and IL-4 were increased after antigen administration while decreased after YWF treatment. YWF may ameliorate AR through inhibiting inflammatory response and promoting Foxp3 expression.

Guiding principles of sublingual immunotherapy for allergic rhinitis in Japanese patients

OBJECTIVE

Sublingual immunotherapy (SLIT) appears to offer practical advantages for the treatment of allergic rhinitis (AR). Based on a review of the scientific literature, we present recommendations as guiding principles to administer SLIT safely.

METHODS

Clinical questions concerning SLIT were prepared. Literature published between January 2003 and December 2012 was searched from PubMed, the Cochrane Library, and Japana Centra Revuo Medicina. Qualified studies were analyzed and the results were evaluated, consolidated, and codified. We answered 17 clinical questions and, based on this, presented evidence-based recommendations.

RESULTS

Sublingual immunotherapy improved symptoms (e.g., quality of life [QOL]) and reduced medication scores in seasonal AR and perennial AR. Most SLIT-induced adverse effects were local oral reactions, although systemic adverse effects such as gastrointestinal symptoms, urticaria, and asthma are occasionally reported. There have been no reports of lethal anaphylactic reactions by SLIT. When SLIT is continued for 3-4 years, its effect persists long after discontinuation.

CONCLUSION

A correct diagnosis of AR and sufficient informed consent from patients are required before initiating SLIT. Sublingual immunotherapy should be continued for 3 years or longer. The initial administration of SLIT during the uptitration of an allergen vaccine and the general condition of patients are critical for the safe performance of SLIT.

Sublingual immunotherapy in preschool children: an update

Allergen immunotherapy is a subject widely debated by allergists. Currently, there are controversial discussions focused on the sublingual route. Sublingual immunotherapy (SLIT) has so far been used in Europe, Asia and Australia for the treatment of allergic respiratory diseases. The minimum age to start specific immunotherapy with inhalant allergens in children has not been clearly established, and position papers discourage its use in children younger than 5 years of age. Nevertheless, it is known that SLIT efficacy is higher when SLIT is started at an earlier age. The aim of this review is to focus on studies in preschool children evaluating SLIT safety and efficacy, in order to improve this practice at an earlier age in childhood.

Efficacy and safety of sublingual immunotherapy in Asian children

OBJECTIVE

Sublingual immunotherapy is currently accepted as a suitable alternative to subcutaneous immunotherapy because of its easy and painless administration and improved safety. Many clinical trials have demonstrated that sublingual immunotherapy is an effective and safe treatment for pollen or mite allergic rhinitis. However, there have been very few studies overall on children with allergic rhinitis who are sensitized to house-dust mites in Asia. The purpose of the present study was to investigate the efficacy and safety of sublingual immunotherapy in children with allergic rhinitis to house-dust mites.

METHODS

A total of 112 patients under the age of 15 who had allergic rhinitis to Dermatophagoides pteronyssinus and Dermatophagoides farinae were included. All patients were treated with sublingual immunotherapy (Staloral(®)). Symptom scores and quality of life were evaluated by questionnaires until one year after sublingual immunotherapy. The medication score was assessed monthly using a diary medication card and serologic tests were evaluated before and 6 and 12 months after treatment. Adverse effects and compliance were also investigated.

RESULTS

All nasal and non-nasal symptoms and quality of life were significantly improved after treatment. The total medication score was decreased significantly after sublingual immunotherapy. There was no significant change in serologic tests. Some minor adverse effects were reported, however there were no systemic reactions. The drop-out rate was 21%.

CONCLUSIONS

Sublingual immunotherapy is a valuable therapy for the treatment of allergic rhinitis in Asian children sensitized to house-dust mites.

Immunological effects of sublingual immunotherapy: clinical efficacy is associated with modulation of programmed cell death ligand 1, IL-10, and IgG4

Sublingual immunotherapy (SLIT) is an alternate route of administration of allergen-specific immunotherapy with an improved safety profile; to clarify the immune mechanisms elicited by this therapy, we analyzed the clinical and immunologic effects of SLIT in patients with a clinical history of ragweed sensitization. To analyze possible difference among immunotherapeutic protocols, we also compared patients receiving preseasonal, seasonal, or prolonged sublingual therapy (≥ 3 y); patients receiving symptomatic therapy alone were enrolled as well in the study. Clinical and immunological parameters were measured twice in and out of the pollination period. Clinical benefits, as measured by the visual analog scale for symptoms and for use of drugs, were evident in all three groups of individuals receiving immunotherapy, but were significantly better in patients undergoing prolonged SLIT. Immunologically, SLIT resulted in increased IL-10 production, programmed cell death ligand 1 expression, and concentration of allergen-specific IgG4, as well as in the reduction of CD80 and CD86 expression and IL-4 production. SLIT, thus, is associated with modulation of programmed cell death ligand 1 expression and IL-10 synthesis and favors the production of allergen-specific IgG4. These effects are evident from the first pollen season, independently from therapeutic regimen (preseasonal or seasonal) even if a prolonged treatment is necessary to obtain full clinical efficacy. A more detailed understanding of the interaction of allergen and APCs within the oral mucosa will allow improved targeting of allergy vaccine.

The pathophysiology, diagnosis and treatment of allergic rhinitis

Treatment of AR requires a stepwise approach depending on the severity and duration of symptoms. Treatment options for AR consist of allergen avoidance, pharmacotherapy, immunotherapy and surgery. For the mechanisms of AR, anti-IgE antibody and specific antibody to cytokines such as IL-4 or IL-5 that correlate with allergic inflammation have recently emerged. SLIT is currently widely used due to its efficacy, safety and convenience, which replaces subcutaneous immunotherapy. Although allergen avoidance and immunotherapy are theoretically ideal, antihistamines and intranasal corticosteroids will play the main role in the management of AR until an innovative treatment develops. However, patients' main symptom, the duration and severity of AR, patients' compliance, safety of medication and cost-effectiveness should be considered when treatment options are chosen. In conclusion, physicians should be aware of etiology, pathophysiology, symptoms, signs and diseases related to AR in order to make a correct diagnosis and choose a proper treatment option for each patient.

[Allergen-specific Immunotherapy for children and adolescents - a review on available products in Austria]

A pediatric consensus report on allergen-specific immunotherapy for children and adolescents is presented for Austria. Products on the market in Austria are presented and categorised according to studies performed on the target population of children and adolescents, their effectiveness and indication. In general, more clinical studies on children and adolescents are mandatory for most of the available allergen-specific immunotherapeutics. In addition, the use of allergen-specific immunotherapy in general should be promoted as the exclusive treatment with long-lasting effects in type I allergies in particular in children.

Sublingual immunotherapy: a novel, albeit not so new, immunotherapy treatment modality

BACKGROUND

Specific allergy immunotherapy traditionally has been thought of as subcutaneous injection immunotherapy (SCIT). There also are noninjection routes for the administration of immunotherapy. The best-known and studied of these noninjection routes is the sublingual route, usually known as sublingual immunotherapy (SLIT). SLIT has been in use for many decades; however, to this date, it is not well known to the majority of allergy practitioners in this country. The purpose of this study is to help change this perception so that SLIT eventually can be considered one more tool in the allergist's armamentarium.

METHODS

A literature review was performed. It included articles from the early American clinicians and present publications that are mostly of European origin.

RESULTS

It will become clear to the reader that the key features of SLIT are its efficacy, great safety, and simplicity of administration.

CONCLUSION

SLIT is a safe treatment modality that should be considered as a useful additional tool in the therapeutic armamentarium.

Sublingual grass allergen tablet immunotherapy provides sustained clinical benefit with progressive immunologic changes over 2 years

BACKGROUND

This is an interim analysis of a randomized, double-blind, placebo-controlled phase III trial with 3 years of daily treatment with grass tablet immunotherapy (GRAZAX; ALK-Abelló A/S, Hørsholm, Denmark) or placebo, followed by 2 years of follow-up to assess the persistent efficacy.

OBJECTIVE

We sought to evaluate the efficacy and safety of specific immunotherapy with grass allergen tablets compared with placebo after treatment covering 2 consecutive grass pollen seasons.

METHODS

The interim analyses included 351 adult participants with moderate-to-severe allergic rhinoconjunctivitis caused by grass pollen. Participants were treated with active (n = 189) or placebo (n = 162) tablets for an average of 22 months. All participants were allowed to use symptomatic rescue medication.

RESULTS

The primary efficacy analysis showed highly significant mean reductions of 36% in rhinoconjunctivitis symptom score (P < .0001; median reduction, 44%) and 46% in rhinoconjunctivitis medication score (P < .0001; median reduction, 73%) in the active group relative to the placebo group. Mean rhinoconjunctivitis quality of life was 33% better (P < .0001; median, 40%). Clinical improvements were paralleled by significant changes in allergen-specific immunoglobulins. The treatment was well tolerated, and adverse events led to withdrawal in less than 1% of participants. There were no serious adverse events related to treatment.

CONCLUSION

Grass allergen tablet immunotherapy showed progressive immunologic changes and highly significant efficacy over 2 years of continued treatment.

Increased frequency of large local reactions among systemic reactors during subcutaneous allergen immunotherapy

BACKGROUND

Large local reactions are not uncommon during allergen immunotherapy (AIT). Dosage adjustments after large local reactions are commonly instituted despite literature that suggests individual large local reactions do not seem to predict subsequent systemic reactions.

OBJECTIVE

To investigate the relationship between large local reactions and the risk of systemic reactions to AIT.

METHODS

Retrospective review of the AIT database of a large, multicenter allergy practice group was conducted between June 1, 2003, and May 31, 2005. Numbers of large local reactions in 258 patients who experienced systemic reactions to AIT were compared with 299 age-, sex-, and sensitivity-matched control patients who did not experience systemic reactions during AIT.

RESULTS

A total of 283 systemic reactions occurred in 258 patients during the surveillance period, which included 661,123 patient visits for 1,108,621 allergy injections. The systemic reaction rate was 0.043% of visits and 0.025% of injections. The large local reaction rate was 35.2% of visits and 19.5% of injections among systemic reactors compared with 8.9% of visits and 5.3% of injections in the controls (P < .001 each). Thus, the odds of experiencing large local reactions were significantly increased among systemic reactors.

CONCLUSIONS

Although AIT is a safe and effective immunomodulatory therapeutic option for the treatment of allergic diseases, patients with increased frequency of large local reactions may have increased risk for future systemic reactions. Identifying additional risk factors remains viable. Recognizing the relevance of frequent large local reactions is important for designing safer protocols for successful AIT in these patients.

Sublingual immunotherapy: the optimism and the issues

The acceptability of sublingual immunotherapy (SLIT) in guidelines or statements has recently increased. SLIT is currently used in Europe, Asia, and Australia for the treatment of allergic respiratory diseases. Four meta-analyses have shown that SLIT is an effective tool for the treatment of patients with asthma and/or rhinitis, and only conflicting results were reported for children with allergic rhinitis. Moreover, it offers logistic advantages and is safe. However, some unmet needs are to be faced, such as the difficulty of manufacturers to achieve the homogeneity of standardized vaccines, the magnitude of their clinical efficacy, and the pivotal question of an early intervention with SLIT in young children with IgE-mediated disorders. Altogether, SLIT has already given convincing results in respiratory diseases both in adults and children. In the future, this route of administration of allergic vaccines may improve even the treatment of patients with IgE-mediated food allergy. These patients indeed deserve better than allergen avoidance. The immunomodulatory treatment of allergic diseases probably has found a new tool; however, a more balanced understanding of this form of allergen immunotherapy is needed. This aim could be achieved through: (1) the improvement of products standardization quality; (2) an attempt to modify in children the natural course of allergic diseases; and (3) new research on mechanisms of action.

Successful sublingual immunotherapy with birch pollen has limited effects on concomitant food allergy to apple and the immune response to the Bet v 1 homolog Mal d 1

BACKGROUND

Cross-reactivity between the major birch pollen allergen, Bet v 1, and the apple protein, Mal d 1, frequently causes food allergy.

OBJECTIVE

To investigate the effects of successful sublingual immunotherapy (SLIT) with birch pollen extract on apple allergy and the immune response to Bet v 1 and Mal d 1.

METHODS

Before and after 1 year of SLIT, Bet v 1-sensitized patients with oral allergy syndrome to apple underwent nasal challenges with birch pollen and double-blind placebo-controlled food challenges with apple. Bet v 1-specific and Mal d 1-specific serum antibody levels and proliferation in PBMCs and allergen-specific T-cell lines (TCLs) were determined. Bet v 1-specific TCLs were mapped for T-cell epitopes.

RESULTS

In 9 patients with improved nasal provocation scores to birch pollen, apple-induced oral allergy syndrome was not significantly reduced. Bet v 1-specific IgE and IgG(4) levels significantly increased. Bet v 1-specific T-cell responses to all epitopes and those cross-reactive with Mal d 1 significantly decreased. However, neither Mal d 1-specific IgE and IgG(4) levels nor Mal d 1-induced T-cell proliferation changed significantly. In contrast, Mal d 1-specific TCLs showed increased responses to Mal d 1 after 1 year of SLIT.

CONCLUSION

This longitudinal study indicates that pollen SLIT does not efficiently alter the immune response to pollen-related food allergens, which may explain why pollen-associated food allergy is frequently not ameliorated by pollen immunotherapy even if respiratory symptoms significantly improve.

CLINICAL IMPLICATIONS

SLIT with birch pollen may have no clinical effect on associated apple allergy.

Novel vaccines and adjuvants for allergen-specific immunotherapy

Advances in genetic engineering and biotechnology, in parallel to increased understanding of disease processes and mechanisms of protective immunity, have facilitated the development of novel rational vaccination concepts for allergy. The spectrum ranges from utilizing recombinant proteins, peptides, new adjuvants, immunomodulatory therapy and DNA vaccines, to use of new application routes for both prophylaxis and treatment of allergic disease. New therapeutic concepts based on patient-tailored immunotherapy using recombinant allergens, anti-IgE and sublingual immunotherapies are slowly moving from the bench to the clinics. The additive value of new treatments above existing therapies must be, however, focused on the improvement of efficacy for long-term cure and increased patient compliance to warrant a broad applicability that has to compete with the symptomatic control of allergic and asthmatic diseases of currently available drugs.