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Melon DE, Pillsbury HC, Harrill WC. Otolaryngic Allergy Patient Journey Mapping: A Framework for Allergy Immunotherapy Adherence. Laryngoscope 2024. [PMID: 39140220 DOI: 10.1002/lary.31690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 05/21/2024] [Accepted: 07/17/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVES Allergen-specific immunotherapy (AIT) is an effective treatment for allergic disease but requires long treatment duration and premature cessation is of significant concern. Drivers of premature cessation remain poorly understood and no predictive models currently exist. We hypothesized that a novel patient journey map and de novo real-time patient electronic health status instruments (eHSIs) could effectively capture patient perceived cost, commitment, and treatment benefit to identify individual patients at risk for premature AIT cessation. STUDY TYPE Cross-Sectional Observational Study. METHODS A single Otolaryngology allergy immunotherapy (AIT) program was studied over 5 years. Instances of premature cessation were classified. An Otolaryngic Allergy Patient Journey Map was developed to identify and target automated, real-time, patient-reported, electronic health status instrument responses. RESULTS Data capture was robust, with 61,406 data points collected and an eHSI survey completion rate of 81.3%. However, based on correlation analysis and logistic regression alone, real-time eHSI responses were not predictive of individual patient premature AIT cessation. A total of 597 AIT patients discontinued treatment prematurely: 64.4% stopping within the first year. Specifically, 74.0%-76.3% of subcutaneous AIT patients and 88.5%-100% of sublingual AIT patients did not complete the minimum recommended treatment duration of 3 years. CONCLUSION Patient journey mapping can aid in the design of longitudinal care models and patient engagement strategies. Yet, eHSI patient responses of perception of AIT cost, benefit, and convenience did not correlate with the likelihood of premature treatment cessation. Our imperfect clinical intuition may not account for the dynamic drivers of premature AIT discontinuation. Future development of predictive tools feed by large patient-centric data sets may be incorporated into routine practice resulting in delivery of a more streamlined and personalized approach with reduced premature AIT cessation, improved outcomes, and reduced health care expenditures. LEVEL OF EVIDENCE NA Laryngoscope, 2024.
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Affiliation(s)
- David E Melon
- Carolina Ear, Nose & Throat-Sinus and Allergy Center, PA, Hickory, North Carolina, U.S.A
| | - Harold C Pillsbury
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, U.S.A
| | - Willard C Harrill
- Carolina Ear, Nose & Throat-Sinus and Allergy Center, PA, Hickory, North Carolina, U.S.A
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Spriggs K, Pfaar O, Pawankar R, Durham S. Is "Maintenance" a Misnomer? A Narrative Framework Setting the Right Expectations of Allergen Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2051-2053. [PMID: 37422324 DOI: 10.1016/j.jaip.2023.02.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/14/2023] [Accepted: 02/21/2023] [Indexed: 03/31/2023]
Affiliation(s)
- Kymble Spriggs
- Department of Allergy and Clinical Immunology, Royal Melbourne Hospital, Parkville, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Philipps-Universität, Marburg, Germany
| | - Ruby Pawankar
- Division of Allergy, Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Stephen Durham
- Allergy and Immunology, National Heart & Lung Institute, Imperial College London, United Kingdom; Royal Brompton Hospital, London, United Kingdom
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Le Mao R, Tromeur C, Lacut K, Couturaud F, Foucaud J, Leroyer C. [Patient expectations in asthma care]. Rev Mal Respir 2021; 38:514-523. [PMID: 34020836 DOI: 10.1016/j.rmr.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/03/2020] [Indexed: 11/27/2022]
Abstract
Asthma, a common chronic disease characterized by variable levels of severity, requires patient-centered management to achieve the best health outcomes. Studies have highlighted the gap between consensus management recommendations and patient goals, which represent a potential source of therapeutic wandering and of poor compliance. Patient expectations are continually evolving and are dependent on knowledge, feelings and individual experience. From this perspective, listening carefully to patients and caregivers makes it easier to exchange views and define common goals. The active participation of patients at all levels of decision-making and transmission of information may improve asthma control and other quality of life parameters.
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Affiliation(s)
- R Le Mao
- EA 3878, CIC Inserm 1412, département de médecine interne, vasculaire et Pneumologie, université de Bretagne Occidentale, centre hospitalo-universitaire de Brest, Brest, France
| | - C Tromeur
- EA 3878, CIC Inserm 1412, département de médecine interne, vasculaire et Pneumologie, université de Bretagne Occidentale, centre hospitalo-universitaire de Brest, Brest, France
| | - K Lacut
- EA 3878, CIC Inserm 1412, département de médecine interne, vasculaire et Pneumologie, université de Bretagne Occidentale, centre hospitalo-universitaire de Brest, Brest, France
| | - F Couturaud
- EA 3878, CIC Inserm 1412, département de médecine interne, vasculaire et Pneumologie, université de Bretagne Occidentale, centre hospitalo-universitaire de Brest, Brest, France
| | - J Foucaud
- Laboratoire éducations et pratiques de santé (UR 3412), université Sorbonne Paris Nord, Paris, France
| | - C Leroyer
- EA 3878, CIC Inserm 1412, département de médecine interne, vasculaire et Pneumologie, université de Bretagne Occidentale, centre hospitalo-universitaire de Brest, Brest, France.
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Devillier P, Demoly P, Molimard M. Allergen immunotherapy: what is the added value of real-world evidence from retrospective claims database studies? Expert Rev Respir Med 2020; 14:445-452. [PMID: 32131649 DOI: 10.1080/17476348.2020.1733417] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Randomized controlled trials (RCTs) show that allergen immunotherapy (AIT) has proven long-term efficacy in patients with allergic rhinitis (AR). However, RCTs have limited generalizability and there is growing recognition that real-world evidence (RWE) is necessary to provide complementary data to those of RCTs, and corroborate their findings. Until recently, data from the real-world setting investigating the benefits of AIT for the treatment of patients with grass and birch pollen-associated AR were sparse, but new retrospective claims database studies from France and Germany have confirmed the sustained benefits of grass and birch pollen AIT in terms of significantly reduced progression of AR and asthma, and a significantly decreased risk of new-onset asthma.Areas covered: Here, we review the value of RWE used alongside data from traditional RCTs, and its potential strengths and limitations, and summarize the findings of the recent RWE studies investigating the benefits of AIT for the management of patients with grass and birch pollen-associated AR.Expert opinion: There is growing recognition of the necessity and value of RWE as a complement to data acquired in RCTs, to better understand the effects of AIT treatments in a broader, more representative patient population, and to help guide clinical decision-making.
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Affiliation(s)
- Philippe Devillier
- UPRES EA 220, Department of Airway Diseases, Hôpital Foch, University of Versailles Saint Quentin, University Paris-Saclay, Suresnes, France
| | - Pascal Demoly
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud De Villeneuve, University Hospital of Montpellier, Montpellier, France and Equipe EPAR - IPLESP, Sorbonne Université, Paris, France
| | - Mathieu Molimard
- Pharmacology Department, University of Bordeaux, INSERM Unit CR1219, Bordeaux, France
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5
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Rizk P, Rodenas M, De Benedetto A. Allergen Immunotherapy and Atopic Dermatitis: the Good, the Bad, and the Unknown. Curr Allergy Asthma Rep 2019; 19:57. [PMID: 31776678 DOI: 10.1007/s11882-019-0893-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW In light of the recent advancements in atopic dermatitis treatment, this review aims to summarize the utility and efficacy of allergy immunotherapy in atopic dermatitis patients. We examine its mechanism, pathophysiology, cost-efficacy, and current guidelines for clinical practice. RECENT FINDINGS The literature supports the use of allergy immunotherapy in atopic conditions such as allergic rhinitis and asthma but insufficient evidence exists to suggest its efficacy in atopic dermatitis. The use of allergy immunotherapy has been shown to provide long-term cost savings in both the USA and the European Union in certain populations but differences in prescribing patterns and manufacturing make it difficult to study its impact on a larger, generalizable scale. Conflicting meta-analyses data and conclusions highlight the need for better, higher quality research to better understand allergy immunotherapy utility in atopic dermatitis.
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Affiliation(s)
- Patrick Rizk
- Department of Dermatology, College of Medicine University of Florida, 4037 NW 86 Terrace, Gainesville, FL, 32606, USA
| | - Mario Rodenas
- Section of Allergy and Clinical Immunology, Division of Rheumatology, Department of Medicine, College of Medicine University of Florida, Gainesville, FL, USA
| | - Anna De Benedetto
- Department of Dermatology, College of Medicine University of Florida, 4037 NW 86 Terrace, Gainesville, FL, 32606, USA.
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Abstract
Adherence to allergen immunotherapy (AIT) is crucial for its efficacy. Subcutaneous AIT requires monthly visits (or more extended in the case of venom immunotherapy), while sublingual AIT is performed with a daily intake of allergen drops. Non-adherence to an AIT schedule and premature discontinuation are common problems. Various studies have shown controversial results on the rate of AIT adherence. The aim of this review is to describe the problem of non-adherence and to offer some evidence-based advice to allergologists on how to increase it. Better patient education at the beginning of treatment, sharing with patients the decision on which type of immunotherapy to select and showing sincere interest in their treatment concerns are some tips that can help to increase adherence. A well organized allergologist time schedule not only increases safety but also offers the possibility of close follow-up and an increase in patient loyalty.
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Affiliation(s)
| | - Nikolas Dietis
- a Medical School, University of Cyprus , Nicosia , Cyprus
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Novak N, Buhl T, Pfaar O. Adherence During Early Allergen Immunotherapy and Strategies to Motivate and Support Patients. EUROPEAN MEDICAL JOURNAL 2018. [DOI: 10.33590/emj/10312545] [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] Open
Abstract
Allergic rhinitis is one of the most common chronic inflammatory conditions, affecting up to 30% of people in Europe. Allergen immunotherapy (AIT) is the only treatment for allergic rhinitis and asthma that has a disease-modifying effect, and it is recommended in European guidelines for use in conjunction with patient education, specific allergen avoidance, and symptomatic pharmacotherapy. Reported AIT adherence rates vary widely but are often low in real-world settings. Factors known to affect adherence are patient, treatment, or physician-related, and vary between healthcare settings. Misconceptions or a lack of AIT knowledge among patients with regard to efficacy and side effects may contribute to high rates of discontinuation observed during the first year of AIT treatment. Interventions to improve patient adherence are multifaceted and should focus on patient education, particularly the provision of accurate information regarding adverse effects of AIT and when to expect an improvement in symptoms, patient-support programmes, and the use of regular eHealth reminders via a telephone call, text message, or social media. Serum-based biomarkers also have the potential to play a role in evaluating early response to AIT and in monitoring treatment adherence in clinical practice. In this review, the authors explore barriers to continuation with AIT and discuss initiatives to motivate and support patients through the challenging early months of treatment, prior to the onset of clinical effect and when side effects are most common, to encourage long-term adherence to therapy and achieve optimal patient outcomes.
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Affiliation(s)
- Natalija Novak
- Department of Dermatology and Allergy, University of Bonn Medical Center, Bonn, Germany
| | - Timo Buhl
- Department of Dermatology, Venereology, and Allergology, University Medical Center, Georg-August University, Göttingen, Germany; Lower Saxony Institute of Occupational Dermatology, University Medical Center Göttingen, Göttingen and University of Osnabrück, Osnabrück, Germany
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Center for Rhinology and Allergology, Wiesbaden, Germany
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Chivato T, Álvarez-Calderón P, Panizo C, Abengozar R, Alías C, Al-Baech A, Arias-Irigoyen J, Caballero MJ, Conill L, de Miguel S, Laguna R, Martínez-Benazet J, Matoses F, Martínez-Alonso JC, Mendizábal L, Pérez-Carral C, Puerto C, Serra-Batllés J, Vélez A, Vicente J, de la Torre F. Clinical management, expectations, and satisfaction of patients with moderate to severe allergic rhinoconjunctivitis treated with SQ-standardized grass-allergen tablet under routine clinical practice conditions in Spain. Clin Mol Allergy 2017; 15:1. [PMID: 28096738 PMCID: PMC5234098 DOI: 10.1186/s12948-016-0057-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 12/18/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Sublingual immunotherapy has been proven as a well-tolerated and effective treatment for allergic rhinitis. Within this type of treatment, GRAZAX® is the most documented product in terms of safety and efficacy. The objective of this study was to identify the patients' expectations and level of treatment satisfaction, as well as the clinical management of patients with moderate/severe allergic rhinoconjunctivitis treated with GRAZAX®. METHODS This was a non-interventional, observational, multi-centre, open-label study involving a total of 131 adult patients aged 18-66 years with confirmed diagnosis of grass-allergy and initiated treatment with GRAZAX® between June 2010 and April 2011. RESULTS In the pollen season after starting treatment, 56.6% of patients stated that their symptoms were much less/less intense, 86% needed less symptomatic medication for control of their symptoms, and 74.4% manifested to have improved (quite/a lot) as regards their allergic disease since treatment was initiated as compared with previous grass pollen season. The patient satisfaction with GRAZAX® was measured using a visual analogue scale (VAS) between 0 (minimum satisfaction) and 100 (maximum satisfaction) comprising five different items: effectiveness, tolerability, cost, convenience and overall satisfaction. The results obtained for each item were [mean (SD)]: 74.7 (18.1), 70.3 (36.1), 39.3 (25.8), 86.2 (12.6), 78.4 (15.8) respectively. The patient's level of satisfaction is highly influenced, especially in terms of assessment of effectiveness, tolerability and convenience, by the information provided by the specialist. CONCLUSIONS In summary, it can be concluded that improved communication leads to increased patient knowledge, greater patient compliance, and increased patient satisfaction.
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Affiliation(s)
- Tomás Chivato
- Decanato. Facultad de Medicina, Facultad de Medicina Universidad CEU San Pablo. Grupo Hospitales HM, Avda. Montepríncipe s/n, Boadilla del Monte, 28668 Madrid, Spain
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Nam YH, Lee SK. Physician's recommendation and explanation is important in the initiation and maintenance of allergen immunotherapy. Patient Prefer Adherence 2017; 11:381-387. [PMID: 28424541 PMCID: PMC5344443 DOI: 10.2147/ppa.s118368] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Allergen immunotherapy (AIT) is currently the only immune-modifying treatment for allergic disease. The clinical efficacy of AIT for the treatment of allergic rhinitis and bronchial asthma is well documented. However, many factors including inconvenience, cost, side effects, and adherence influence the initiation and persistence of AIT, and patients lack knowledge and have misconceptions about the treatment. OBJECTIVE We evaluated the knowledge, attitude, and satisfaction of patients who received AIT. METHODS We conducted a retrospective analysis of medical records of 167 patients who received AIT, and compared the clinical characteristics between conventional immunotherapy (CIT) and rush immunotherapy (RIT). Ninety-nine patients completed a questionnaire survey. RESULTS Of the total 167 patients, 65.9% (n=110) were treated with CIT and 34.1% (n=57) with RIT. More than half of the patients (68.7%) initiated AIT according to their physician's recommendation. Frequent hospital visits were the main barrier for persistence of AIT. RIT patients were younger and started AIT earlier than CIT patients. The majority (77%) of patients who received AIT were satisfied, with no significant difference between CIT and RIT groups. RIT and fewer allergens used in AIT were related with preference for AIT to pharmacotherapy. The longer duration of AIT was associated with higher treatment satisfaction. CONCLUSION A majority of patients initiated AIT by the physician's recommendation and were satisfied with treatment regardless of CIT or RIT schedule. Adequate patient education and a strict patient-physician relationship in early AIT period could improve the effectiveness and compliance of AIT.
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Affiliation(s)
- Young-Hee Nam
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Soo-Keol Lee
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Republic of Korea
- Correspondence: Soo-Keol Lee, Department of Internal Medicine, College of Medicine, Dong-A University, 26 Daesingongwon-ro, Seo-gu, Busan 602-715, Republic of Korea, Tel +82 51 240 2810, Fax +82 51 242 5852, Email
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10
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Sánchez J. Adherence to allergen immunotherapy improves when patients choose the route of administration: Subcutaneous or sublingual. Allergol Immunopathol (Madr) 2015; 43:436-41. [PMID: 25201758 DOI: 10.1016/j.aller.2014.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 04/20/2014] [Accepted: 04/24/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Immunotherapy has shown to be an effective treatment for the management of some IgE-mediated allergies. However, due to its long duration, a high number of patients withdraw from it before completion. OBJECTIVE Explore if allowing patients to select the route of immunotherapy, educational sessions and strict follow-up could improve treatment compliance. METHODS Patients consulting allergy service were divided into two groups; if they chose the route of administration of immunotherapy, they were selected for the active group; if their physician decided, they were selected for the control group. All patients had to attend the allergy service monthly for control. Before the first application of immunotherapy, all patients received an educative session about the benefits and risks of the treatment. Patients in the active group received an additional session about subcutaneous and sublingual routes and they chose the most appropriate according to their personal characteristics. RESULTS A total of 204 patients were in the active group and 103 were included in the control group. At six months, a total of 46 patients withdrew from immunotherapy during follow-up, 24 (11%) in the active group and 22 (21%) in the control group (p=0.02). In the active group we observed no statistically significant difference in adherence between those who preferred subcutaneous or sublingual immunotherapy; however in the control group, the drop out of sublingual immunotherapy was significantly higher than those who received subcutaneous (p=0.05). CONCLUSION Educational sessions, strict follow-up and considering personal preferences of patients could improve adherence to allergen immunotherapy.
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Papadopoulos NG, Bernstein JA, Demoly P, Dykewicz M, Fokkens W, Hellings PW, Peters AT, Rondon C, Togias A, Cox LS. Phenotypes and endotypes of rhinitis and their impact on management: a PRACTALL report. Allergy 2015; 70:474-94. [PMID: 25620381 DOI: 10.1111/all.12573] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 12/29/2022]
Abstract
Rhinitis is an umbrella term that encompasses many different subtypes, several of which still elude complete characterization. The concept of phenotyping, being the definition of disease subtypes on the basis of clinical presentation, has been well established in the last decade. Classification of rhinitis entities on the basis of phenotypes has facilitated their characterization and has helped practicing clinicians to efficiently approach rhinitis patients. Recently, the concept of endotypes, that is, the definition of disease subtypes on the basis of underlying pathophysiology, has emerged. Phenotypes/endotypes are dynamic, overlapping, and may evolve into one another, thus rendering clear-cut definitions difficult. Nevertheless, a phenotype-/endotype-based classification approach could lead toward the application of stratified and personalized medicine in the rhinitis field. In this PRACTALL document, rhinitis phenotypes and endotypes are described, and rhinitis diagnosis and management approaches focusing on those phenotypes/endotypes are presented and discussed. We emphasize the concept of control-based management, which transcends all rhinitis subtypes.
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Affiliation(s)
- N G Papadopoulos
- Centre for Paediatrics and Child Health, Institute of Human Development, University of Manchester, Manchester, UK; Allergy Department, 2nd Paediatric Clinic, University of Athens, Athens, Greece
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Senna G, Caminati M, Lockey RF. Allergen Immunotherapy Adherence in the Real World: How Bad Is It and How Can It Be Improved? CURRENT TREATMENT OPTIONS IN ALLERGY 2014. [DOI: 10.1007/s40521-014-0037-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Cox LS, Hankin C, Lockey R. Allergy immunotherapy adherence and delivery route: location does not matter. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:156-60. [PMID: 24607042 DOI: 10.1016/j.jaip.2014.01.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Accepted: 01/26/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Linda S Cox
- Allergy and Asthma Center, Ft Lauderdale, Fla.
| | | | - Richard Lockey
- University of South Florida Morsani College of Medicine, Tampa, Fla
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Makatsori M, Scadding GW, Lombardo C, Bisoffi G, Ridolo E, Durham SR, Senna G. Dropouts in sublingual allergen immunotherapy trials - a systematic review. Allergy 2014; 69:571-80. [PMID: 24673502 DOI: 10.1111/all.12385] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2014] [Indexed: 11/27/2022]
Abstract
Participant dropouts can reduce the power of allergen immunotherapy clinical trials. Evaluation of the dropout rate and reasons for dropout are important not only in the planning of clinical studies but are also relevant for adherence to immunotherapy in daily clinical practice. A systematic review was carried out in order to establish the overall dropout rate among published double-blind, placebo-controlled randomized clinical trials of sublingual immunotherapy for respiratory allergic diseases. Dropouts were analysed in regards to allergen, formulation, treatment schedule, participant age, study size, number of centres and type of allergic disease. Relative dropout rates in placebo and active groups as well as reasons for dropout were also assessed. A total of 81 studies, comprising 9998 patients, were included. Dropout rates in sublingual immunotherapy controlled studies do not appear to be a major problem with a composite dropout percentage of 14% (95% CI:11.9-16). Furthermore, they are not different for active compared to placebo-treated participants. This lends support to the positive clinical outcomes seen in meta-analyses of these trials.
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Affiliation(s)
- M. Makatsori
- Allergy Department; Royal Brompton & Harefield NHS Foundation Trust; London UK
- National Heart & Lung Institute; Allergy & Clinical Immunology; Imperial College London; London UK
| | - G. W. Scadding
- Allergy Department; Royal Brompton & Harefield NHS Foundation Trust; London UK
- National Heart & Lung Institute; Allergy & Clinical Immunology; Imperial College London; London UK
| | - C. Lombardo
- Verona University Hospital; Allergy Unit; Verona Italy
| | - G. Bisoffi
- Verona University Hospital; Research Support Unit and Biostatistics; Verona
| | - E. Ridolo
- Department of Clinical and Experimental Medicine; University of Parma; Parma Italy
| | - S. R. Durham
- Allergy Department; Royal Brompton & Harefield NHS Foundation Trust; London UK
- National Heart & Lung Institute; Allergy & Clinical Immunology; Imperial College London; London UK
| | - G. Senna
- Verona University Hospital; Allergy Unit; Verona Italy
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15
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Canonica GW, Cox L, Pawankar R, Baena-Cagnani CE, Blaiss M, Bonini S, Bousquet J, Calderón M, Compalati E, Durham SR, van Wijk RG, Larenas-Linnemann D, Nelson H, Passalacqua G, Pfaar O, Rosário N, Ryan D, Rosenwasser L, Schmid-Grendelmeier P, Senna G, Valovirta E, Van Bever H, Vichyanond P, Wahn U, Yusuf O. Sublingual immunotherapy: World Allergy Organization position paper 2013 update. World Allergy Organ J 2014; 7:6. [PMID: 24679069 PMCID: PMC3983904 DOI: 10.1186/1939-4551-7-6] [Citation(s) in RCA: 325] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 02/07/2014] [Indexed: 02/07/2023] Open
Abstract
We have prepared this document, "Sublingual Immunotherapy: World Allergy Organization Position Paper 2013 Update", according to the evidence-based criteria, revising and updating chapters of the originally published paper, "Sublingual Immunotherapy: World Allergy Organization Position Paper 2009", available at http://www.waojournal.org. Namely, these comprise: "Mechanisms of sublingual immunotherapy;" "Clinical efficacy of sublingual immunotherapy" - reporting all the data of all controlled trials published after 2009; "Safety of sublingual immunotherapy" - with the recently published Grading System for adverse reactions; "Impact of sublingual immunotherapy on the natural history of respiratory allergy" - with the relevant evidences published since 2009; "Efficacy of SLIT in children" - with detailed analysis of all the studies; "Definition of SLIT patient selection" - reporting the criteria for eligibility to sublingual immunotherapy; "The future of immunotherapy in the community care setting"; "Methodology of clinical trials according to the current scientific and regulatory standards"; and "Guideline development: from evidence-based medicine to patients' views" - including the evolution of the methods to make clinical recommendations.Additionally, we have added new chapters to cover a few emerging crucial topics: "Practical aspects of schedules and dosages and counseling for adherence" - which is crucial in clinical practice for all treatments; "Perspectives and new approaches" - including recombinant allergens, adjuvants, modified allergens, and the concept of validity of the single products. Furthermore, "Raising public awareness about sublingual immunotherapy", as a need for our patients, and strategies to increase awareness of allergen immunotherapy (AIT) among patients, the medical community, all healthcare stakeholders, and public opinion, are also reported in detail.
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Affiliation(s)
- Giorgio Walter Canonica
- Respiratory and Allergy Clinic, DIMI—Department of Internal Medicine, University of Genoa, IRCCS Aou San Martino, Largo Rosanna Benzi 10, Genoa 1-16132, Italy
| | - Linda Cox
- Department of Medicine, Nova Southeastern University, College of Osteopathic Medicine, Davie Florida, USA
| | - Ruby Pawankar
- Division of Allergy, Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Carlos E Baena-Cagnani
- Research Center for Respiratory Medicine (CIMER), Catholic University, Fundación LIBRA, Córdoba, Argentina
| | - Michael Blaiss
- Department of Pediatrics and Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sergio Bonini
- Department of Medicine, Second University of Naples, Institute of Translational Pharmacology, Italian National Research Council, Rome, Italy
| | - Jean Bousquet
- Centre Hospitalier Regional Universitaire de Montpellier, Université de Montpellier, Montpellier, France
| | - Moises Calderón
- Section of Allergy and Clinical Immunology, Imperial College of London, National Heart and Lung Institute, Royal Brompton Hospital, London, UK
| | - Enrico Compalati
- Allergy and Respiratory Diseases Clinic, Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Stephen R Durham
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College of London, London, UK
| | - Roy Gerth van Wijk
- Department of Allergology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Harold Nelson
- National Jewish Health, University of Colorado – Denver School of Medicine, Denver, Colorado, USA
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino IST, University of Genoa, Genova, Italy
| | - Oliver Pfaar
- Center for Rhinology and Allergology Wiesbaden, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Nelson Rosário
- Pediatric Allergy and Immunology Division, Hospital de Clínicas, Federal University of Parana, Curitiba, Brazil
| | - Dermot Ryan
- Academic Centre of Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Lanny Rosenwasser
- Children’s Mercy Hospital, University of Missouri – Kansas City School of Medicine, Kansas City, Missouri
| | | | | | - Erkka Valovirta
- Department of Clinical Allergology and Pulmonary Diseases, University of Turku, Finland, and Allergy Clinic, Terveystalo, Turku, Finland
| | - Hugo Van Bever
- Department of Paediatrics, University Children’s Medical Institute, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Pakit Vichyanond
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ulrich Wahn
- Department of Pediatric Pneumology and Immunology, Charité, Humboldt University, Berlin, Germany
| | - Osman Yusuf
- The Allergy and Asthma Institute, Islamabad, Pakistan
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Abstract
PURPOSE OF REVIEW This article reviews the literature on patient adherence to two different approaches to allergen-specific immunotherapy for allergic disease. Factors related to adherence in general, as well as the various methods used to measure adherence, will be discussed. RECENT FINDINGS Although a complex interaction of factors related to both the physician and the patient influence the adherence to a particular therapeutic regimen, effective communication between these two parties and the simplicity of the regimen are frequently noted to be of primary importance. Variability with respect to the definition of adherence, the method of measuring adherence, and the length of the measuring period has resulted in a wide range of adherence rates to allergy immunotherapy reported in the literature. Patients most often site inconvenience, side-effects, and poor efficacy as reasons for discontinuing allergy immunotherapy. SUMMARY Adherence to therapy not only improves individual patient outcomes, but also helps determine the best treatment modalities and reduces the burden of disease on society. As new methods of delivering immunotherapy are being developed, such as allergy immunotherapy tablets and oral mucosal immunotherapy, the factors associated with patient adherence should be carefully considered.
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Caminati M, Dama A, Schiappoli M, Senna G. Balancing efficacy against safety in sublingual immunotherapy with inhalant allergens: what is the best approach? Expert Rev Clin Immunol 2013; 9:937-47. [PMID: 24099148 DOI: 10.1586/1744666x.2013.837262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Over the last 20 years, studies and clinical trials have demonstrated efficacy, safety and cost-effectiveness of sublingual immunotherapy (SLIT) for respiratory allergic diseases. Nevertheless, it seems to be mostly used as a second-line therapeutic option, and adherence to treatment is not always optimal. Selective literature research was done in Medline and PubMed, including guidelines, position papers and Cochrane meta-analyses concerning SLIT in adult patients. The most recent reviews confirm SLIT as viable and efficacious treatment especially for allergic rhinitis, even if the optimal dosage, duration, schedule are not clearly established for most of the products. Despite an optimal safety profile, tolerability and patient-reported outcomes concerning SLIT have received poor attention until now. Recently, new tools have been specifically developed in order to investigate these aspects. Regular assessment of tolerability profile and SLIT-related patient-reported outcomes will allow balancing efficacy with tolerability and all the other patient-related variables that may affect treatment effectiveness beyond its efficacy.
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Affiliation(s)
- Marco Caminati
- Allergy Unit, Verona University Hospital, Piazzale Aristide Stefani 1, 37126 Verona, Italy
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Savi E, Peveri S, Senna G, Passalacqua G. Causes of SLIT discontinuation and strategies to improve the adherence: a pragmatic approach. Allergy 2013; 68:1193-5. [PMID: 23915164 DOI: 10.1111/all.12198] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2013] [Indexed: 11/28/2022]
Abstract
Sublingual immunotherapy (SLIT) is often discontinued, and many patients do not renew the prescription. We evaluated the reasons for discontinuation and set up an educational/follow-up plan to improve the adherence. In a first phase, the adherence at 4 months was directly assessed. Based on those results, an action plan (education, frequent contacts, and strictly scheduled visits) was developed and tested in other patients. A group of matched patients did not undergo the follow-up plan (controls). In the first phase, involving 252 subjects, at 4 months, there were 30% dropouts, mainly due to side-effects. In the second phase, 149 patients underwent education/follow-up and 90 received no intervention. In the first group, discontinuations at 4 months were 5%, vs 18% in the controls (P = 0.01). After one year, 12% of patients were lost in the first group and 35% in the control group (P < 0.001). An adequate education and a strict follow-up can significantly reduce SLIT's discontinuations.
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Affiliation(s)
- E. Savi
- Allergy Unit; G. da Saliceto Hospital; Piacenza; Italy
| | - S. Peveri
- Allergy Unit; G. da Saliceto Hospital; Piacenza; Italy
| | - G. Senna
- Allergy Unit; Azienda Ospedaliera Universitaria di Verona; Verona; Italy
| | - G. Passalacqua
- Allergy and Respiratory Diseases; IRCCS San Martino-IST-University of Genoa; Genoa; Italy
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Baiardini I, Puggioni F, Menoni S, Boot JD, Diamant Z, Braido F, Canonica GW. Patient knowledge, perceptions, expectations and satisfaction on allergen-specific immunotherapy: a survey. Respir Med 2012; 107:361-7. [PMID: 23218454 DOI: 10.1016/j.rmed.2012.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 11/02/2012] [Accepted: 11/07/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Assessing patient's perspective provides useful information enabling a customized approach which has been advocated by current guidelines. In this multicentre cross-sectional study we evaluated personal viewpoints on allergen-specific immunotherapy (SIT) in patients treated with subcutaneous (SCIT) or sublingual (SLIT) immunotherapy. METHODS A survey of 28 questions assessing patient's knowledge, perceptions, expectations and satisfaction was developed by an expert panel and was applied by physicians from allergology centres in patients with respiratory allergy treated with SIT. Treating physicians independently reported their satisfaction level regarding SIT for each patient. RESULTS Fully completed surveys from 434 patients (55.3% male; 66.7% poly-sensitized, 74% SLIT) were analysed. Mean duration of SIT was 2.5 years with different allergens. Most patients acquired their SIT knowledge from their physician (95%) and consequently, their physicians' opinion in their choice to start with SIT was important. Most patients perceived SIT to be safe and easy to integrate into their daily routine. The main motivations for SIT were its supposed potential to alter the course of the disease (45.7%), less need of (28.2%), or dissatisfaction with current pharmacotherapy (19.3%). Both patients' and physicians' satisfaction was high (VAS-scores 74/100 and 78/100, respectively) and showed a significant correlation (SCIT: r=0.612; SLIT: r=0.608). No major difference was found in patients' answers based on the level of education. CONCLUSION In this real life study evaluating different aspects of patient's perspective on SIT, the majority of patients had an adequate level of knowledge, perceptions, expectations and satisfaction about SIT, which corresponded well with the physician's perceptions and satisfaction. Our data warrant the use of patient's perspectives on chronic SIT treatment.
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Affiliation(s)
- Ilaria Baiardini
- Allergy and Respiratory Diseases Clinic, DIMI, University of Genoa, IRCCS AOU San Martino-IST, Genova, Italy
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20
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Hsu NM, Reisacher WR. A comparison of attrition rates in patients undergoing sublingual immunotherapy vs subcutaneous immunotherapy. Int Forum Allergy Rhinol 2012; 2:280-4. [PMID: 22434716 DOI: 10.1002/alr.21037] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Revised: 12/29/2011] [Accepted: 02/07/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND Effective allergy immunotherapy (IT) requires patient compliance. Numerous studies have shown high noncompliance rates in patients undergoing IT. For patients enrolled in subcutaneous IT (SCIT), noncompliance rates were noted to range from 11% to 50%, whereas sublingual IT (SLIT) patients had noncompliance rates ranging from 3% to 25%. Comparing noncompliance rates is difficult because noncompliance in SCIT is defined as withdrawal from therapy, whereas in SLIT it is considered poor adherence to daily administration. The aim of this study was to compare attrition rates in patients enrolled in SCIT vs SLIT, as well as major factors leading to termination of IT. METHODS We retrospectively compared attrition rates, IT duration, and reasons for termination between patients enrolled in SCIT (n = 139) and SLIT (n = 78), over a 4-year period. RESULTS Attrition rates for SCIT and SLIT were 45% and 41%, respectively (p = 0.669). No significant difference in duration of IT was observed between the groups (≤1 month, p = 0.079; 1-2 months, p = 0.486; 2-3 months, p = 0.165; 3-6 months, p = 0.575; 6-12 months, p = 0.361; 12-24 months, p = 1.000; and ≥24 months, p = 0.258). Among reasons cited for discontinuing IT, SCIT patients reported inconvenience (p = 0.001), whereas SLIT patients indicated efficacy concerns (p = 0.022) as the major basis for withdrawal. CONCLUSION No significant difference was observed in attrition rates between SCIT and SLIT. While there was no significant difference in duration of IT prior to withdrawal, there was a trend toward earlier withdrawal in SCIT patients. The reasons for withdrawal, however, were considerably different between the 2 groups.
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Affiliation(s)
- Nicole M Hsu
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY, USA.
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21
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Didier A, Chartier A, Démonet G. Immunothérapie spécifique sublinguale : ODISSEE un an après. Résultats préliminaires d’ODISSEE (Observatoire de l’indication, du choix de prise en charge par Immunothérapie spécifique sublinguale ainsi que de l’adhésion et de l’observance au traitement chez les patients souffrant d’allergie respiratoire – rhinite et/ou conjonctivite et/ou asthme allergique). REVUE FRANCAISE D ALLERGOLOGIE 2011. [DOI: 10.1016/j.reval.2011.07.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
PURPOSE OF REVIEW The main feature of allergen-specific immunotherapy is its capacity to modify the natural history of the disease, reducing the development of asthma and new sensitizations after 3-4 years of treatment. For this reason, adherence to the therapy is mandatory, as happens for all chronic medical treatment. RECENT FINDINGS Though subcutaneous immunotherapy is administered directly by physicians, the rate of adherence is surprisingly low, at less than 70%. The explanations for a poor subcutaneous immunotherapy adherence include inconvenience, lack of efficacy, costs and loss of working hours.Local nasal immunotherapy has a very low adherence rate (27%), due to the local nasal side effects.For sublingual immunotherapy, data are available from clinical trials and postmarketing surveys, which are favourable overall (rates of compliance >75%). Cost was the most common reason for discontinuation, followed by inconvenience, feeling of inefficacy and side effects. SUMMARY Studies addressing the adherence to allergen-specific immunotherapy in literature are lacking. In real life, costs and patient education are crucial issues in conditioning adherence to this treatment. Reduction of costs and more efforts in education of patients and also specialists may improve the adherence to immunotherapy.
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Incorvaia C, Mauro M, Ridolo E, Puccinelli P, Liuzzo M, Scurati S, Frati F. Patient's compliance with allergen immunotherapy. Patient Prefer Adherence 2008; 2:247-51. [PMID: 19920970 PMCID: PMC2770419 DOI: 10.2147/ppa.s3806] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Allergen immunotherapy (IT) is an effective treatment of respiratory allergy, but requires strict rules of performance. This makes compliance particularly relevant, but thus far only a few studies have investigated this issue. METHODS We reviewed all the available articles on compliance and adherence with IT in its different forms of administration, ie, subcutaneous (SCIT), sublingual (SLIT), and local nasal (LNIT). RESULTS Early studies, when only SCIT was available, reported a low compliance, ranging from 45% to 60%, but the demanding schedules used, with very frequent injections, accounted for this outcome, as shown by patients' recognition of inconvenience as the major cause of noncompliance. The most recent studies reported a good compliance, estimated in 75% to 90%, to both SCIT and SLIT, inconvenience remaining the major cause of noncompliance, followed by cost of the treatment. The only study addressing LNIT found a very poor compliance (27%), the major cause being the side effects, with repeated nasal reactions to the allergen extract. CONCLUSIONS Adequate education of patients and optimization of administration schedules, with fine balancing between dose effectiveness and cost, are the factors most likely to achieve further improvement of compliance with IT.
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Affiliation(s)
| | | | - Erminia Ridolo
- University Department of Clinical Sciences, Parma, Italy
| | | | | | - Silvia Scurati
- Medical and Scientific Department, Stallergenes, Milan, Italy
| | - Franco Frati
- Medical and Scientific Department, Stallergenes, Milan, Italy
- Pediatrics, University Department of Medical and Surgical Specialty and Public Health, Perugia, Italy
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Kae Kintner E. Testing the acceptance of asthma model with children and adolescents. West J Nurs Res 2007; 29:410-31. [PMID: 17538124 DOI: 10.1177/0193945907299657] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Older school-age children and early adolescents with asthma have demonstrated and verbalized difficulty in accepting their condition. Although researchers have explored adult acceptance, few have explored child or adolescent acceptance. The purpose was to explore the fit of the data to a specified latent variable acceptance of asthma model. School-age children and early adolescents (N = 118), ages 9 to 14 years enrolled in Grades 4 to 9, diagnosed with asthma and their parents completed self-report instruments. EQS was used for structural equation modeling analyses. The specified model was a good fit to the data and accounted for more than 70% in the explained variance of vigilance, 30% of participation in life activities, 25% of taking control, and 20% of asthma health behaviors. Support for the model possess implications for development of theory-based education and counseling interventions to support participation in life activities by targeting cognitive, behavioral, and psychosocial aspects of living with the asthma.
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Affiliation(s)
- C Lombardi
- Department of Internal Medicine Padiglione Maragliano, Genoa, Italy
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26
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Rathkopf MM, Quinn JM, Proffer DL, Napoli DC. Patient knowledge of immunotherapy before and after an educational intervention: a comparison of 2 methods. Ann Allergy Asthma Immunol 2004; 93:147-53. [PMID: 15328674 DOI: 10.1016/s1081-1206(10)61467-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Immunotherapy is an invaluable therapy for allergic asthma, allergic rhinitis, and hymenoptera hypersensitivity. It is, however, not without risks. OBJECTIVES To examine patient knowledge regarding immunotherapy and to determine the most effective educational method to improve their knowledge by answering the following questions: Before educational intervention, what is the current knowledge level regarding allergy vaccinations of patients receiving immunotherapy? What effect does an educational encounter have on that level of knowledge? Which educational intervention--a one-on-one session vs a handout--if either, increases patient knowledge more? METHODS An original, self-administered patient questionnaire was distributed to all patients receiving immunotherapy. Patients were randomly assigned to a control group, an intervention group that received an educational handout monthly for 2 months, or an intervention group that had a one-on-one educational session with a physician or nurse practitioner. After 3 months, all patients completed an identical follow-up questionnaire. Pretest and posttest scores were compared for each group and among the different groups to determine which method was more effective. Repeated-measures analysis of variance was used to determine the effect of instruction type on differences in pretest and posttest scores. RESULTS All 3 groups significantly improved their mean overall questionnaire scores (P < .001). The amount of change was greater in the intervention groups than in the control group, but it did not reach statistical significance (P = .59). CONCLUSIONS Baseline immunotherapy knowledge of allergy vaccination patients was better than expected, and further educational interventions did not significantly improve this knowledge.
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Affiliation(s)
- Melinda M Rathkopf
- Department of Allergy/Immunology, Wilford Hall Medical Center, Lackland AFB, Texas 78236, USA.
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Current World Literature. Curr Opin Allergy Clin Immunol 2004. [DOI: 10.1097/01.all.0000136752.28324.26] [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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Bousquet J. Written information plans for patients receiving immunotherapy. Ann Allergy Asthma Immunol 2004; 91:423-4. [PMID: 14692423 DOI: 10.1016/s1081-1206(10)61508-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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