1
|
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.
Collapse
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.
| |
Collapse
|
2
|
Gazi U, Bahceciler NN. Immune mechanisms induced by sublingual immunotherapy in allergic respiratory diseases. Clin Exp Immunol 2022; 209:262-269. [PMID: 35975953 PMCID: PMC9521660 DOI: 10.1093/cei/uxac075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/22/2022] [Accepted: 08/15/2022] [Indexed: 01/25/2023] Open
Abstract
Allergic respiratory diseases (ARDs) are still a major burden on global public health. Sublingual immunotherapy (SLIT) is a mode of allergen immunotherapy (AIT) which involves administration of the allergen under the tongue, and benefits from tolerogenic properties of the oral mucosa. Studies revealed reduced levels of eosinophilia and eosinophil-dominated inflammation in airways of both animals and humans after SLIT. SLIT was also suggested to lower basophil responsiveness and innate lymphoid cell-2 function in blood samples collected from patients with ARD. Moreover, apart from shifting pathogenic type 2 (TH2) to a type 1 (TH1) and protective regulatory (Treg) polarization of helper T-cell immune response, antibody isotype switch from IgE to IgG1, IgG2, IgG4 and IgA was also reported in patients with ARD receiving SLIT. Today, the literature on SLIT-mediated activities is still scarce and more studies are required to further enlighten the mechanisms utilized by SLIT for the induction of tolerance. The aim of this review is to summarize the current knowledge about the immune-regulatory mechanisms induced by SLIT against ARDs.
Collapse
Affiliation(s)
- Umut Gazi
- Department of Medical Microbiology and Clinical Microbiology, Faculty of Medicine, Near East University, Nicosia, Cyprus
| | - Nerin Nadir Bahceciler
- Department of Pediatrics, Division of Allergy and Immunology, Faculty of Medicine, Near East University, Nicosia, Cyprus
| |
Collapse
|
3
|
Sialakis C, Antoniou Sialaki P, Frantzana A, Iliadis C, Ouzounakis P, Kourkouta L. House Dust Mite and Grass Pollen Allergen Extracts for Seasonal Allergic Rhinitis Treatment: A Systematic Review. Cureus 2022; 14:e27289. [PMID: 36039254 PMCID: PMC9407027 DOI: 10.7759/cureus.27289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/05/2022] Open
|
4
|
Shamji MH, Layhadi JA, Sharif H, Penagos M, Durham SR. Immunological Responses and Biomarkers for Allergen-Specific Immunotherapy Against Inhaled Allergens. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1769-1778. [PMID: 33781958 DOI: 10.1016/j.jaip.2021.03.029] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/22/2021] [Accepted: 03/22/2021] [Indexed: 12/15/2022]
Abstract
Long-term efficacy that occurs with allergen immunotherapy of proven value is associated with decreases in IgE-dependent activation of mast cells and tissue eosinophilia. This suppression of type 2 immunity is accompanied by early induction of regulatory T cells, immune deviation in favor of TH1 responses, and induction of local and systemic IgG, IgG4, and IgA antibodies. These "protective" antibodies can inhibit allergen-IgE complex formation and consequent mast cell triggering and IgE-facilitated TH2-cell activation. Recent studies have highlighted the importance of innate responses mediated by type 2 dendritic cells and innate lymphoid cells in allergic inflammation. These cell types are under the regulation of cytokines such as thymic stromal lymphopoietin and IL-33 derived from the respiratory epithelium. Novel subsets of regulatory cells induced by immunotherapy include IL-35-producing regulatory T cells, regulatory B cells, a subset of T follicular regulatory cells, and IL-10-producing group 2 innate lymphoid cells. These mechanisms point to biomarkers that require testing for their ability to predict clinical response to immunotherapy and to inform novel approaches for better efficacy, safety, and long-term tolerance.
Collapse
Affiliation(s)
- Mohamed H Shamji
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, Imperial College London, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom.
| | - Janice A Layhadi
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, Imperial College London, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom
| | - Hanisah Sharif
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, Imperial College London, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom; PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, Brunei
| | - Martin Penagos
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Stephen R Durham
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Department of National Heart and Lung Institute, Imperial College London, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, United Kingdom
| |
Collapse
|
5
|
Sublingual Immunotherapy: How Sublingual Allergen Administration Heals Allergic Diseases; Current Perspective about the Mode of Action. Pathogens 2021; 10:pathogens10020147. [PMID: 33540540 PMCID: PMC7912807 DOI: 10.3390/pathogens10020147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 01/09/2023] Open
Abstract
Owing to the successful application of sublingual immunotherapy (SLIT), allergen immunotherapy (AIT) has become one of the leading treatments for allergic diseases. Similar to the case with other AITs, such as subcutaneous and oral immunotherapies, not only the alleviation of allergic symptoms, but also the curing of the diseases can be expected in patients undergoing SLIT. However, how and why such strong efficacy is obtained by SLIT, in which allergens are simply administered under the tongue, is not clearly known. Various potential mechanisms, including the induction of blocking antibodies, T cell tolerance, regulatory B and T cells, CD103-CD11b+ classical dendritic cells, and CD206+ macrophages, and the reduction of innate lymphoid cells, mast cells, and basophils, have been suggested. Recently, through a comparative analysis between high- and non-responder patients of SLIT, we have successfully proposed several novel mechanisms. Here, we introduce our recent findings and summarize the current understanding of the mechanisms underlying the strong efficacy of SLIT.
Collapse
|
6
|
Calderon MA, Waserman S, Bernstein DI, Demoly P, Douglass J, Gagnon R, Katelaris CH, Kim H, Nelson HS, Okamoto Y, Okubo K, Virchow JC, DuBuske L, Casale TB, Canonica GW, Nolte H. Clinical Practice of Allergen Immunotherapy for Allergic Rhinoconjunctivitis and Asthma: An Expert Panel Report. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2920-2936.e1. [PMID: 32422372 DOI: 10.1016/j.jaip.2020.04.071] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/13/2020] [Accepted: 04/20/2020] [Indexed: 12/18/2022]
Abstract
Allergen immunotherapy (AIT) reduces symptoms and medication use associated with allergic rhinitis with or without conjunctivitis and allergic asthma. Although several AIT guidelines exist, there remain unanswered questions about AIT that are relevant to everyday practice. Our objective was to prepare an evidence-based overview addressing the practical aspects of AIT in clinical practice based on published evidence and the experience of international experts in the field. Topics covered include interpretation and translation of clinical trial data into everyday clinical practice (eg, allergen doses and treatment duration), assessment of risk and treatment of local and systemic allergic reactions, recommendations for improvement of AIT guidelines, and identification of appropriate data for seeking regulatory approval, to name a few. Many informational gaps in AIT practice need further evaluation as products and practices evolve.
Collapse
Affiliation(s)
- Moisés A Calderon
- Section of Allergy and Clinical Immunology, Imperial College London-NHLI, London, United Kingdom.
| | - Susan Waserman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David I Bernstein
- Division of Allergy, Rheumatology and Immunology, Department of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Pascal Demoly
- Department of Pulmonology, University Hospital of Montpellier, & IPLESP, Sorbonne Université - Inserm, Paris, France
| | - Jo Douglass
- The Royal Melbourne Hospital & The University of Melbourne, Melbourne, VIC, Australia
| | - Remi Gagnon
- Clinique Spécialisée en Allergie de la Capitale, Québec, QC, Canada
| | - Constance H Katelaris
- Campbelltown Hospital and the School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Harold Kim
- Division of Clinical Immunology and Allergy, Western University, London, ON, Canada; Division of Clinical Immunology & Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Harold S Nelson
- Department of Medicine, National Jewish Health, Denver, Colo
| | - Yoshitaka Okamoto
- Department of Otorhinolaryngology, Chiba University Hospital, Chiba, Japan
| | - Kimihiro Okubo
- Department of Otolaryngology, Nippon Medical School, Nippon, Japan
| | - J Christian Virchow
- Department of Pneumology/Intensive Care Medicine, University of Rostock, Rostock, Germany
| | - Lawrence DuBuske
- Department of Medicine, Division of Allergy and Immunology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Thomas B Casale
- Division of Allergy/Immunology, University of South Florida, Tampa, Fla
| | - G Walter Canonica
- Personalized Medicine Clinic Asthma & Allergy, Humanitas Clinical and Research Center, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | | |
Collapse
|
7
|
Heeringa JJ, McKenzie CI, Varese N, Hew M, Bakx ATCM, Aui PM, Rolland JM, O’Hehir RE, Zelm MC. Induction of IgG 2 and IgG 4 B-cell memory following sublingual immunotherapy for ryegrass pollen allergy. Allergy 2020; 75:1121-1132. [PMID: 31587307 PMCID: PMC7317934 DOI: 10.1111/all.14073] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/06/2019] [Accepted: 08/29/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND While treatment for atopic rhinitis is aimed mostly to relieve symptoms, only allergen-specific immunotherapy (AIT) is targeted to modify the natural history of allergic diseases. This results in sustained clinical tolerance, even when treatment has stopped. The immunomodulatory effects of AIT are attributed mainly to increased regulatory T-cell function and increased allergen-specific IgG4 , yet little is known about the effect on the memory B-cell compartment. OBJECTIVE We aimed to examine the effects of AIT on the IgE- and IgG subclass-expressing memory B cells. METHODS We recruited 29 patients with atopic seasonal rhinoconjunctivitis and performed a longitudinal analysis of the peripheral immune compartment before, during, and after sublingual immunotherapy (SLIT) for allergy to temperate grass pollen, predominantly to ryegrass pollen (RGP; Lolium perenne). Using flow cytometry on peripheral blood mononuclear cells and serum immunoassays, we analyzed the effects of a 4 months preseasonal treatment regimen comprising two or three courses in consecutive years on circulating IgE+ and IgG+ memory B cells and allergen-specific Ig levels. RESULTS SLIT increased RGP-specific serum IgG2 and IgG4 , as well as the frequencies of IgG2 + and IgG4 + memory B cells, whereas no effect was observed on the IgE+ memory B-cell compartment. Furthermore, SLIT enhanced proportions of regulatory T cells specific to RGP. These changes were associated with clinical improvement. CONCLUSION Our data provide evidence for immunological effects of SLIT on B-cell memory. Skewing responses toward IgG2 and IgG4 subclasses might be a mechanism to suppress IgE-mediated allergic responses.
Collapse
Affiliation(s)
- Jorn J. Heeringa
- Department of Immunology and Pathology Central Clinical School Monash University Melbourne Vic. Australia
- Department of Immunology Erasmus MC University Medical Center Rotterdam the Netherlands
- Department of Pediatrics Erasmus MC University Medical Center Rotterdam the Netherlands
| | - Craig I. McKenzie
- Department of Immunology and Pathology Central Clinical School Monash University Melbourne Vic. Australia
| | - Nirupama Varese
- Department of Immunology and Pathology Central Clinical School Monash University Melbourne Vic. Australia
- Department of Respiratory Medicine Allergy and Clinical Immunology (Research) Central Clinical School Monash University, and Alfred Hospital Melbourne Vic. Australia
| | - Mark Hew
- Department of Respiratory Medicine Allergy and Clinical Immunology (Research) Central Clinical School Monash University, and Alfred Hospital Melbourne Vic. Australia
- School of Public Health and Preventive Medicine Monash University Melbourne Vic. Australia
| | - Amy T. C. M. Bakx
- Department of Immunology and Pathology Central Clinical School Monash University Melbourne Vic. Australia
| | - Pei M. Aui
- Department of Immunology and Pathology Central Clinical School Monash University Melbourne Vic. Australia
| | - Jennifer M. Rolland
- Department of Immunology and Pathology Central Clinical School Monash University Melbourne Vic. Australia
- Department of Respiratory Medicine Allergy and Clinical Immunology (Research) Central Clinical School Monash University, and Alfred Hospital Melbourne Vic. Australia
| | - Robyn E. O’Hehir
- Department of Immunology and Pathology Central Clinical School Monash University Melbourne Vic. Australia
- Department of Respiratory Medicine Allergy and Clinical Immunology (Research) Central Clinical School Monash University, and Alfred Hospital Melbourne Vic. Australia
| | - Menno C. Zelm
- Department of Immunology and Pathology Central Clinical School Monash University Melbourne Vic. Australia
- Department of Respiratory Medicine Allergy and Clinical Immunology (Research) Central Clinical School Monash University, and Alfred Hospital Melbourne Vic. Australia
| |
Collapse
|
8
|
Crowley AR, Ackerman ME. Mind the Gap: How Interspecies Variability in IgG and Its Receptors May Complicate Comparisons of Human and Non-human Primate Effector Function. Front Immunol 2019; 10:697. [PMID: 31024542 PMCID: PMC6463756 DOI: 10.3389/fimmu.2019.00697] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 03/13/2019] [Indexed: 01/08/2023] Open
Abstract
The field of HIV research relies heavily on non-human primates, particularly the members of the macaque genus, as models for the evaluation of candidate vaccines and monoclonal antibodies. A growing body of research suggests that successful protection of humans will not solely rely on the neutralization activity of an antibody's antigen binding fragment. Rather, immunological effector functions prompted by the interaction of the immunoglobulin G constant region and its cognate Fc receptors help contribute to favorable outcomes. Inherent differences in the sequences, expression, and activities of human and non-human primate antibody receptors and immunoglobulins have the potential to produce disparate results in the observations made in studies conducted in differing species. Having a more complete understanding of these differences, however, should permit the more fluent translation of observations between model organisms and the clinic. Here we present a guide to such translations that encompasses not only what is presently known regarding the affinity of the receptor-ligand interactions but also the influence of expression patterns and allelic variation, with a focus on insights gained from use of this model in HIV vaccines and passive antibody therapy and treatment.
Collapse
Affiliation(s)
- Andrew R. Crowley
- Molecular and Cellular Biology Program, Dartmouth College, Hanover, NH, United States
| | - Margaret E. Ackerman
- Molecular and Cellular Biology Program, Dartmouth College, Hanover, NH, United States
- Thayer School of Engineering, Dartmouth College, Hanover, NH, United States
| |
Collapse
|
9
|
Blanco C, Bazire R, Argiz L, Hernández-Peña J. Sublingual allergen immunotherapy for respiratory allergy: a systematic review. Drugs Context 2018; 7:212552. [PMID: 30416528 PMCID: PMC6220898 DOI: 10.7573/dic.212552] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 01/01/2023] Open
Abstract
The objective of the systematic review is to provide complete and updated information on efficacy and safety of sublingual immunotherapy (SLIT) formulations for the treatment of allergic respiratory diseases (ARDs). The literature search was conducted on PubMed database, involving double-blind, randomized clinical trials published between January 1992 and 2018, written in English, and performed in humans. The number of articles finally selected for review was 112. Data from the majority of properly controlled clinical trials demonstrate that SLIT is effective not only with short-term use (first year) but also with long-term use (up to the third year of active therapy), for treating ARDs in children and adults. Both continuous and discontinuous schemes of administration showed significant reductions in symptom and medication scores. Moreover, a SLIT-induced disease-modifying effect has been documented mainly with grass pollen extracts, since improvement is maintained during at least 2 years of follow-up after a 3-year treatment period. Additionally, allergen immunotherapy should also be considered a preventive strategy, especially for decreasing bronchial asthma incidence in children and adolescents with allergic rhinitis treated with SLIT. This therapy is also safe, producing only a few mainly local and mild-to-moderate adverse events, and usually self-limited in time. The registration and authorization of allergen SLIT preparations (grasses and house-dust mite tablets) as drugs by regulatory agencies, such as the United States Food and Drug Administration (FDA) and the European Medicines Agency (EMA), has represented a landmark in allergy immunotherapy research. Further long-term studies, specially designed with allergens other than grass pollen or house-dust mites, not only in allergic rhinoconjunctivitis but also on asthmatic subjects, as well as studies comparing different administration schedules and/or routes, are required in order to continue the progress in the modern development of this particularly promising therapy.
Collapse
Affiliation(s)
- Carlos Blanco
- Allergy Service, University Hospital La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
- RETIC ARADYAL RD16/0006/0015, Instituto de Salud Carlos III, Madrid, Spain
| | - Raphaelle Bazire
- Allergy Service, University Hospital La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
| | - Laura Argiz
- Allergy Service, University Hospital La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
| | | |
Collapse
|
10
|
Does clinical outcome of birch pollen immunotherapy relate to induction of blocking antibodies preventing IgE from allergen binding? A pilot study monitoring responses during first year of AIT. Clin Transl Allergy 2018; 8:39. [PMID: 30338052 PMCID: PMC6174570 DOI: 10.1186/s13601-018-0226-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/06/2018] [Indexed: 01/04/2023] Open
Abstract
Background The clinical benefit of allergen-specific immunotherapy (AIT) involves induction of blocking antibodies. It is not clear if these antibodies function via steric hindrance alone or a combination of levels, avidities, and epitope specificities, and clinical outcome cannot be predicted. We aim to in-depth characterize serum antibody profiles during birch pollen AIT, investigate therapy-induced antibodies for their capacity to block IgE binding to Bet v 1 and correlate data with clinical outcomes. Methods Immune responses of five birch pollen allergic patients were monitored during the first year of AIT by nasal provocation tests (NPTs), ImmunoCAP, immunoblots, direct and avidity enzyme-linked immunosorbent assays, mediator release assays, facilitated antigen binding (FAB) assays, and inhibition mediator release assays. Results There was no correlation between NPT results and therapy-induced changes in levels (IgE, IgG, IgA, IgM), avidities, or mediator release potency of Bet v 1-specific antibodies. In FAB assays, blocking antibodies initiated upon AIT were shown to prevent formation of Bet v 1-IgE complexes of an indicator serum pool and significantly correlated with clinical readout. Inhibition mediator release assays using patient-specific IgE for passive sensitization revealed therapy-induced blocking capacities with very good correlation to NPT results. Notably, this assay was the only one to detect a non-responder during treatment in this pilot study. Conclusions Clinical outcome of AIT depends on induction of blocking antibodies able to prevent the patient’s own IgE from allergen binding. Monitoring of clinical efficacy seems to be best achieved using the inhibition mediator release assay, as development of relevant blocking antibodies can be verified in a patient-tailored manner. Electronic supplementary material The online version of this article (10.1186/s13601-018-0226-7) contains supplementary material, which is available to authorized users.
Collapse
|
11
|
Jutel M, Rudert M, Kreimendahl F, Kuna P. Efficacy and tolerability of a house dust mite allergoid in allergic bronchial asthma: a randomized dose-ranging trial. Immunotherapy 2018; 10:1149-1161. [PMID: 30089430 DOI: 10.2217/imt-2018-0087] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM This multicenter randomized placebo-controlled double-blind clinical trial investigated which maintenance dose shows the optimal benefit-risk ratio for subcutaneous immunotherapy with a Dermatophagoides pteronyssinus allergoid preparation. OBJECTIVE To evaluate four maintenance doses of the allergoid preparation versus placebo. METHODS The late-phase reaction of the intracutaneous test was chosen as efficacy parameter and minimal dose of fluticasone required for asthma control. RESULTS A total of 146 adults with bronchial asthma were randomized. After subcutaneous immunotherapy, reductions in swelling size were greatest with 10,000 therapeutic units (TU). The 18,000 TU group showed the highest percentage of patients with fluticasone dose reduced to 0 μg/day. CONCLUSION The optimal dose of allergoid for the investigation in a confirmatory trial with inhaled corticosteroid reduction is 18,000 TU.
Collapse
Affiliation(s)
- Marek Jutel
- "ALL-MED" Medical Research Institute, Wroclaw, Poland.,Department of Clinical Immunology, Silesian Piasts University of Medicine, Wroclaw, Poland
| | - Michael Rudert
- Allergopharma GmbH & Co. KG, Medical Department, Reinbek, Germany
| | | | - Piotr Kuna
- Barlicki University Hospital, Medical University, Lodz, Poland
| |
Collapse
|
12
|
The status of sublingual immunotherapy in the treatment of allergic diseases. Allergol Int 2018; 67:299-300. [PMID: 29981741 DOI: 10.1016/j.alit.2018.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
13
|
Pfaar O, Hohlfeld JM, Al-Kadah B, Hauswald B, Homey B, Hunzelmann N, Schliemann S, Velling P, Worm M, Klimek L. Dose-response relationship of a new Timothy grass pollen allergoid in comparison with a 6-grass pollen allergoid. Clin Exp Allergy 2017; 47:1445-1455. [PMID: 28696503 DOI: 10.1111/cea.12977] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 03/22/2017] [Accepted: 05/23/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Subcutaneous allergen immunotherapy with grass pollen allergoids has been proven to be effective and safe in the treatment of patients with allergic rhinoconjunctivitis. Based on the extensive cross-reactivity among Pooideae species, it has been suggested that grass pollen extracts could be prepared from a single species, rather than from a multiple species mixture. OBJECTIVE To find the optimal dose of a Phleum pratense (P. pratense) allergoid preparation and compare its efficacy and safety to a 6-grass pollen allergoid preparation. METHODS In this double-blind, placebo-controlled study (EudraCT: 2011-000674-58), three doses of P. pratense allergoid (1800 therapeutic units (TU), standard-dose 6000 TU and 18 000 TU) were compared with placebo and the marketed 6-grass pollen allergoid (6000 TU). In a pre-seasonal dosing regimen, 102 patients were randomized to five treatment groups and received nine subcutaneous injections. The primary efficacy endpoint was the change in weal size (late-phase reaction [LPR]) in response to the intracutaneous testing (ICT) before and after treatment, comparing the active allergoids to placebo. Secondary outcomes were the change in Total Nasal Symptom Score (TNSS) assessed in the allergen exposure chamber (AEC), the changes in P. pratense-serum-specific IgG4 and the incidence of adverse events (AEs). RESULTS All three doses of the P. pratense and the 6-grass pollen allergoid preparations were significantly superior to placebo for the primary outcome, whereas there were no significant differences in the change in TNSS. Compared to the standard-dose, the high-dose of P. pratense did not produce any additional significant benefit, but showed a slight increase in AEs. Yet this increase in AEs was lower than for the 6-grass pollen preparation. CONCLUSIONS & CLINICAL RELEVANCE The standard-dose of the new P. pratense allergoid was comparable to the marketed 6-grass pollen preparation at equal dose for the parameters measured.
Collapse
Affiliation(s)
- O Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Center for Rhinology and Allergology Wiesbaden, Wiesbaden, Germany
| | - J M Hohlfeld
- Fraunhofer Institute for Toxicology and Experimental Medicine ITEM; Member of the German Center for Lung Research, Hannover, Germany.,Hannover Medical School, Hannover, Germany
| | - B Al-Kadah
- Department of Otorhinolaryngology, Saarland University Medical Center, Homburg/Saar, Germany
| | - B Hauswald
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - B Homey
- Department of Dermatology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - N Hunzelmann
- Department of Dermatology, University Hospital of Cologne, Cologne, Germany
| | - S Schliemann
- Department of Dermatology, Jena University Hospital, Jena, Germany
| | - P Velling
- Medical Care Centre of Evangelical Chest Clinic Berlin, Berlin, Germany
| | - M Worm
- Division of Allergy and Immunology, Department of Dermatology and Allergy, Charité Campus Mitte, Universitätsmedizin Berlin, Berlin, Germany
| | - L Klimek
- Center for Rhinology and Allergology Wiesbaden, Wiesbaden, Germany
| |
Collapse
|
14
|
Shamji MH, Kappen JH, Akdis M, Jensen-Jarolim E, Knol EF, Kleine-Tebbe J, Bohle B, Chaker AM, Till SJ, Valenta R, Poulsen LK, Calderon MA, Demoly P, Pfaar O, Jacobsen L, Durham SR, Schmidt-Weber CB. Biomarkers for monitoring clinical efficacy of allergen immunotherapy for allergic rhinoconjunctivitis and allergic asthma: an EAACI Position Paper. Allergy 2017; 72:1156-1173. [PMID: 28152201 DOI: 10.1111/all.13138] [Citation(s) in RCA: 229] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Allergen immunotherapy (AIT) is an effective treatment for allergic rhinoconjunctivitis (AR) with or without asthma. It is important to note that due to the complex interaction between patient, allergy triggers, symptomatology and vaccines used for AIT, some patients do not respond optimally to the treatment. Furthermore, there are no validated or generally accepted candidate biomarkers that are predictive of the clinical response to AIT. Clinical management of patients receiving AIT and efficacy in randomised controlled trials for drug development could be enhanced by predictive biomarkers. METHOD The EAACI taskforce reviewed all candidate biomarkers used in clinical trials of AR patients with/without asthma in a literature review. Biomarkers were grouped into seven domains: (i) IgE (total IgE, specific IgE and sIgE/Total IgE ratio), (ii) IgG-subclasses (sIgG1, sIgG4 including SIgE/IgG4 ratio), (iii) Serum inhibitory activity for IgE (IgE-FAB and IgE-BF), (iv) Basophil activation, (v) Cytokines and Chemokines, (vi) Cellular markers (T regulatory cells, B regulatory cells and dendritic cells) and (vii) In vivo biomarkers (including provocation tests?). RESULTS All biomarkers were reviewed in the light of their potential advantages as well as their respective drawbacks. Unmet needs and specific recommendations on all seven domains were addressed. CONCLUSIONS It is recommended to explore the use of allergen-specific IgG4 as a biomarker for compliance. sIgE/tIgE and IgE-FAB are considered as potential surrogate candidate biomarkers. Cytokine/chemokines and cellular reponses provided insight into the mechanisms of AIT. More studies for confirmation and interpretation of the possible association with the clinical response to AIT are needed.
Collapse
Affiliation(s)
- M. H. Shamji
- Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College London; London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; London UK
- Allergy and Clinical Immunology; Immunomodulation and Tolerance Group; Imperial College London; London UK
| | - J. H. Kappen
- Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College London; London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; London UK
- Allergy and Clinical Immunology; Immunomodulation and Tolerance Group; Imperial College London; London UK
- Department of Pulmonology; STZ Centre of Excellence for Asthma & COPD; Sint Franciscus Vlietland Group; Rotterdam The Netherlands
| | - M. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF); University of Zürich; Davos Switzerland
| | - E. Jensen-Jarolim
- Department of Pathophysiology and Allergy Research; Center of Pathophysiology, Infectiology and Immunology; Medical University Vienna; Vienna Austria
- The interuniversity Messerli Research Institute; University of Veterinary Medicine Vienna; Medical University Vienna; Vienna Austria
| | - E. F. Knol
- Departments Immunology and Dermatology/Allergology; University Medical Center Utrecht; Utrecht The Netherlands
| | - J. Kleine-Tebbe
- Allergy & Asthma Center Westend; Outpatient Clinic and Research Center Hanf, Ackermann & Kleine-Tebbe; Berlin Germany
| | - B. Bohle
- Department of Pathophysiology and Allergy Research; Medical University of Vienna; Vienna Austria
| | - A. M. Chaker
- Center of Allergy and Environment (ZAUM); Technische Universität and Helmholtz Center Munich; Munich Germany
- Department of Otolaryngology; Allergy Section; Klinikum rechts der Isar; Technische Universität; Munich Germany
| | - S. J. Till
- Division of Asthma, Allergy and Lung Biology; King's College London; London UK
- Department of Allergy; Guy's and St. Thomas’ NHS Foundation Trust; London UK
| | - R. Valenta
- Division of Immunopathology; Department of Pathophysiology and Allergy Research; Center for Pathophysiology, Infectiology and Immunology; Medical University of Vienna; Vienna Austria
| | - L. K. Poulsen
- Allergy Clinic; Copenhagen University Hospital at Gentofte; Copenhagen Denmark
| | - M. A. Calderon
- Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College London; London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; London UK
- Allergy and Clinical Immunology; Immunomodulation and Tolerance Group; Imperial College London; London UK
| | - P. Demoly
- Division of Allergy; Department of Pulmonology; Arnaud de Villeneuve Hospital; University Hospital of Montpellier and Sorbonne University; Paris France
| | - O. Pfaar
- Department of Otorhinolaryngology; Head and Neck Surgery; Universitätsmedizin Mannheim; Medical Faculty Mannheim; Heidelberg University; Mannheim Germany
- Center for Rhinology and Allergology; Wiesbaden Germany
| | - L. Jacobsen
- Allergy Learning and Consulting; Copenhagen Denmark
| | - S. R. Durham
- Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College London; London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; London UK
- Allergy and Clinical Immunology; Immunomodulation and Tolerance Group; Imperial College London; London UK
| | - C. B. Schmidt-Weber
- Center of Allergy and Environment (ZAUM); Technische Universität and Helmholtz Center Munich; Munich Germany
| |
Collapse
|
15
|
Lawrence MG, Steinke JW, Borish L. Basic science for the clinician: Mechanisms of sublingual and subcutaneous immunotherapy. Ann Allergy Asthma Immunol 2017; 117:138-42. [PMID: 27499541 DOI: 10.1016/j.anai.2016.06.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/18/2016] [Accepted: 06/27/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To discuss the general immunologic changes that occur during immunotherapy, focusing on the differences between subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT). DATA SOURCES PubMed literature review. STUDY SELECTIONS Articles pertaining to SCIT and SLIT, with specific emphasis on those that included immune mechanistic studies. RESULTS Both SCIT and SLIT are characterized by the induction of regulatory B and T cells, decreased allergen-specific T-cell proliferation, a shift from a TH2 to TH1 cytokine milieu and from an IgE to an IgG4/IgA antibody response. These changes are accompanied by clinical improvement in symptoms. CONCLUSION Immunotherapy using allergen extracts administered via both subcutaneous and sublingual approaches have demonstrated efficacy in the treatment of allergic rhinoconjunctivitis and other allergic conditions. There are subtle differences between the approaches, and understanding these differences may help clinicians select a preferred route of therapy for particular patients or allergens, depending on the immune response that is being targeted.
Collapse
Affiliation(s)
- Monica G Lawrence
- Asthma and Allergic Disease Center, University of Virginia Health System, Charlottesville, Virginia; Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - John W Steinke
- Asthma and Allergic Disease Center, University of Virginia Health System, Charlottesville, Virginia; Department of Medicine, University of Virginia Health System, Charlottesville, Virginia; Carter Immunology Center, University of Virginia Health System, Charlottesville, Virginia
| | - Larry Borish
- Asthma and Allergic Disease Center, University of Virginia Health System, Charlottesville, Virginia; Department of Medicine, University of Virginia Health System, Charlottesville, Virginia; Carter Immunology Center, University of Virginia Health System, Charlottesville, Virginia; Department of Microbiology, University of Virginia Health System, Charlottesville, Virginia.
| |
Collapse
|
16
|
Scadding GW, Calderon MA, Shamji MH, Eifan AO, Penagos M, Dumitru F, Sever ML, Bahnson HT, Lawson K, Harris KM, Plough AG, Panza JL, Qin T, Lim N, Tchao NK, Togias A, Durham SR. Effect of 2 Years of Treatment With Sublingual Grass Pollen Immunotherapy on Nasal Response to Allergen Challenge at 3 Years Among Patients With Moderate to Severe Seasonal Allergic Rhinitis: The GRASS Randomized Clinical Trial. JAMA 2017; 317:615-625. [PMID: 28196255 PMCID: PMC5479315 DOI: 10.1001/jama.2016.21040] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Sublingual immunotherapy and subcutaneous immunotherapy are effective in seasonal allergic rhinitis. Three years of continuous treatment with subcutaneous immunotherapy and sublingual immunotherapy has been shown to improve symptoms for at least 2 years following discontinuation of treatment. OBJECTIVE To assess whether 2 years of treatment with grass pollen sublingual immunotherapy, compared with placebo, provides improved nasal response to allergen challenge at 3-year follow-up. DESIGN, SETTING, AND PARTICIPANTS A randomized double-blind, placebo-controlled, 3-parallel-group study performed in a single academic center, Imperial College London, of adult patients with moderate to severe seasonal allergic rhinitis (interfering with usual daily activities or sleep). First enrollment was March 2011, last follow-up was February 2015. INTERVENTIONS Thirty-six participants received 2 years of sublingual immunotherapy (daily tablets containing 15 µg of major allergen Phleum p 5 and monthly placebo injections), 36 received subcutaneous immunotherapy (monthly injections containing 20 µg of Phleum p 5 and daily placebo tablets) and 34 received matched double-placebo. Nasal allergen challenge was performed before treatment, at 1 and 2 years of treatment, and at 3 years (1 year after treatment discontinuation). MAIN OUTCOMES AND MEASURES Total nasal symptom scores (TNSS; range; 0 [best] to 12 [worst]) were recorded between 0 and 10 hours after challenge. The minimum clinically important difference for change in TNSS within an individual is 1.08. The primary outcome was TNSS comparing sublingual immunotherapy vs placebo at year 3. Subcutaneous immunotherapy was included as a positive control. The study was not powered to compare sublingual immunotherapy with subcutaneous immunotherapy. RESULTS Among 106 randomized participants (mean age, 33.5 years; 34 women [32.1%]), 92 completed the study at 3 years. In the intent-to-treat population, mean TNSS score for the sublingual immunotherapy group was 6.36 (95% CI, 5.76 to 6.96) at pretreatment and 4.73 (95% CI, 3.97 to 5.48) at 3 years, and for the placebo group, the score was 6.06 (95% CI, 5.23 to 6.88) at pretreatment and 4.81 (95% CI, 3.97 to 5.65) at 3 years. The between-group difference (adjusted for baseline) was -0.18 (95% CI, -1.25 to 0.90; [P = .75]). CONCLUSIONS AND RELEVANCE Among patients with moderate to severe seasonal allergic rhinitis, 2 years of sublingual grass pollen immunotherapy was not significantly different from placebo in improving the nasal response to allergen challenge at 3-year follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01335139; EudraCT Number: 2010-023536-16.
Collapse
Affiliation(s)
- Guy W Scadding
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | - Moises A Calderon
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | - Mohamed H Shamji
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | - Aarif O Eifan
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | - Martin Penagos
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | - Florentina Dumitru
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Henry T Bahnson
- Rho Federal Systems Division, Chapel Hill, North Carolina3currently with the Immune Tolerance Network, Benaroya Research Institute, Seattle, Washington
| | - Kaitie Lawson
- Rho Federal Systems Division, Chapel Hill, North Carolina
| | | | | | | | - Tielin Qin
- Immune Tolerance Network, Bethesda, Maryland
| | - Noha Lim
- Immune Tolerance Network, Bethesda, Maryland
| | - Nadia K Tchao
- Immune Tolerance Network, San Francisco, California7currently with the Department of Early Development Hematology/Oncology, Amgen, San Francisco, California
| | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, Rockville, Maryland
| | - Stephen R Durham
- Imperial College, London, and Royal Brompton and Harefield Hospitals NHS Foundation Trust, London, United Kingdom
| | | |
Collapse
|
17
|
Aissa S, Ben Jazia R, Ayachi J, Ben Salem C, Hayouni A, Abdelghani A, Ben Saad H, Boussarsar M. Critical appraisal of the clinical utility of sublingual immunotherapy in allergy. Contemp Clin Trials Commun 2016; 4:1-8. [PMID: 29736465 PMCID: PMC5935903 DOI: 10.1016/j.conctc.2016.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/25/2016] [Accepted: 06/15/2016] [Indexed: 11/30/2022] Open
Abstract
Since it was introduced by Noon in 1911, allergen-specific immunotherapy or desensitization has been widely prescribed in the management of allergic diseases. Aimed at the etiology, it represents the only effective treatment for allergy. The basic mechanisms of immunotherapy are becoming better understood and allow us to improve this technique in the future. The sublingual immunotherapy as an alternative to subcutaneous route has been widely studied. Several clinical trials confirmed that sublingual immunotherapy is efficient in reducing allergic respiratory symptoms. The sublingual immunotherapy reduces the risk of developing serious side effects due to desensitization. We performed a literature review in order to remind the mechanisms of action and to demonstrate efficacy and tolerability of the sublingual immunotherapy in the treatment of allergic rhinoconjunctivitis and asthma and its impact on the quality of life.
Collapse
Affiliation(s)
- S. Aissa
- Pulmonology Department, Farhat Hached University Hospital, Sousse, 4000, Tunisia
| | - R. Ben Jazia
- Pulmonology Department, Farhat Hached University Hospital, Sousse, 4000, Tunisia
| | - J. Ayachi
- Medical Intensive Care Unit, Farhat Hached University Hospital, Sousse, Tunisia
| | - C. Ben Salem
- Department of Clinical Pharmacology, Faculty of Medicine of Sousse, Tunisia
| | - A. Hayouni
- Pulmonology Department, Farhat Hached University Hospital, Sousse, 4000, Tunisia
| | - A. Abdelghani
- Pulmonology Department, Farhat Hached University Hospital, Sousse, 4000, Tunisia
| | - H. Ben Saad
- Laboratory of Physiology, Farhat Hached University Hospital, Sousse, Tunisia
| | - M. Boussarsar
- Medical Intensive Care Unit, Farhat Hached University Hospital, Sousse, Tunisia
| |
Collapse
|
18
|
Slovick A, Douiri A, Muir R, Guerra A, Tsioulos K, Hay E, Lam EPS, Kelly J, Peacock JL, Ying S, Shamji MH, Cousins DJ, Durham SR, Till SJ. Intradermal grass pollen immunotherapy increases T H2 and IgE responses and worsens respiratory allergic symptoms. J Allergy Clin Immunol 2016; 139:1830-1839.e13. [PMID: 27773851 PMCID: PMC5457129 DOI: 10.1016/j.jaci.2016.09.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 09/09/2016] [Accepted: 09/19/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Repeated low-dose grass pollen intradermal allergen injection suppresses allergen-induced cutaneous late-phase responses comparably with conventional subcutaneous and sublingual immunotherapy. OBJECTIVE We sought to evaluate the efficacy and safety of grass pollen intradermal immunotherapy in the treatment of allergic rhinitis. METHODS We randomly assigned 93 adults with grass pollen-induced allergic rhinitis to receive 7 preseasonal intradermal allergen injections (containing 7 ng of Phl p 5 major allergen) or a histamine control. The primary end point was daily combined symptom-medication scores during the 2013 pollen season (area under the curve). Analysis was by intention to treat. Skin biopsy specimens were collected after intradermal allergen challenges, and late-phase responses were measured 4 and 7, 10, or 13 months after treatment. RESULTS There was no significant difference in the primary end point between treatment arms (active, n = 46; control, n = 47; median difference, 14; 95% CI, -172.5 to 215.1; P = .80). Among secondary end points, nasal symptoms were worse in the intradermal treatment group, as measured based on daily (median difference, 35; 95% CI, 4.0-67.5; P = .03) and visual analog scale (median difference, 53; 95% CI, -11.6 to 125.2; P = .05) scores. In a per-protocol analysis intradermal immunotherapy was further associated with worse asthma symptoms and fewer symptom-free days. Intradermal immunotherapy increased serum Phleum pratense-specific IgE levels (P = .001) compared with those in the control arm. T cells cultured from biopsy specimens of subjects undergoing intradermal immunotherapy had higher expression of the TH2 surface marker CRTH2 (P = .04) and lower expression of the TH1 marker CXCR3 (P = .01), respectively. Late-phase responses remained inhibited 7 months after treatment (P = .03). CONCLUSION Intradermal allergen immunotherapy suppressed skin late-phase responses but was not clinically effective and resulted in worsening of respiratory allergic symptoms.
Collapse
Affiliation(s)
- Anna Slovick
- Division of Asthma, Allergy and Lung Biology, King's College London, School of Medicine, Guy's Hospital, London, United Kingdom; MRC-Asthma UK Centre for Allergic Mechanisms of Asthma, London, United Kingdom
| | - Abdel Douiri
- Division of Health and Social Care Research, King's College London, 4th floor Addison House, Guy's Campus, London, United Kingdom
| | - Rachel Muir
- Clinical Research Facility, NIHR Biomedical Research Centre, Guy's Hospital, London, United Kingdom
| | - Andrea Guerra
- Division of Asthma, Allergy and Lung Biology, King's College London, School of Medicine, Guy's Hospital, London, United Kingdom
| | - Konstantinos Tsioulos
- Division of Asthma, Allergy and Lung Biology, King's College London, School of Medicine, Guy's Hospital, London, United Kingdom
| | - Evie Hay
- Division of Asthma, Allergy and Lung Biology, King's College London, School of Medicine, Guy's Hospital, London, United Kingdom
| | - Emily P S Lam
- Division of Asthma, Allergy and Lung Biology, King's College London, School of Medicine, Guy's Hospital, London, United Kingdom
| | - Joanna Kelly
- King's Clinical Trials Unit, King's College London, Institute of Psychiatry, London, United Kingdom
| | - Janet L Peacock
- Division of Health and Social Care Research, King's College London, 4th floor Addison House, Guy's Campus, London, United Kingdom
| | - Sun Ying
- Division of Asthma, Allergy and Lung Biology, King's College London, School of Medicine, Guy's Hospital, London, United Kingdom
| | - Mohamed H Shamji
- Allergy and Clinical Immunology, National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, United Kingdom
| | - David J Cousins
- Division of Asthma, Allergy and Lung Biology, King's College London, School of Medicine, Guy's Hospital, London, United Kingdom; Department of Infection, Immunity and Inflammation, NIHR Leicester Respiratory Biomedical Research Unit, Leicester Institute for Lung Health, University of Leicester, Leicester, United Kingdom; MRC-Asthma UK Centre for Allergic Mechanisms of Asthma, London, United Kingdom
| | - Stephen R Durham
- Allergy and Clinical Immunology, National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Stephen J Till
- Division of Asthma, Allergy and Lung Biology, King's College London, School of Medicine, Guy's Hospital, London, United Kingdom; MRC-Asthma UK Centre for Allergic Mechanisms of Asthma, London, United Kingdom.
| |
Collapse
|
19
|
Kappen JH, Durham SR, Veen HI', Shamji MH. Applications and mechanisms of immunotherapy in allergic rhinitis and asthma. Ther Adv Respir Dis 2016; 11:73-86. [PMID: 27678500 DOI: 10.1177/1753465816669662] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Clinical and immunologic tolerance are hallmarks of successful allergen immunotherapy (AIT). Clinical benefits such as reduced symptoms, pharmacotherapy intake and improvement of quality of life persist following cessation of treatment. Successful AIT is associated with suppression of allergic inflammatory cells such as mast cells, eosinophils and basophils in target organs. Furthermore, AIT down-regulates type 2 innate lymphoid cells and allergen-specific type 2 T-helper (Th2) cells. The immunologic tolerant state following AIT is associated with the induction of distinct phenotypes of regulatory T-cells (T-regs) including interleukin (IL)-10-, IL-35- and transforming growth factor (TGF)-β- producing T-regs and FoxP3+ T-regs. B-cell responses, including the induction of IL-10+ regulatory B-cells (B-regs) and the production of IgG4-associated blocking antibodies are also induced following successful AIT. These events are associated with the suppression of antigen-specific Th2 responses and delayed immune deviation in favour of Th1 type responses. Insight into the mechanisms of AIT has allowed identification of novel biomarkers with potential to predict the clinical response to AIT and also novel therapeutic strategies for more effective and safer AIT.
Collapse
Affiliation(s)
- Jasper H Kappen
- Department of Pulmonology, STZ centre of excellence for Asthma & COPD, Franciscus Gasthuis & Vlietland, Kleiweg 500, 3045 PM, Rotterdam, The Netherlands
| | - Stephen R Durham
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Hans In 't Veen
- Department of Pulmonology, STZ centre of excellence for Asthma & COPD, Franciscus Gasthuis & Vlietland, Kleiweg 500, 3045 PM, Rotterdam, The Netherlands
| | - Mohamed H Shamji
- Allergy and Clinical Immunology, Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, Sir Alexander Fleming Building, South Kensington Campus, London SW7 2AZ, UK
| |
Collapse
|
20
|
Larenas-Linnemann D. Direct comparison of efficacy of sublingual immunotherapy tablets for rhinoconjunctivitis. Ann Allergy Asthma Immunol 2016; 116:274-86. [PMID: 27055988 DOI: 10.1016/j.anai.2016.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/03/2015] [Accepted: 02/15/2016] [Indexed: 02/08/2023]
|
21
|
Passalacqua G, Guerra L, Fumagalli F, Canonica GW. Safety profile of sublingual immunotherapy. ACTA ACUST UNITED AC 2016; 5:225-34. [PMID: 16808542 DOI: 10.2165/00151829-200605040-00001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Sublingual immunotherapy (SLIT) was proposed for clinical practice about 20 years ago with the main aim of improving the safety and avoiding the adverse effects of traditional treatment for allergic airways disease. To date, 32 randomized controlled trials and 6 postmarketing surveys have been published that provide a robust documentation of the safety profile of the treatment.Looking at the randomized trials it emerges that the more frequent adverse event of SLIT is oral itching or swelling, followed by gastrointestinal complaints. These adverse events are invariably described as mild and easily managed by adjusting the dose. Relevant systemic adverse events (asthma, urticaria, angioedema) occur sporadically and, with the exception of oral/gastrointestinal adverse events, the incidence of adverse events seems not to differ between the placebo and active groups. The safety profile of SLIT does not differ between adults and children.The postmarketing surveys consistently show that the incidence of adverse events associated with SLIT is less than 10%, corresponding to less than 1 adverse event per 1000 doses, and is thus quite superior to the safety profile of subcutaneous immunotherapy. Of note, the most recent data show that the rate of adverse events with SLIT is not increased in children below the age of 5 years.
Collapse
Affiliation(s)
- Giovanni Passalacqua
- Department of Internal Medicine, Allergy and Respiratory Diseases, University of Genoa, Genoa, Italy
| | | | | | | |
Collapse
|
22
|
Masuyama K, Goto M, Takeno S, Ohta N, Okano M, Kamijo A, Suzuki M, Terada T, Sakurai D, Horiguchi S, Honda K, Matsune S, Yamada T, Sakashita M, Yuta A, Fuchiwaki T, Miyanohara I, Nakayama T, Okamoto Y, Fujieda S. Guiding principles of sublingual immunotherapy for allergic rhinitis in Japanese patients. Auris Nasus Larynx 2015; 43:1-9. [PMID: 26615715 DOI: 10.1016/j.anl.2015.08.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 08/03/2015] [Accepted: 08/26/2015] [Indexed: 12/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- Keisuke Masuyama
- Department of Otorhinolaryngology, University of Yamanashi, Japan
| | - Minoru Goto
- Department of Otorhinolaryngology - Head and Neck Surgery, Nippon Medical School, Japan
| | - Sachio Takeno
- Department of Otolaryngology - Head and Neck Surgery, Hiroshima University, Japan
| | - Nobuo Ohta
- Department of Otolaryngology - Head and Neck Surgery, Yamagata University, Japan
| | - Mitsuhiro Okano
- Department of Otolaryngology - Head and Neck Surgery, Okayama University, Okayama, Japan
| | - Atsushi Kamijo
- Otorhinolaryngology/Allergy Center, Saitama Medical University, Japan
| | - Motohiko Suzuki
- Department of Otolaryngology - Head and Neck Surgery, Nagoya City University, Japan
| | - Tetsuya Terada
- Department of Otorhinolaryngology, Osaka Medical University, Japan
| | - Daiju Sakurai
- Department of Otolaryngology - Head and Neck Surgery, Chiba University, Japan
| | | | - Kohei Honda
- Department of Otorhinolaryngology - Head and Neck Surgery, Akita University, Japan
| | - Shoji Matsune
- Department of Otolaryngology Nippon Medical School, Musashikosugi Hospital, Japan
| | - Takechiyo Yamada
- Department of Otolaryngology - Head and Neck Surgery, University of Fukui, Japan
| | - Masafumi Sakashita
- Department of Otolaryngology - Head and Neck Surgery, University of Fukui, Japan
| | | | | | - Ikuyo Miyanohara
- Department of Otolaryngology - Head and Neck Surgery, Kagoshima University, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Japan
| | - Yoshitaka Okamoto
- Department of Otolaryngology - Head and Neck Surgery, Chiba University, Japan
| | - Shigeharu Fujieda
- Department of Otolaryngology - Head and Neck Surgery, University of Fukui, Japan.
| |
Collapse
|
23
|
Nagai Y, Shiraishi D, Tanaka Y, Nagasawa Y, Ohwada S, Shimauchi H, Aso H, Endo Y, Sugawara S. Transportation of sublingual antigens across sublingual ductal epithelial cells to the ductal antigen-presenting cells in mice. Clin Exp Allergy 2015; 45:677-86. [PMID: 24773115 DOI: 10.1111/cea.12329] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 11/29/2013] [Accepted: 03/07/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND Sublingual immunotherapy (SLIT) has proven to be safe and efficient for the treatment of type I allergies. However, the mechanisms underlying allergen transportation within the sublingual compartment, the localization of antigens, and the identities of the cells responsible for this immunization remain incompletely understood. OBJECTIVE In this study, we focused on the sublingual ductal system and analysed the localization and transportation of antigens after their sublingual application. METHODS In mice given adjuvant-free antigens sublingually, tissues were removed at 0, 0.5, 1, or 2 h after the application and subjected to immunohistochemistry. Cells isolated from the sublingual duct and mucosa were analysed by flow cytometry. RESULTS Substantial immunoreactivity to ovalbumin (OVA) was evident in sublingual ductal epithelial cells at 30 min and 1 h after sublingual administration of OVA, but it had disappeared at 2 h. The ductal epithelial cells incorporated not only OVA, but also particulate antigens such as latex or silica beads and microbes. MHC class II (MHCII)(+) antigen-presenting cells (APCs) were located around the sublingual ductal system, and MHCII(+) cells were co-localized with, and around, antigen-incorporated sublingual duct cells. CD11b(+) CD11c(-) cells were present among CD45(+) MHCII(+) cells at greater frequency in the sublingual duct than in the sublingual mucosa, and they were the main contributors to the incorporation of OVA in vitro. CONCLUSIONS AND CLINICAL RELEVANCE This study reveals that sublingual antigens can be transported across sublingual ductal epithelial cells to the ductal APCs. If the system is the same in humans as in mice, the ductal APCs may prove to be important target cells for SLIT.
Collapse
Affiliation(s)
- Y Nagai
- Division of Oral Immunology, Department of Oral Biology, Tohoku University Graduate School of Dentistry, Sendai, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Scaparrotta A, Attanasi M, Petrosino MI, Di Filippo P, Di Pillo S, Chiarelli F. Critical appraisal of Timothy grass pollen extract GRAZAX in the management of allergic rhinitis. Drug Des Devel Ther 2015; 9:5897-909. [PMID: 26604688 PMCID: PMC4639524 DOI: 10.2147/dddt.s70432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Allergic rhinitis is one of the most common diseases of adult and pediatric age, associated with grass pollen (GP) allergy in >50% cases, with a consistent impact on quality of life of affected patients. A grass allergen tablet, containing standardized extract derived from Timothy grass (Phleum pratense) pollen and ~15 μg major allergen P. pratense (rPhl p 5), may be the future of allergen-specific immunotherapy (IT) for GP allergy. The aim of this review was to critically evaluate the role of Timothy GP extract IT for the management of allergic rhinitis. For this purpose, we have tried to analyze potential mechanisms of action at the basis of Timothy GP extract, we have reviewed efficacy studies to establish potential benefits and clinical response, and we have also evaluated safety and tolerability profiles and patient focus perspective, such as quality of life, satisfaction and acceptability, and compliance to this IT.
Collapse
Affiliation(s)
| | - Marina Attanasi
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | | | | | | |
Collapse
|
25
|
Chaker AM, Shamji MH, Dumitru FA, Calderon MA, Scadding GW, Makatsori M, Jones I, He QA, Subramanian KK, Arm JP, Durham SR, Schmidt-Weber CB. Short-term subcutaneous grass pollen immunotherapy under the umbrella of anti-IL-4: A randomized controlled trial. J Allergy Clin Immunol 2015; 137:452-461.e9. [PMID: 26531865 DOI: 10.1016/j.jaci.2015.08.046] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 08/23/2015] [Accepted: 08/31/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Allergen immunotherapy is currently the only disease-modifying treatment available for allergic rhinitis and allergic asthma. OBJECTIVES We sought to evaluate the induction of sustained tolerance to allergen when anti-IL-4 was combined with a suboptimal course of grass pollen subcutaneous immunotherapy (SCIT) using the allergen-induced skin late-phase response (LPR) and exploratory immune monitoring as surrogate markers of therapeutic response. METHODS In this randomized, double-blind, 3-group parallel design trial, 37 participants with seasonal allergic rhinitis received suboptimal SCIT (30,000 standardized quality units) in combination with anti-IL-4 (VAK694) and suboptimal SCIT (30,000 standardized quality units) plus placebo antibody or double placebo (placebo SCIT and placebo antibody) restricted to 13 weeks before the grass pollen season. The primary end point was the size of the LPR at 12 months. Exploratory end points included measures of the immunomodulatory activity of treatment by using IL-4 and IL-10 FluoroSpot assays, flow cytometry of T cells, and measurement of IgE, IgG4, and facilitated antigen binding. RESULTS Both active treatment arms led to a substantial and sustained reduction of the LPR with no additional suppression with addition of anti-IL-4. Treatment with anti-IL-4 and SCIT compared with SCIT alone led to a sustained reduction in allergen-specific IL-4-producing cell counts (P < .01). Both active treatment arms led to induction of dual IL-4/IL-10-producing cells during the pollen season. CONCLUSION The combination of anti-IL-4 with SCIT provided no additional benefit over SCIT alone in suppressing the allergen-induced skin LPR. A larger trial is needed to assess whether the observed ex vivo downregulation of TH2 responses might translate into clinical benefit.
Collapse
Affiliation(s)
- Adam M Chaker
- Allergy and Clinical Immunology, Imperial College, National Heart and Lung Institute, London, United Kingdom; Center of Allergy and Environment (ZAUM), Technische Universität and Helmholtz Center Munich, Munich, Germany; Department of Otolaryngology, Allergy Section, Klinikum rechts der Isar, Technische Universität, Munich, Germany
| | - Mohamed H Shamji
- Allergy and Clinical Immunology, Imperial College, National Heart and Lung Institute, London, United Kingdom; Immunomodulation and Tolerance group, Allergy and Clinical Immunology, Imperial College London, London, United Kingdom
| | - Florentina A Dumitru
- Allergy and Clinical Immunology, Imperial College, National Heart and Lung Institute, London, United Kingdom
| | - Moises A Calderon
- Allergy and Clinical Immunology, Imperial College, National Heart and Lung Institute, London, United Kingdom
| | - Guy W Scadding
- Allergy and Clinical Immunology, Imperial College, National Heart and Lung Institute, London, United Kingdom
| | - Melina Makatsori
- Allergy and Clinical Immunology, Imperial College, National Heart and Lung Institute, London, United Kingdom
| | - Ieuan Jones
- Novartis Institutes for Biomedical Research, Cambridge, Mass, and Basel, Switzerland
| | - Qiuling A He
- Novartis Institutes for Biomedical Research, Cambridge, Mass, and Basel, Switzerland
| | | | - Jonathan P Arm
- Novartis Institutes for Biomedical Research, Cambridge, Mass, and Basel, Switzerland
| | - Stephen R Durham
- Allergy and Clinical Immunology, Imperial College, National Heart and Lung Institute, London, United Kingdom; Immunomodulation and Tolerance group, Allergy and Clinical Immunology, Imperial College London, London, United Kingdom
| | - Carsten B Schmidt-Weber
- Allergy and Clinical Immunology, Imperial College, National Heart and Lung Institute, London, United Kingdom; Center of Allergy and Environment (ZAUM), Technische Universität and Helmholtz Center Munich, Munich, Germany.
| |
Collapse
|
26
|
Leatherman BD, Khalid A, Lee S, McMains K, Peltier J, Platt MP, Stachler RJ, Toskala E, Tropper G, Venkatraman G, Lin SY. Dosing of sublingual immunotherapy for allergic rhinitis: evidence-based review with recommendations. Int Forum Allergy Rhinol 2015; 5:773-83. [PMID: 26097218 DOI: 10.1002/alr.21561] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/27/2015] [Accepted: 05/02/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Since the mid 1980s, the clinical use of sublingual immunotherapy (SLIT) has dramatically increased. However, 1 of the primary barriers to providing SLIT is lack of a published dosing recommendations. The purpose of this work is to provide a range of effective SLIT dosing based upon a rigorous review of the existing evidence base. An appendix with SLIT dosing recommendations is also included. METHODS A comprehensive search of the past 25 years of the medical literature using PubMed was performed for specific antigens. Inclusion criteria for articles included: randomized, placebo-controlled studies of SLIT, studies with clinical allergic rhinitis outcomes, and dosing units available to determine the micrograms per month of major allergen administered. The extracted data was used to compile a range of effective SLIT dosing for individual antigens. RESULTS Seventy-five articles met the inclusion criteria, providing a range of effective dosing for some allergens. There was commonly a wide range in doses for particular antigens between the individual studies. For some antigens, there was significant overlap in dosage amount between studies showing efficacy and lack of efficacy. Clinical trials meeting inclusion criteria are not available for many allergens. CONCLUSION This study provided a comprehensive review of the published sublingual dosing ranges for specific antigens. The review provided a range of effective sublingual doses for some allergens, whereas for other allergens there was insufficient published data to determine specific doses. Recommendations for SLIT dosing were produced based on the data revealed in the review and expert opinion.
Collapse
Affiliation(s)
- Bryan D Leatherman
- Coastal Sinus and Allergy Center, Gulfport, MS.,Coastal Ear Nose and Throat Associates, Gulfport, MS
| | | | - Stella Lee
- Department of Otolaryngology-Head and Neck Surgery, Division of Sinonasal Disorders and Allergy, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kevin McMains
- Otolaryngology, South Texas Veterans Health Care System, San Antonio, TX
| | | | - Michael P Platt
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, Boston, MA
| | | | - Elina Toskala
- Department of Otolaryngology-Head and Neck Surgery, Temple University, School of Medicine, Philadelphia, PA
| | - Guy Tropper
- Avant Garde Medical Care, Boucherville, QC, Canada
| | | | - Sandra Y Lin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| |
Collapse
|
27
|
Aasbjerg K, Dalhoff KP, Backer V. Adverse Events During Immunotherapy Against Grass Pollen-Induced Allergic Rhinitis - Differences Between Subcutaneous and Sublingual Treatment. Basic Clin Pharmacol Toxicol 2015; 117:73-84. [DOI: 10.1111/bcpt.12416] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 05/04/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Kristian Aasbjerg
- Respiratory Research Unit; Bispebjerg University Hospital; Copenhagen Denmark
- Department of Cardiology; Aalborg University Hospital; Aalborg Denmark
| | - Kim Peder Dalhoff
- Department of Clinical Pharmacology; Bispebjerg University Hospital; Copenhagen Denmark
| | - Vibeke Backer
- Respiratory Research Unit; Bispebjerg University Hospital; Copenhagen Denmark
| |
Collapse
|
28
|
Senti G, Moos S, Tay F, Graf N, Johansen P, Kündig TM. Determinants of efficacy and safety in epicutaneous allergen immunotherapy: summary of three clinical trials. Allergy 2015; 70:707-10. [PMID: 25704072 PMCID: PMC4654258 DOI: 10.1111/all.12600] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2015] [Indexed: 11/29/2022]
Abstract
The results of our third trial on epicutaneous allergen-specific immunotherapy (EPIT) will be presented and discussed in the context of our previous trials. This monocentric, placebo-controlled, double-blind phase I/IIa trial included 98 patients with grass pollen rhinoconjunctivitis. Prior to the pollen season 2009, patients received six patches (allergen extract: n = 48; placebo: n = 50) with weekly intervals, administered onto tape-stripped skin. Allergen EPIT produced a median symptom improvement of 48% in 2009 and 40% in the treatment-free follow-up year 2010 as compared to 10% and 15% improvement after placebo EPIT (P = 0.003). After allergen EPIT but not placebo EPIT, conjunctival allergen reactivity was significantly decreased and allergen-specific IgG4 responses were significantly elevated (P < 0.001). In conclusion, our three EPIT trials found that allergen EPIT can ameliorate hay fever symptoms. Overall, treatment efficacy appears to be determined by the allergen dose. Local side-effects are determined by the duration of patch administration, while risk of systemic allergic side-effects is related to the degree of stratum corneum disruption.
Collapse
Affiliation(s)
- G. Senti
- Clinical Trials Center University of Zurich Zurich Switzerland
| | - S. Moos
- Department of Internal Medicine University Hospital Zurich Zurich Switzerland
| | - F. Tay
- Clinical Trials Center University of Zurich Zurich Switzerland
| | - N. Graf
- Graf Biostatistics Winterthur Switzerland
| | - P. Johansen
- Department of Dermatology University Hospital Zurich Zurich Switzerland
| | - T. M. Kündig
- Department of Dermatology University Hospital Zurich Zurich Switzerland
| |
Collapse
|
29
|
Scadding GW, Eifan AO, Lao‐Araya M, Penagos M, Poon SY, Steveling E, Yan R, Switzer A, Phippard D, Togias A, Shamji MH, Durham SR. Effect of grass pollen immunotherapy on clinical and local immune response to nasal allergen challenge. Allergy 2015; 70:689-96. [PMID: 25773990 PMCID: PMC4826905 DOI: 10.1111/all.12608] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2015] [Indexed: 02/03/2023]
Abstract
Rationale Nasal allergen provocations may be useful in investigating the pathophysiology of allergic rhinitis and effects of treatments. Objective To use grass pollen nasal allergen challenge (NAC) to investigate the effects of allergen immunotherapy in a cross‐sectional study. Methods We studied nasal and cutaneous responses in untreated subjects with seasonal grass‐pollen allergic rhinitis (n = 14) compared with immunotherapy‐treated allergics (n = 14), plus a nonatopic control group (n = 14). Volunteers underwent a standardized NAC with 2000 biological units of timothy grass allergen (equivalent to 1.3 μg major allergen, Phl p5). Nasal fluid was collected and analysed by ImmunoCAP and multiplex assays. Clinical response was assessed by symptom scores and peak nasal inspiratory flow (PNIF). Cutaneous response was measured by intradermal allergen injection. Retrospective seasonal symptom questionnaires were also completed. Results Immunotherapy‐treated patients had lower symptom scores (P = 0.04) and higher PNIF (P = 0.02) after challenge than untreated allergics. They had reduced early (P = 0.0007) and late (P < 0.0001) skin responses, and lower retrospective seasonal symptom scores (P < 0.0001). Compared to untreated allergics, immunotherapy‐treated patients had reduced nasal fluid concentrations of IL‐4, IL‐9 and eotaxin (all P < 0.05, 8 h level and/or area under the curve comparison), and trends for reduced IL‐13 (P = 0.07, area under the curve) and early‐phase tryptase levels (P = 0.06). Conclusions Nasal allergen challenge is sensitive in the detection of clinical and biological effects of allergen immunotherapy and may be a useful surrogate marker of treatment efficacy in future studies.
Collapse
Affiliation(s)
- G. W. Scadding
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
| | - A. O. Eifan
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
| | - M. Lao‐Araya
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
| | - M. Penagos
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
| | - S. Y. Poon
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
| | - E. Steveling
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
| | - R. Yan
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
| | - A. Switzer
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
| | | | - A. Togias
- The National Institute of Allergy and Infectious Diseases Bethesda MDUSA
| | - M. H. Shamji
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
| | - S. R. Durham
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
| |
Collapse
|
30
|
Mascarell L, Rak S, Worm M, Melac M, Soulie S, Lescaille G, Lemoine F, Jospin F, Paul S, Caplier L, Hasséus B, Björhn C, Zeldin RK, Baron-Bodo V, Moingeon P. Characterization of oral immune cells in birch pollen-allergic patients: impact of the oral allergy syndrome and sublingual allergen immunotherapy on antigen-presenting cells. Allergy 2015; 70:408-19. [PMID: 25631199 DOI: 10.1111/all.12576] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND A detailed characterization of human oral immune cells is needed to better understand local mechanisms associated with allergen capture following oral exposure. METHODS Oral immune cells were characterized by immunohistology and immunofluorescence in biopsies obtained from three healthy individuals and 23 birch pollen-allergic patients with/without oral allergy syndrome (OAS), at baseline and after 5 months of sublingual allergen immunotherapy (AIT). RESULTS Similar cell subsets (i.e., dendritic cells, mast cells, and T lymphocytes) were detected in oral tissues from healthy and birch pollen-allergic individuals. CD207+ Langerhans cells (LCs) and CD11c+ myeloid dendritic cells (DCs) were found in both the epithelium and the papillary layer of the Lamina propria (LP), whereas CD68+ macrophages, CD117+ mast cells, and CD4+ /CD8+ T cells were rather located in both the papillary and reticular layers of the LP. Patterns of oral immune cells were identical in patients with/without OAS, except lower numbers of CD207+ LCs found in oral tissues from patients with OAS, when compared to OAS- patients (P < 0.05). A 5-month sublingual AIT had a limited impact on oral immune cells, with only a significant increase in IgE+ cells in patients from the active group. Colocalization experiments confirmed that such IgE-expressing cells mostly encompass CD68+ macrophages located in the LP, and to a lesser extent CD207+ LCs in the epithelium. CONCLUSION Two cell subsets contribute to antigen/allergen uptake in human oral tissues, including (i) CD207+ LCs possibly involved in the physiopathology of OAS and (ii) CD68+ macrophages likely critical in allergen capture via IgE-facilitated mechanisms during sublingual AIT.
Collapse
Affiliation(s)
- L. Mascarell
- Research and Development; Stallergenes; Antony France
| | - S. Rak
- Department of Respiratory Diseases and Allergology; Institute of Medicine; The Sahlgrenska Academy at University of Göteborg; Göteborg Sweden
| | - M. Worm
- Klinik für Dermatologie; Venerologie und Allergologie; Allergie-Centrum-Charité; CCM; Charité - Universitätsmedizin; Berlin Germany
| | - M. Melac
- Research and Development; Stallergenes; Antony France
| | - S. Soulie
- Research and Development; Stallergenes; Antony France
| | - G. Lescaille
- Department of Odontology; AP-HP University Hospital La Pitié-Salpêtrière; Paris France
- Université Paris Diderot; Paris France
- Sorbonne Universités; UPMC Paris 06; UMR-S CR7 & INSERM; UMR-S 1135; CIMI-Paris; Paris France
| | - F. Lemoine
- Sorbonne Universités; UPMC Paris 06; UMR-S CR7 & INSERM; UMR-S 1135; CIMI-Paris; Paris France
| | - F. Jospin
- GIMAP EA3064; INSERM CIC1408 Vaccinologie; Universités de Lyon; Saint Etienne France
| | - S. Paul
- GIMAP EA3064; INSERM CIC1408 Vaccinologie; Universités de Lyon; Saint Etienne France
| | - L. Caplier
- BiodOxis; Laboratoire d’ Histo-cyto-pathologie Expérimentale; Romainville France
| | - B. Hasséus
- Institute of Odontology; Department of Oral Medicine and Pathology; The Sahlgrenska Academy at University of Göteborg; Göteborg Sweden
| | - C. Björhn
- ENT Clinic; Västmanlands Hospital Västerås; Västerås Sweden
| | - R. K. Zeldin
- Research and Development; Stallergenes; Antony France
| | - V. Baron-Bodo
- Research and Development; Stallergenes; Antony France
| | - P. Moingeon
- Research and Development; Stallergenes; Antony France
| |
Collapse
|
31
|
Network Meta-analysis Shows Commercialized Subcutaneous and Sublingual Grass Products Have Comparable Efficacy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:256-266.e3. [DOI: 10.1016/j.jaip.2014.09.018] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 09/12/2014] [Accepted: 09/16/2014] [Indexed: 01/29/2023]
|
32
|
|
33
|
Baron-Bodo V, Horiot S, Lautrette A, Chabre H, Drucbert AS, Danzé PM, Sénéchal H, Peltre G, Galvain S, Zeldin RK, Horak F, Moingeon P. Heterogeneity of antibody responses among clinical responders during grass pollen sublingual immunotherapy. Clin Exp Allergy 2014; 43:1362-73. [PMID: 24261946 DOI: 10.1111/cea.12187] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 07/17/2013] [Accepted: 08/15/2013] [Indexed: 01/03/2023]
Abstract
BACKGROUND During allergen-specific sublingual immunotherapy (SLIT), the relevance of changes in specific IgE and IgG antibody titres to treatment efficacy remains to be evaluated at an individual patient level. OBJECTIVE To investigate whether antibody responses can be used as biomarkers for SLIT efficacy. METHODS Comprehensive quantitative, qualitative and functional analyses of allergen-specific IgA, IgE, IgG1-4 and IgM responses were performed using purified Phl p 1 to 12 allergens in sera, saliva and nasal secretions from 82 grass pollen allergic patients. These patients were enrolled in a randomized, double-blind placebo-controlled study and assessed in an allergen challenge chamber (ClinicalTrials.gov NCT00619827). Antibody responses were monitored in parallel to clinical responses before and after daily sublingual treatment for 4 months with either a grass pollen or a placebo tablet. RESULTS A significant mean improvement (i.e. 33-40.6%) in rhinoconjunctivitis total symptom scores was observed in SLIT recipients, irrespective of their baseline patterns of IgE sensitization (i.e. narrow, intermediate, broad) to grass pollen allergens. SLIT did not induce any de novo IgE sensitization. Clinical responders encompassed both immunoreactive patients who exhibited strong increases in titres, affinity and/or blocking activity of grass-pollen-specific IgGs (representing 17% of treated patients), as well as patients with no detectable antibody responses distinguishing them from the placebo group. No significant changes were detected in antibody titres in saliva and nasal washes, even in clinical responders. CONCLUSIONS AND CLINICAL RELEVANCE Sublingual immunotherapy with a grass pollen tablet is efficacious irrespective of the patients' baseline sensitization to either single or multiple grass pollen allergens. Seric IgG responses may contribute to SLIT-induced clinical tolerance in a fraction (i.e. 17%) of patients, but additional immune mechanisms are involved in most patients. Consequently, antibody responses cannot be used as a marker of SLIT efficacy at an individual patient level.
Collapse
|
34
|
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.
Collapse
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
| |
Collapse
|
35
|
Castillo J, Dimov V. Investigational drugs for the treatment of allergic rhinitis. Expert Opin Investig Drugs 2014; 23:823-36. [PMID: 24708183 DOI: 10.1517/13543784.2014.907271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Allergic rhinitis is characterized by paroxysms of sneezing, rhinorrhea and nasal obstruction. Its prevalence is increasing in industrialized countries worldwide and imposes a significant economic burden as a result of reduced school performance, work productivity and medical expenses. Allergic rhinitis impairs the quality of life of those affected, and current treatment regimens are inadequate for those whose symptoms are severe or refractory to standard drug therapies. They mainly include symptom control with intranasal glucocorticoids, oral and intranasal antihistamines. AREAS COVERED This article provides a review of the most current literature on research that has focused on improving the efficacy of current treatment regimens and developing new drugs. It also provides the reader with an improved understanding of the pathogenesis of allergic rhinitis, including the inflammatory mediators and cell types involved, which has led to novel treatment options that are under investigation. These new drugs aim to alter the immunologic response to allergens in order to achieve greater clinical efficacy. EXPERT OPINION It is our opinion that despite developments in new therapies, a multidrug approach is vital for successful treatment of allergic rhinitis. Furthermore, immunotherapy in the form of sublingual immunotherapy is a promising additional therapeutic approach that will potentially make immunotherapy available to a wider selection of eligible patients with allergic rhinitis.
Collapse
Affiliation(s)
- Jamee Castillo
- University of Chicago, Department of Internal Medicine , 5841 S. Maryland Ave. MC 7082, Chicago, IL 60637 , USA
| | | |
Collapse
|
36
|
Shamji MH. Mechanisms of Allergen-Specific Sublingual Immunotherapy and the Use of Biological Markers in Allergic Rhinitis. CURRENT TREATMENT OPTIONS IN ALLERGY 2014. [DOI: 10.1007/s40521-013-0009-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
37
|
Allergen Immunotherapy: Clinical Outcomes Assessment. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:123-9; quiz 130. [DOI: 10.1016/j.jaip.2014.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/20/2014] [Accepted: 01/22/2014] [Indexed: 12/16/2022]
|
38
|
Sublingual Immunotherapy for Aeroallergens: Optimal Patient Dosing, Regimen and Duration. CURRENT TREATMENT OPTIONS IN ALLERGY 2014. [DOI: 10.1007/s40521-013-0002-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
39
|
Affiliation(s)
- Su Young Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, Kyung Hee Medical Center, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sung Wan Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Kyung Hee Medical Center, Kyung Hee University School of Medicine, Seoul, Korea
| |
Collapse
|
40
|
Liu LL, Wan KS, Cheng CF, Tsai MH, Wu YL, Wu WF. Effectiveness of MORA electronic homeopathic copies of remedies for allergic rhinitis: A short-term, randomized, placebo-controlled PILOT study. Eur J Integr Med 2013. [DOI: 10.1016/j.eujim.2012.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
41
|
Efficacy of subcutaneous and sublingual immunotherapy with grass allergens for seasonal allergic rhinitis: a meta-analysis-based comparison. J Allergy Clin Immunol 2012; 130:1097-1107.e2. [PMID: 23021885 DOI: 10.1016/j.jaci.2012.08.012] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 07/31/2012] [Accepted: 08/09/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Subcutaneous (SCIT) and sublingual (SLIT) immunotherapy are the 2 most prescribed routes for administering allergen-specific immunotherapy. They were shown to be effective in control of symptoms and in reducing rescue medication use in patients with allergic diseases, but their effectiveness has to be balanced against side effects. In recent years, SLIT has been increasingly prescribed, instead of SCIT, because of improved safety and easy administration. OBJECTIVE We assessed which route is the most effective in the treatment of patients with seasonal allergic rhinitis to grass pollen. METHODS An indirect meta-analysis-based comparison between SCIT and SLIT was performed. Treatment efficacy was determined as the standardized mean difference (SMD) in symptom and medication scores obtained with active treatment, SCIT or SLIT, compared with placebo. Studies were included if they were double-blind randomized controlled trials comparing SCIT or SLIT with placebo. Thirty-six randomized controlled trials (3014 patients; 2768 controls) were analyzed. RESULTS The overall effect size of SCIT for symptom score (SMD, -0.92; 95%CI, -1.26 to -0.58) was significantly higher than SLIT, both administered via drops (SMD, -0.25; 95% CI, -0.45 to -0.05) and tablets (SMD, -0.40; 95%CI, -0.54 to -0.27). Similar results were reported for medication score (SCIT: SMD, -0.58; 95% CI, -0.86 to -0.30. SLIT drops: SMD, -0.37; 95% CI, -0.74 to -0.00. SLIT tablets SMD, -0.30; 95% CI, -0.44 to -0.16). CONCLUSIONS Our results provide indirect but solid evidence that SCIT is more effective than SLIT in controlling symptoms and in reducing the use of antiallergic medications in seasonal allergic rhinoconjuntivitis to grass pollen.
Collapse
|
42
|
Rotiroti G, Shamji M, Durham SR, Till SJ. Repeated low-dose intradermal allergen injection suppresses allergen-induced cutaneous late responses. J Allergy Clin Immunol 2012; 130:918-24.e1. [PMID: 22971521 DOI: 10.1016/j.jaci.2012.06.052] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 04/30/2012] [Accepted: 06/22/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND Subcutaneous immunotherapy with high-dose grass pollen was first described more than 100 years ago. This treatment suppresses allergen-induced cutaneous late responses, with lesser effects on early responses. In contrast, low-dose subcutaneous immunotherapy has not shown clinical benefit. Uncontrolled reports from the early 20th century describe low-dose allergen inoculation directly into the dermis, an immunologically active area containing abundant dendritic cells and lymphatics. OBJECTIVE We sought to investigate the effect of low-dose intradermal grass pollen administration on cutaneous reactivity to allergen. METHODS Thirty adults sensitized to grass and tree pollens were randomized to receive (1) 6 repeat intradermal injections at 2-week intervals of grass pollen extract (estimated 7 ng of the major grass allergen Phl p 5 per injection), (2) 2 intradermal injections separated by 10 weeks, or (3) a single intradermal injection at 10 weeks. At the end of the study, cutaneous early and late responses were measured after double-blind intradermal injection with grass and birch pollen. RESULTS Participants who received 6 fortnightly intradermal grass pollen injections had markedly smaller cutaneous late responses to grass pollen than control subjects who received 2 injections separated by 10 weeks (P < .01) or a single injection (P < .001) and showed induction of grass pollen-specific IgG antibodies. Suppression was observed whether late responses were measured on the arms or the back. However, early responses were equivalent in all groups. CONCLUSION Low-dose intradermal allergen, like conventional subcutaneous high-dose immmunotherapy, suppresses allergen-induced cutaneous late responses in a manner that is allergen specific, systemic, and associated with induction of IgG antibodies.
Collapse
Affiliation(s)
- Giuseppina Rotiroti
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | | | | |
Collapse
|
43
|
Can Serum-Specific IgE/Total IgE Ratio Predict Clinical Response to Allergen-Specific Immunotherapy in Children Monosensitized to House Dust Mite? J Allergy (Cairo) 2012; 2012:694094. [PMID: 22536274 PMCID: PMC3321312 DOI: 10.1155/2012/694094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 01/24/2012] [Accepted: 01/24/2012] [Indexed: 11/18/2022] Open
Abstract
Background. Allergen-specific immunotherapy (SIT) is one of the important regimens for the treatment of allergic diseases. Predictive tests for the clinical response to SIT are limited. In this study we aimed to evaluate whether specific IgE/total IgE levels can predict clinical improvement in monosensitized patients to house dust mite treated with immunotherapy. Patients and Methods. We analyzed 32 patients who had undergone 2 years of SIT. Serum t-IgE and s-IgE levels, and serum s-IgE/t-IgE ratios were calculated and tested for correlation with clinical response to SIT. Asthma symptom score (ASS), rhinitis symptom score (RSS), pulmonary functions and visual analogue scales (VAS) were evaluated at the beginning and after 2 years. Results. There were 17 boys and 15 girls with the mean age of 10.78 ± 3.03 years. The mean serum house dust mite s-IgE level was 128.62 ± 142.61 kU/L, t-IgE 608.90 ± 529.98 IU/mL, and s-IgE/t-IgE ratio 33.83 ± 53.18. Before immunotherapy, ASS was 6.23 ± 1.63, RSS; 8.20 ± 1.88, VAS; 7.38 ± 2.01, FEV1 (%); 89.14 ± 8.48, PEF (%); 88.93 ± 13.57, and after 2 years, these values were determined as 1.90 ± 1.10, 3.05 ± 1.39, 1.35 ± 1.24, 97.6 ± 11.26, and 97.0 ± 11.55, respectively. s-IgE/t-IgE ratio was correlated with change in RSS (r = −0.392, P = 0.08) and VAS (r = −0.367, P = 0.05). Conclusion. Although SIT is very effective treatment, all patients do not benefit from treatment. We assumed that s-IgE/t-IgE ratio would be useful to predict the clinical response to SIT.
Collapse
|
44
|
Bahceciler NN, Cobanoglu N. Subcutaneous versus sublingual immunotherapy for allergic rhinitis and/or asthma. Immunotherapy 2012; 3:747-56. [PMID: 21668312 DOI: 10.2217/imt.11.48] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Subcutaneous allergen-specific immunotherapy has long been used in allergic rhinitis and/or asthma and has been recognized to be efficacious. However, owing to the inconvenience of injection and the risk of serious side effects, alternative concepts inspiring the search for effective noninjective routes, namely sublingual administration of allergens, have emerged. Sublingual immunotherapy (SLIT) appears to be associated with a lower incidence of systemic reactions. The clinical efficacy of subcutaneous immunotherapy (SCIT) is well established for both rhinitis and asthma. Meta-analyses relating to its efficacy on asthma and rhinitis are available. SLIT has also been validated in this respect. Comparative clinical studies of SLIT versus SCIT are scarce demonstrating both routes to be clinically efficient. Knowledge of the exact mechanism of action of SLIT has been increasing in the last decade. In addition, recent studies have proved similarities of the immunological changes with the treatment of both routes. Further comparative clinical and immunological studies of SLIT versus SCIT are needed to confirm the long-term efficacy and to complete the knowledge of immunological mechanisms of both routes. Moreover, better understanding of the interaction of allergen and oral mucosal dendritic cells during SLIT may allow improved targeting of SLIT vaccines.
Collapse
|
45
|
Abstract
PURPOSE OF REVIEW To summarize novel insights into the immunological mechanisms of sublingual immunotherapy (SLIT). Within the recent decades, several alternative noninvasive allergen application strategies have been investigated in allergen-specific immunotherapy (AIT), of which intra-oral allergen application to sublingual mucosa has been proven to be well tolerated and effective. RECENT FINDINGS To date, SLIT is widely accepted by most allergists as an alternative option to conventional subcutaneous immunotherapy (SCIT). Although detailed immunological mechanisms remain to be elucidated, much scientific effort has been made to shed some light on local and systemic immunological responses to SLIT in mice as well as humans. Only a few studies focused on the detailed mechanisms following allergen application to the oral mucosa as part of the sophisticated mucosal immunological network. Within this network, the pro-tolerogenic properties of local antigen-presenting cells (APCs) such as dendritic cells - which are able to enforce tolerogenic mechanisms and to induce T-cell immune responses - play a central role. Further on, basic research focused not only on the immune response in nasal and bronchial mucosa but also on the systemic T-cell immune response. SUMMARY Thus, much exiting data have been published providing a better understanding of immunological features of SLIT but far more investigations are necessary to uncover further exciting details on the key mechanisms of SLIT.
Collapse
|
46
|
Mondoulet L, Dioszeghy V, Ligouis M, Dhelft V, Puteaux E, Dupont C, Benhamou PH. Epicutaneous Immunotherapy Compared with Sublingual Immunotherapy in Mice Sensitized to Pollen (Phleum pratense). ISRN ALLERGY 2012; 2012:375735. [PMID: 23724241 PMCID: PMC3658791 DOI: 10.5402/2012/375735] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 01/04/2012] [Indexed: 01/30/2023]
Abstract
Background. The aim of this study was to compare the efficacy of epicutaneous immunotherapy (EPIT) to sublingual immunotherapy (SLIT) in a model of mice sensitized to Phleum pratense pollen. Methods. BALB/c mice were sensitized by sub-cutaneous route to pollen protein extract mixed treated for 8 weeks, using sham, EPIT, or SLIT. Measurements involved the serological response and cytokine profile from reactivated splenocytes, plethysmography after aerosol challenge to pollen, cell, and cytokine contents in the bronchoalveolar lavages (BALs). Results. After immunotherapy, sIgE was significantly decreased in the treated groups compared to sham (P < 0.001), whereas sIgG2a increased with EPIT and SLIT (P < 0.001 and P < 0.005 versus sham). Reactivated splenocytes secreted higher levels of Th2 cytokines with sham (P < 0.01). Penh values were higher in sham than EPIT and SLIT. Eosinophil recruitment in BAL was significantly reduced only by EPIT (P < 0.01). Conclusion. In this model of mice sensitized to pollen, EPIT was at least as efficient as SLIT.
Collapse
|
47
|
Abstract
Sublingual immunotherapy (SLIT) has been shown to be safe and efficacious in treating allergic rhinitis. It has been used in Europe for more than 20 years, and interest in the United States is increasing. SLIT has been shown to elicit immunologic changes similar to subcutaneous injection immunotherapy. SLIT may prevent new sensitizations, improve asthma control, and decrease asthma development in allergic individuals. Although differences in antigen quantification and standardization make European dosing schemes difficult to translate in the United States, several new studies suggest the range for effective dosing. Further studies will help clarify optimal dosing.
Collapse
Affiliation(s)
- Sandra Y Lin
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
| | | |
Collapse
|
48
|
Nelson HS. Subcutaneous injection immunotherapy for optimal effectiveness. Immunol Allergy Clin North Am 2011; 31:211-26, viii. [PMID: 21530815 DOI: 10.1016/j.iac.2011.02.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Immunotherapy by the subcutaneous injection of increasing doses and then maintenance doses of extracts of inhalant allergens has been practiced for 100 years. Controlled clinical trials have established its efficacy in treating allergic rhinitis, asthma, and stinging insect sensitivity, and there are preliminary data to suggest a favorable response in some patients with atopic dermatitis. The response to subcutaneous injection immunotherapy is dose dependent. Disease-modifying actions include blocking development of new sensitivities in monosensitized patients, blocking progression to asthma in patients with allergic rhinitis, and persistence of treatment effects for up to 7 to 10 years after an initial course.
Collapse
Affiliation(s)
- Harold S Nelson
- Department of Medicine, National Jewish Health and University of Colorado School of Medicine, 1400 Jackson Street, Denver, CO 80206, USA.
| |
Collapse
|
49
|
An evidence-based appraisal of the surrogate markers of efficacy of allergen immunotherapy. Curr Opin Allergy Clin Immunol 2011; 11:375-80. [DOI: 10.1097/aci.0b013e328348a7cd] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
50
|
Immunologic effects and tolerability profile of in-season initiation of a standardized-quality grass allergy immunotherapy tablet: a phase III, multicenter, randomized, double-blind, placebo-controlled trial in adults with grass pollen-induced rhinoconjunctivitis. Clin Ther 2011; 33:828-40. [PMID: 21741092 DOI: 10.1016/j.clinthera.2011.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND The summary of product characteristics of the grass allergy immunotherapy tablet (AIT) (Phleum pratense grass pollen allergen extract) states that clinical effect may be observed in the first pollen season of treatment, if treatment is initiated ≥2 months (8 weeks) before the start of the grass pollen season. However, because patients with grass allergy may first present to physicians during the season, immediate treatment initiation (ie, in-season initiation) may increase treatment compliance and reduce the risk for disease progression compared with asking patients to return before the next pollen season to initiate treatment. This "in-season approach" may offer more patients the potentially beneficial treatment option of specific immunotherapy. However, to date, the immunomodulatory effects and tolerability of in-season treatment initiation is unknown. OBJECTIVE The aim of this study was to assess the immunologic effects and tolerability of in-season initiation of treatment with the grass AIT. METHODS This multicenter, randomized, double-blind, placebo-controlled trial was carried out in Germany and Austria. Adults with grass pollen allergy (positive skin-prick test and specific grass-pollen immunoglobulin [Ig] E) and grass pollen-induced moderate to severe persistent rhinoconjunctivitis were enrolled. Patients were randomly assigned to receive once-daily grass AIT or placebo, starting during the 2008 grass pollen season and continuing for 8 to 10 weeks. The primary end point was change from baseline in IgE-blocking factor (serum components competing with IgE for allergen binding). Secondary end points included changes from baseline in specific IgE and IgG(4) and measures of tolerability (assessed mainly by adverse events [AEs]). Blood samples for immunologic assessment were obtained by the investigators at baseline and after treatment. All AEs observed by the investigator and/or reported by the patient were recorded throughout the trial and follow-up. RESULTS A total of 276 patients were enrolled and formed the full analysis set (mean age, 35 years; 55% men, 45% women; 99% white; mean weight, 76 kg; history of asthma, 41%; mean duration of grass allergy, 15.1 years). No major differences in medical history were found between the grass AIT group (n = 219) and the placebo group (n = 57). The change from baseline in mean concentration of IgE-blocking factor was significantly greater with grass AIT compared with placebo (+0.14 vs +0.05; P < 0.0001). The changes from baseline in specific IgE and specific IgG(4) concentrations were significantly greater with AIT compared with placebo (IgE, +0.59 vs +0.21 log kU/L; IgG(4), +0.18 vs +0.04 log relative units; both, P < 0.0001). At least 1 AE was reported in 58% of patients in the AIT group and in 40% of patients in the placebo group. Most AEs considered related to AIT were mild or moderate events in the mouth, throat, and/or ears (eg, oral pruritus). Four serious AEs were reported in the AIT group (sinusitis, road traffic accident, salmonellosis, meniscus lesion), but all were considered unlikely to be related to treatment. Three percent of the grass AIT group and 2% of the placebo group were withdrawn from the trial due to an AE. CONCLUSIONS In-season initiation of grass AIT was associated with an immunomodulatory response in terms of induction of IgE-blocking factor, specific IgE, and specific IgG(4). In-season initiation of grass AIT was generally well tolerated in this group of adults with moderate to severe grass pollen-induced rhinoconjunctivitis. These findings are consistent with those related to the preseasonal initiation of AIT therapy.
Collapse
|