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Gurgel RK, Baroody FM, Damask CC, Mims JW, Ishman SL, Baker DP, Contrera KJ, Farid FS, Fornadley JA, Gardner DD, Henry LR, Kim J, Levy JM, Reger CM, Ritz HJ, Stachler RJ, Valdez TA, Reyes J, Dhepyasuwan N. Clinical Practice Guideline: Immunotherapy for Inhalant Allergy. Otolaryngol Head Neck Surg 2024; 170 Suppl 1:S1-S42. [PMID: 38408152 DOI: 10.1002/ohn.648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care. PURPOSE The purpose of this clinical practice guideline (CPG) is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce the risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS The GDG made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitizations, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions (LRs) to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The GDG offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.
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Affiliation(s)
| | - Fuad M Baroody
- The University of Chicago Medicine, Chicago, Illinois, USA
| | | | - James Whit Mims
- Wake Forest Baptist Health, Winston Salem, North Carolina, USA
| | | | - Dole P Baker
- Anderson ENT & Facial Plastics, Anderson, South Carolina, USA
| | | | | | - John A Fornadley
- Associated Otolaryngologists of PA, Inc, Hershey, Pennsylvania, USA
| | | | | | - Jean Kim
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua M Levy
- National Institute on Deafness and Other Communication Disorders, Bethesda, Maryland, USA
| | - Christine M Reger
- Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | - Joe Reyes
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Kappen J, Diamant Z, Agache I, Bonini M, Bousquet J, Canonica GW, Durham SR, Guibas GV, Hamelmann E, Jutel M, Papadopoulos NG, Roberts G, Shamji MH, Zieglmayer P, Gerth van Wijk R, Pfaar O. Standardization of clinical outcomes used in allergen immunotherapy in allergic asthma: An EAACI position paper. Allergy 2023; 78:2835-2850. [PMID: 37449468 DOI: 10.1111/all.15817] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/17/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION In allergic asthma patients, one of the more common phenotypes might benefit from allergen immunotherapy (AIT) as add-on intervention to pharmacological treatment. AIT is a treatment with disease-modifying modalities, the evidence for efficacy is based on controlled clinical trials following standardized endpoint measures. However, so far there is a lack of a consensus for asthma endpoints in AIT trials. The aim of a task force (TF) of the European Academy of Allergy and Clinical Immunology (EAACI) is evaluating several outcome measures for AIT in allergic asthma. METHODS The following domains of outcome measures in asthmatic patients have been evaluated for this position paper (PP): (i) exacerbation rate, (ii) lung function, (iii) ICS withdrawal, (iv) symptoms and rescue medication use, (v) questionnaires (PROMS), (vi) bronchial/nasal provocation, (vii) allergen exposure chambers (AEC) and (viii) biomarkers. RESULTS Exacerbation rate can be used as a reliable objective primary outcome; however, there is limited evidence due to different definitions of exacerbation. The time after ICS withdrawal to first exacerbation is considered a primary outcome measure. Besides, the advantages and disadvantages and clinical implications of further domains of asthma endpoints in AIT trials are elaborated in this PP. CONCLUSION This EAACI-PP aims to highlight important aspects of current asthma measures by critically evaluating their applicability for controlled trials of AIT.
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Affiliation(s)
- Jasper Kappen
- Department of Pulmonology, STZ Centre of Excellence for Asthma, COPD and Respiratory Allergy, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
- Department of National Heart and Lung Institute, Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Imperial College London, London, UK
| | - Zuzana Diamant
- Departmentt of Microbiology Immunology & Transplantation, KU Leuven, Catholic University of Leuven, Leuven, Belgium
- Department of Respiratory Medicine & Allergology, Institute for Clinical Science, Skane University Hospital, Lund University, Lund, Sweden
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | | | - Matteo Bonini
- Department of National Heart and Lung Institute, Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Imperial College London, London, UK
- Department of Cardiovascular and Thoracic Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Clinical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Jean Bousquet
- Charite Universitatsmedizin Berlin Campus Berlin Buch, MASK-air, Montpellier, France
| | - G Walter Canonica
- Personalized Medicine Asthma & Allergy Clinic Humanitas University & Research Hospital-IRCCS, Milan, Italy
| | - Stephen R Durham
- Department of National Heart and Lung Institute, Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Imperial College London, London, UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - George V Guibas
- Department of Allergy and Clinical Immunology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
- School of Biological Sciences, Medicine and Health, University of Manchester, Manchester, UK
| | - Eckard Hamelmann
- Children's Center Bethel, University Hospital Bielefeld, University Bielefeld, Bielefeld, Germany
| | - Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
- ALL-MED Medical Research Institute, Wroclaw, Poland
| | | | - Graham Roberts
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport, UK
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Paediatric Allergy and Respiratory Medicine (MP803), Clinical & Experimental Sciences & Human Development in Health Academic Units University of Southampton Faculty of Medicine & University Hospital Southampton, Southampton, UK
| | - Mohamed H Shamji
- Department of National Heart and Lung Institute, Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Imperial College London, London, UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - Petra Zieglmayer
- Karl Landsteiner University, Competence Center for Allergology and Immunology, Krems, Austria
| | - Roy Gerth van Wijk
- Section of Allergology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
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Su Q, Ren N, Feng M, Zeng X, Dong Y, Xian M, Shi X, Luo T, Liu G, Li J. Specific immunoglobulin G4 correlates with Th2 cytokine reduction in patients with allergic asthma treated by Dermatophagoides pteronyssinus subcutaneous immunotherapy. World Allergy Organ J 2023; 16:100715. [PMID: 36820309 PMCID: PMC9937843 DOI: 10.1016/j.waojou.2022.100715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 01/27/2023] Open
Abstract
Background The modulations of lymphocyte subsets and cytokine production due to subcutaneous allergen immunotherapy (SCIT) are not fully clarified. Objective We investigated the changes in T-lymphocyte subsets and serum Dermatophagoides pteronyssinus-specific immunoglobulin G4 (Der-p sIgG4), as well as cytokine production during Der-p SCIT, in patients with allergic asthma. Methods This study involved 20 patients with allergic asthma who were receiving 156-week Der-p SCIT and 20 patients without SCIT (non-SCIT). We measured symptom and medication scores (SMS), serum Der-p sIgG4 levels, CD4+CD25+Foxp3+ T regulatory (Treg), CD4+IL-4-IFN-γ+ T-helper (Th) 1, and CD4+IL-4+IFN-γ- Th2 lymphocyte percentages in peripheral blood mononuclear cells (PBMCs) with/without Der-p extract stimulation at weeks 0, 4, 12, 16, 52, 104, and 156. Cytokine release inhibition assays were performed by incubation with serum from SCIT and non-SCIT patients, Der-p allergen, and PBMCs. Levels of interleukin (IL)-4, IL-5, IL-10, IL-13, IL-17, interferon (IFN)-γ, tumor necrosis factor (TNF)-α, and transforming growth factor (TGF)-β1 were evaluated in supernatant. Results We found that SCIT patients had significantly lower SMS after week 52. Der-p sIgG4 levels in SCIT patients significantly increased at week 16 compared with non-SCIT subjects. CD4+IL-4+IFN-γ- Th2% in SCIT patients showed a significant decrease from weeks 104-156 compared with week 0, while no change was observed in CD4+CD25+Foxp3+ Treg and CD4+IL-4-IFN-γ+ Th1 percentages. IL-5, IL-13, IL-4, IL-17, and TNF-α levels in supernatant of PBMCs cultured with serum of SCIT patients after 16 weeks showed significant lower levels compared with non-SCIT patients, and showed significant reverse associations with Der-p sIgG4 levels. Conclusion SCIT induced Dep-p sIgG4 may be involved in downregulating Th2 cytokine production in Der-p allergic asthma patients.
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Affiliation(s)
- Qiujuan Su
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Nina Ren
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China,Department of Respiratory Medicine, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Mulin Feng
- Yangjiang Key Laboratory of Respiratory Disease, Department of Respiratory Medicine, People's Hospital of Yangjiang, Yangjiang, China
| | - Xueni Zeng
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yan Dong
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Mo Xian
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xu Shi
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Tian Luo
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Gang Liu
- Clinical Research Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Jing Li
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China,Yangjiang Key Laboratory of Respiratory Disease, Department of Respiratory Medicine, People's Hospital of Yangjiang, Yangjiang, China,Corresponding author. Department of Allergy and Clinical Immunology, State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China.
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Rosenberg D, Palmon P. Approaches to Management of Asthma: Guidelines for Stepped Care and Self-Monitoring. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1426:355-375. [PMID: 37464128 DOI: 10.1007/978-3-031-32259-4_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
While the twentieth century brought rapid changes to the diagnosis and management of asthma, consensus guidelines did not exist until the mid-1980s. Over the subsequent four decades, guidelines evolved from expert-based recommendations to comprehensive, evidenced-based references. The main two guidelines to be discussed in this chapter are the expert panel reports (EPR) published by the United States National Heart, Lung, and Blood Institute (NHLBI) and the Global Strategy for Asthma Management and Prevention Report (GINA) published by the NHLBI and World Health Organization (WHO). While these guidelines both focus on evidence-based approaches to the diagnosis and management of asthma, there are significant differences in both organization and recommendations. Just as the introduction of evidence-based guidelines was revolutionary to asthma management over the last 20 years, we anticipate further development of recommendations specific to precision medicine based on ongoing cutting-edge clinical research.
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Affiliation(s)
- Daniel Rosenberg
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Madison, WI, USA.
| | - Philip Palmon
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Lee DL, Baptist AP. Understanding the Updates in the Asthma Guidelines. Semin Respir Crit Care Med 2022; 43:595-612. [PMID: 35728605 DOI: 10.1055/s-0042-1745747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Asthma is a chronic inflammatory lung disease that affects millions of Americans, with variable symptoms of bronchospasm and obstruction among individuals over time. The National Heart, Lung, and Blood Institute (NHLBI) published the 2020 Focused Updates to the Asthma Management Guidelines based on the latest research since the 2007 Expert Panel Report-3 (EPR-3). The following article reviews the 21 new recommendations on the six core topics in asthma: use of intermittent inhaled corticosteroids, long-acting muscarinic antagonist therapy, use of the fractional exhaled nitric oxide test in asthma diagnosis and monitoring, indoor allergen mitigation, immunotherapy, and bronchial thermoplasty. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to rate recommendations as strong or conditional based on the evidence. The recommendations were based on systematic reviews of the literature and focused on patient-centered critical outcomes of asthma exacerbations, asthma control, and asthma-related quality of life. Understanding the recommendations with consideration of individual values through shared decision-making may improve asthma outcomes.
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Affiliation(s)
- Deborah L Lee
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, MI
| | - Alan P Baptist
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, MI
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Eremija J, Carr TF. Immunotherapy for Asthma. Semin Respir Crit Care Med 2022; 43:709-719. [PMID: 35714626 DOI: 10.1055/s-0042-1749454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Asthma represents one of the biggest global health concerns with increasing prevalence and influence on global health. Several distinct asthma phenotypes have been identified with one of the most common, earliest recognized, and described being the allergic asthma phenotype, in which allergens trigger asthma through mechanisms involving allergen-specific immunoglobulin E (IgE). Allergen-specific immunotherapy (AIT), in the forms of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT), has been used for many decades as a tool for reducing IgE-mediated sensitization and controlling symptoms of allergic disease, most commonly for allergic rhinitis, and it remains the only currently available disease modifying therapy in atopic patients. AIT has been studied for use in mild to moderate allergic asthma. While the data are often inconsistent, and utilize a multitude of different methods, antigens, and outcome measures, in general, AIT may have several beneficial effects on asthma disease control, quality of life, and requirement for medication. These benefits are notable when immunotherapy is used as an adjunct to pharmacologic treatment in carefully selected and monitored patients with mild to moderate persistent asthma. Patients with severe asthma are excluded from these trials. Importantly, patients with asthma, and in particular severe asthma, may have a higher rate of systemic adverse reactions to SCIT, including anaphylaxis, however, these events are overall rare. Future research in the area is needed to definitively assess the benefit of SCIT and SLIT for patients with asthma, comparing outcomes with different methods, addressing the role of AIT in severe asthma, significance of multiallergen AIT in allergic asthma, and safety concerns in asthma.
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Affiliation(s)
- Jelena Eremija
- Section of Allergy & Immunology, Department of Medicine, Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
| | - Tara F Carr
- Section of Allergy & Immunology, Department of Medicine, Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
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Chipps BE, Murphy KR, Oppenheimer J. 2020 NAEPP Guidelines Update and GINA 2021-Asthma Care Differences, Overlap, and Challenges. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:S19-S30. [PMID: 34718214 DOI: 10.1016/j.jaip.2021.10.032] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/29/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022]
Abstract
The 2020 National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group (NAEPP [2020 Focused Asthma Update]) guidelines and the Global Initiative for Asthma (GINA) 2021 strategy report are compared in this Rostrum article. The methodologies of each publication are described. Subsequently, 4 different selected pharmacological recommendations are compared in the 2 documents: step 1 for children 0 to 4 years of age with viral-induced wheezing, step 2 in ages 12 years and older with the intermittent use of inhaled corticosteroid, steps 3 and 4 with single-inhaler maintenance and reliever therapy with inhaled corticosteroids-formoterol (SMART), and steps 3, 4, and 5 with add-on long-acting muscarinic antagonist therapy. Nonpharmacological recommendations are also considered and contrasted, including for exhaled nitric oxide, environmental control, immunotherapy, and bronchial thermoplasty. Similarities and differences in these 2 documents are highlighted, and recommendations are made about harmonizing the approaches where possible.
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Affiliation(s)
- Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, Calif.
| | - Kevin R Murphy
- Boys Town National Research Hospital, Section of Adult and Pediatric Allergy and Pediatric Pulmonary, Boystown, Neb
| | - John Oppenheimer
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ
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Controversies in Allergy: A Pro/Con Review of Sublingual Allergen Immunotherapy and Allergic Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1818-1825. [PMID: 33652134 DOI: 10.1016/j.jaip.2021.02.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/18/2021] [Accepted: 02/18/2021] [Indexed: 12/12/2022]
Abstract
Sublingual allergen immunotherapy (SLIT) is a therapeutic intervention used in the treatment of respiratory allergies, including asthma. Multiple randomized, double-blind, placebo controlled clinical trials have evaluated the efficacy and safety of SLIT for asthma. These data provide a good platform to appraise the evidence critically to evaluate the effect of SLIT in the management of asthma for the administration of SLIT by both SLIT drops and SLIT tablets, from a clinical perspective. In this clinical review, presented in a pro and con format, we examined (1) evidence from systematic reviews and meta-analyses; (2) clinical efficacy on asthma symptoms, asthma exacerbations, and quality of life; (3) clinical efficacy on reduction of asthma controller medication; (4) asthma severity; (5) safety profile; (6) long-term effect and prevention; (7) international guidelines, and (8) real-world evidence. Identified inconsistency in the data results from wide variations and differences in outcome measures, specific allergens, delivery approaches, schedules, and age groups. The house dust mite SLIT tablet demonstrated efficacy when it was used in the add-on management of house dust mite-associated allergic asthma in adults. Sublingual allergen immunotherapy for asthma may represent an important advance in incorporating a personalized medicine approach for patients with allergic asthma.
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Tabar AI, Delgado J, González-Mancebo E, Arroabarren E, Soto Retes L, Domínguez-Ortega J. Recent Advances in Allergen-Specific Immunotherapy as Treatment for Allergic Asthma: A Practical Overview. Int Arch Allergy Immunol 2021; 182:496-514. [PMID: 33631755 DOI: 10.1159/000513811] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 12/11/2020] [Indexed: 11/19/2022] Open
Abstract
The Global Initiative for Asthma Report updated in 2019 stated that potential benefits of allergen immunotherapy (AIT), compared to pharmacological and avoidance options, must be weighed against the risk of adverse effects and the inconvenience and cost of the prolonged course of therapy in asthma. Thus, with the aim of clarifying some aspects with regard to the possible use of AIT in allergic asthma treatment armamentarium, a group of expert allergists from the Spanish Allergy and Clinical Immunology Scientific Society (SEAIC), particularly from the Immunotherapy and Asthma Interest Groups developed a frequently asked questions in clinical practice. This document updates relevant topics on the use of AIT in asthma and could facilitate physician clinical decisions and improve health outcomes for individual patients.
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Affiliation(s)
- Ana I Tabar
- Department of Allergy, Hospital Complex of Navarra, Pamplona, Spain, .,Navarra Institute for Health Research (IdiSNA), Cooperative Health Research Thematic Networks (RETICs) for Asthma, Adverse Reactions to Drugs, and Allergy (ARADYAL) Research Network, Pamplona, Spain,
| | - Julio Delgado
- Clinical Management for Allergy Unit, University Hospital Virgen Macarena, Seville, Spain
| | - Eloina González-Mancebo
- Department of Allergy, University Hospital Fuenlabrada, La Paz Hospital Institute for Health Research (IdiPAZ), Madrid, Spain.,Cooperative Health Research Thematic Networks (RETICs) for Asthma, Adverse Reactions to Drugs and Allergy (ARADYAL) Research Network, Madrid, Spain
| | | | - Lorena Soto Retes
- Department of Pneumology and Allergy, Santa Creu i Sant Pau Hospital, Barcelona, Spain.,Department of Medicine, Sant Pau Biomedical Research Institute (IIB Sant Pau), Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - Javier Domínguez-Ortega
- Department of Allergy, La Paz Hospital Institute for Health Research (IdiPAZ), CIBER of Respiratory Diseases, CIBERES, Madrid, Spain
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A Retrospective Nationwide Non-Interventional Study of an Aqueous Sublingual Immunotherapy Formulation Administered with a 200-µL Dosing Pump. Drugs Real World Outcomes 2021; 8:241-251. [PMID: 33591547 PMCID: PMC8128946 DOI: 10.1007/s40801-021-00233-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 11/27/2022] Open
Abstract
Background Convenient dosing is a key component of treatment adherence and thus efficacy and safety. Aqueous sublingual immunotherapy (SLIT) formulations can be administered with a dosing pump that delivers 200 µL of volume per actuation. Objective The objective of this study was to describe the use of Staloral® 300 Rapid in its new dosing pump presentation and to evaluate the safety and satisfaction from both the patient and doctor. Patients and Methods We performed a retrospective non-interventional study in a population (aged 5 years or over) of individuals with allergic rhinitis or allergic asthma who were being treated with aqueous 300 index of reactivity SLIT formulations of various allergens (grass pollen, tree pollen, house dust mites). Based on a detailed, SLIT-specific, patient self-questionnaire (Quartis®) and the inspection of medical records, we assessed the characteristics of the SLIT, safety, patient satisfaction and willingness to continue SLIT. The physician’s satisfaction with the treatment was measured on a 0–100 visual analogue scale. Adverse events were coded with the Medical Dictionary for Regulatory Activities. Results A total of 801 valid patients were included (52.4% male; mean ± standard deviation age: 25.9 ± 17.2 years; mean time since diagnosis: 4.56 ± 4.68 years; mean time using the previous dosing pump: 19.2 ± 13.0 months; time using the 200-µL dosing pump: 14.95 ± 3.80 months). Among the study population, 317 subjects comprised the paediatric subgroup (57%: male; mean age: 9.8 ± 2.5 years). Overall, 54 patients (6.7%) reported a total of 68 adverse events (including 51 gastrointestinal adverse events). The large majority of adverse events were mild, local and transient and did not require treatment. There were no severe adverse events. The level of patient satisfaction with the ease of SLIT administration was high (84.3% overall, and 82.6% in the paediatric subgroup). The mean ± standard deviation visual analogue scale score for physician satisfaction with the treatment was 70.6 ± 25.1 out of 100. Conclusions Administration of 300 index of reactivity SLIT with a 200-µL dosing pump is safe, well tolerated and associated with good levels of patient satisfaction.
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Cloutier MM, Dixon AE, Krishnan JA, Lemanske RF, Pace W, Schatz M. Managing Asthma in Adolescents and Adults: 2020 Asthma Guideline Update From the National Asthma Education and Prevention Program. JAMA 2020; 324:2301-2317. [PMID: 33270095 DOI: 10.1001/jama.2020.21974] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Asthma is a major public health problem worldwide and is associated with excess morbidity, mortality, and economic costs associated with lost productivity. The National Asthma Education and Prevention Program has released the 2020 Asthma Guideline Update with updated evidence-based recommendations for treatment of patients with asthma. OBJECTIVE To report updated recommendations for 6 topics for clinical management of adolescents and adults with asthma: (1) intermittent inhaled corticosteroids (ICSs); (2) add-on long-acting muscarinic antagonists; (3) fractional exhaled nitric oxide; (4) indoor allergen mitigation; (5) immunotherapy; and (6) bronchial thermoplasty. EVIDENCE REVIEW The National Heart, Lung, and Blood Advisory Council chose 6 topics to update the 2007 asthma guidelines based on results from a 2014 needs assessment. The Agency for Healthcare Research and Quality conducted systematic reviews of these 6 topics based on literature searches up to March-April 2017. Reviews were updated through October 2018 and used by an expert panel (n = 19) that included asthma content experts, primary care clinicians, dissemination and implementation experts, and health policy experts to develop 19 new recommendations using the GRADE method. The 17 recommendations for individuals aged 12 years or older are reported in this Special Communication. FINDINGS From 20 572 identified references, 475 were included in the 6 systematic reviews to form the evidence basis for these recommendations. Compared with the 2007 guideline, there was no recommended change in step 1 (intermittent asthma) therapy (as-needed short-acting β2-agonists [SABAs] for rescue therapy). In step 2 (mild persistent asthma), either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy are recommended. Formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) is recommended as the preferred therapy for moderate persistent asthma in step 3 (low-dose ICS-formoterol therapy) and step 4 (medium-dose ICS-formoterol therapy) for both daily and as-needed therapy. A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended. Add-on long-acting muscarinic antagonists are recommended in individuals whose asthma is not controlled by ICS-formoterol therapy for step 5 (moderate-severe persistent asthma). Fractional exhaled nitric oxide testing is recommended to assist in diagnosis and monitoring of symptoms, but not alone to diagnose or monitor asthma. Allergen mitigation is recommended only in individuals with exposure and relevant sensitivity or symptoms. When used, allergen mitigation should be allergen specific and include multiple allergen-specific mitigation strategies. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma. Bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort. CONCLUSIONS AND RELEVANCE Asthma is a common disease with substantial human and economic costs globally. Although there is no cure or established means of prevention, effective treatment is available. Use of the recommendations in the 2020 Asthma Guideline Update should improve the health of individuals with asthma.
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Affiliation(s)
| | | | - Jerry A Krishnan
- University of Illinois Hospital and Health Sciences System, Chicago
| | - Robert F Lemanske
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Wilson Pace
- University of Colorado School of Medicine, Aurora
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente Medical Center, San Diego, California
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12
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Cloutier MM, Baptist AP, Blake KV, Brooks EG, Bryant-Stephens T, DiMango E, Dixon AE, Elward KS, Hartert T, Krishnan JA, Lemanske RF, Ouellette DR, Pace WD, Schatz M, Skolnik NS, Stout JW, Teach SJ, Umscheid CA, Walsh CG. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol 2020; 146:1217-1270. [PMID: 33280709 PMCID: PMC7924476 DOI: 10.1016/j.jaci.2020.10.003] [Citation(s) in RCA: 434] [Impact Index Per Article: 108.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 12/22/2022]
Abstract
The 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group was coordinated and supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. It is designed to improve patient care and support informed decision making about asthma management in the clinical setting. This update addresses six priority topic areas as determined by the state of the science at the time of a needs assessment, and input from multiple stakeholders:A rigorous process was undertaken to develop these evidence-based guidelines. The Agency for Healthcare Research and Quality's (AHRQ) Evidence-Based Practice Centers conducted systematic reviews on these topics, which were used by the Expert Panel Working Group as a basis for developing recommendations and guidance. The Expert Panel used GRADE (Grading of Recommendations, Assessment, Development and Evaluation), an internationally accepted framework, in consultation with an experienced methodology team for determining the certainty of evidence and the direction and strength of recommendations based on the evidence. Practical implementation guidance for each recommendation incorporates findings from NHLBI-led patient, caregiver, and clinician focus groups. To assist clincians in implementing these recommendations into patient care, the new recommendations have been integrated into the existing Expert Panel Report-3 (EPR-3) asthma management step diagram format.
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Affiliation(s)
- Michelle M Cloutier
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Alan P Baptist
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Kathryn V Blake
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Edward G Brooks
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Tyra Bryant-Stephens
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Emily DiMango
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Anne E Dixon
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Kurtis S Elward
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Tina Hartert
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Jerry A Krishnan
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Robert F Lemanske
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Daniel R Ouellette
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Wilson D Pace
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Michael Schatz
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Neil S Skolnik
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - James W Stout
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Stephen J Teach
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Craig A Umscheid
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Colin G Walsh
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
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Abstract
BACKGROUND Asthma is a common long-term respiratory disease affecting approximately 300 million people worldwide. Approximately half of people with asthma have an important allergic component to their disease, which may provide an opportunity for targeted treatment. Sublingual immunotherapy (SLIT) aims to reduce asthma symptoms by delivering increasing doses of an allergen (e.g. house dust mite, pollen extract) under the tongue to induce immune tolerance. Fifty-two studies were identified and synthesised in the original Cochrane Review in 2015, but questions remained about the safety and efficacy of sublingual immunotherapy for people with asthma. OBJECTIVES To assess the efficacy and safety of sublingual immunotherapy compared with placebo or standard care for adults and children with asthma. SEARCH METHODS The original searches for trials from the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov, WHO ICTRP, and reference lists of all primary studies and review articles found trials up to 25 March 2015. The most recent search for trials for the current update was conducted on 29 October 2019. SELECTION CRITERIA We included parallel randomised controlled trials, irrespective of blinding or duration, that evaluated sublingual immunotherapy versus placebo or as an add-on to standard asthma management. We included both adults and children with asthma of any severity and with any allergen-sensitisation pattern. We included studies that recruited participants with asthma, rhinitis, or both, providing at least 80% of trial participants had a diagnosis of asthma. We selected outcomes to reflect recommended outcomes for asthma clinical trials and those most important to people with asthma. Primary outcomes were asthma exacerbations requiring a visit to the emergency department (ED) or admission to hospital, validated measures of quality of life, and all-cause serious adverse events (SAEs). Secondary outcomes were asthma symptom scores, exacerbations requiring systemic corticosteroids, response to provocation tests, and dose of inhaled corticosteroids (ICS). DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results for included trials, extracted numerical data, and assessed risk of bias, all of which were cross-checked for accuracy. Any disagreements were resolved by discussion. We analysed dichotomous data as odds ratios (ORs) or risk differences (RDs) using study participants as the unit of analysis; we analysed continuous data as mean differences (MDs) or standardised mean differences (SMDs) using random-effects models. We considered the strength of evidence for all primary and secondary outcomes using the GRADE approach. MAIN RESULTS Sixty-six studies met the inclusion criteria for this update, including 52 studies from the original review. Most studies were double-blind and placebo-controlled, varied in duration from one day to three years, and recruited participants with mild or intermittent asthma, often with comorbid allergic rhinitis. Twenty-three studies recruited adults and teenagers; 31 recruited only children; three recruited both; and nine did not specify. The pattern of reporting and results remained largely unchanged from the original review despite 14 further studies and a 50% increase in participants studied (5077 to 7944). Reporting of primary efficacy outcomes to measure the impact of SLIT on asthma exacerbations and quality of life was infrequent, and selective reporting may have had a serious effect on the completeness of the evidence; 16 studies did not contribute any data, and a further six studies could only be included in a post hoc analysis of all adverse events. Allocation procedures were generally not well described; about a quarter of the studies were at high risk of performance or detection bias (or both); and participant attrition was high or unknown in around half of the studies. The primary outcome in most studies did not align with those of interest to the review (mostly asthma or rhinitis symptoms), and only two small studies reported our primary outcome of exacerbations requiring an ED or hospital visit; the pooled estimate from these studies suggests SLIT may reduce exacerbations compared with placebo or usual care, but the evidence is very uncertain (OR 0.35, 95% confidence interval (CI) 0.10 to 1.20; n = 108; very low-certainty evidence). Nine studies reporting quality of life could not be combined in a meta-analysis and, whilst the direction of effect mostly favoured SLIT, the effects were often uncertain and small. SLIT likely does not increase SAEs compared with placebo or usual care, and analysis by risk difference suggests no more than 1 in 100 people taking SLIT will have a serious adverse event (RD -0.0004, 95% CI -0.0072 to 0.0064; participants = 4810; studies = 29; moderate-certainty evidence). Regarding secondary outcomes, asthma symptom and medication scores were mostly measured with non-validated scales, which precluded meaningful meta-analysis or interpretation, but there was a general trend of SLIT benefit over placebo. Changes in ICS use (MD -17.13 µg/d, 95% CI -61.19 to 26.93; low-certainty evidence), exacerbations requiring oral steroids (studies = 2; no events), and bronchial provocation (SMD 0.99, 95% CI 0.17 to 1.82; low-certainty evidence) were not often reported. Results were imprecise and included the possibility of important benefit or little effect and, in some cases, potential harm from SLIT. More people taking SLIT had adverse events of any kind compared with control (OR 1.99, 95% CI 1.49 to 2.67; high-certainty evidence; participants = 4251; studies = 27), but events were usually reported to be transient and mild. Lack of data prevented most of the planned subgroup and sensitivity analyses. AUTHORS' CONCLUSIONS Despite continued study in the field, the evidence for important outcomes such as exacerbations and quality of life remains too limited to draw clinically useful conclusions about the efficacy of SLIT for people with asthma. Trials mostly recruited mixed populations with mild and intermittent asthma and/or rhinitis and focused on non-validated symptom and medication scores. The review findings suggest that SLIT may be a safe option for people with well-controlled mild-to-moderate asthma and rhinitis who are likely to be at low risk of serious harm, but the role of SLIT for people with uncontrolled asthma requires further evaluation.
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Affiliation(s)
- Rebecca Fortescue
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Kayleigh M Kew
- Cochrane Editorial and Methods Department, Cochrane, London, UK
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14
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Evidence and Practicalities of Aqueous Sublingual Immunotherapy, Tablet Sublingual Immunotherapy, and Oral Mucosal Immunotherapy for Allergic Rhinitis and Allergic Asthma. CURRENT OTORHINOLARYNGOLOGY REPORTS 2020. [DOI: 10.1007/s40136-020-00268-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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15
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Feng M, Zeng X, Su Q, Shi X, Xian M, Qin R, Li J. Allergen Immunotherapy-Induced Immunoglobulin G4 Reduces Basophil Activation in House Dust Mite-Allergic Asthma Patients. Front Cell Dev Biol 2020; 8:30. [PMID: 32154245 PMCID: PMC7044416 DOI: 10.3389/fcell.2020.00030] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 01/14/2020] [Indexed: 12/12/2022] Open
Abstract
It is unclear if allergen immunotherapy (AIT) can reduce allergy effector cell activation. We evaluated the basophil response during Dermatophagoides pteronyssinus (Der p) subcutaneous immunotherapy (SCIT) and its relationship to allergen-specific immunoglobulin G4 (sIgG4) in allergic rhinitis and/or asthma patients. The study included 55 subjects, of which 35 cases received Der p SCIT and 20 controls received standard medications. Symptom and medication scores (SMSs), sIgG4 levels, specific immunoglobulin E (sIgE) levels, allergen-induced basophil activation tests (BATs) in whole blood, and BAT inhibition assays in serum were determined at weeks 0, 4, 12, 16, 52, and 104 of SCIT. Levels of Der p sIgG4 in SCIT patients significantly increased after 12 weeks of treatment compared to week 0. Serum obtained from SCIT patients significantly inhibited basophil activation after 12 weeks of treatment. Removal of immunoglobulin G4 (IgG4) antibodies at week 104 reduced the ability of serum to block basophil activation. An increase of Der p sIgG4 rather than reduction of Der p sIgE correlated with the reduction of basophil activation during SCIT. The sIgG4 antibodies may compete with sIgE binding to allergens to form an immunoglobulin E (IgE)-allergen complex. SCIT reduced the sensitivity of allergen-triggered basophil activation in Der p allergic rhinitis and/or asthma patients through induction of sIgG4.
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Affiliation(s)
| | | | | | | | | | | | - Jing Li
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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16
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Novakova P, Tiotiu A, Baiardini I, Krusheva B, Chong-Neto H, Novakova S. Allergen immunotherapy in asthma: current evidence. J Asthma 2019; 58:223-230. [PMID: 31638840 DOI: 10.1080/02770903.2019.1684517] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: Allergic asthma is the predominant phenotype in clinical practice. Allergen immunotherapy is the only curative and specific approach for the treatment of allergies with clinical benefits for several years after its discontinuation. Despite advances, the use of allergen immunotherapy in allergic asthma is still suboptimal and controversial.Objective: The purpose of this article is to review the published data about the impact of allergen immunotherapy with the most commonly used allergen extracts on allergic asthma outcomes, including both clinical parameters and patients' subjective experience (quality of life).Methods: As data sources several databases were used, including PubMed, Scopus, Web of Science (2002-2019) and search in English and Spanish languages was performed using the following terms: "allergen immunotherapy" and "asthma" in combination with "house dust mite", "birch pollen", "grass pollen", "olive tree pollen", "molds", "pets" and "asthma quality of life". Randomised control trials and meta-analysis from reviewed publications were selected.Results: Emerging data relating to the positive impact on asthma outcomes of allergen immunotherapy allows the addition of this treatment as a therapeutic option in mild to moderate asthmatics sensitized to house dust mite and pollens. Limited data are available for patients sensitized to molds and pets, as well in severe allergic asthma population.Conclusion: Allergen immunotherapy remains a potential therapeutic option for some patients with allergic asthma. Further research is needed to define the optimal period of treatment, the possible therapeutic role in the treatment of severe allergic asthma, and the cost-effectiveness of allergen immunotherapy in asthmatic patients.
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Affiliation(s)
- Plamena Novakova
- Clinic of Clinical Allergy, Medical University Sofia, Sofia, Bulgaria
| | - Angelica Tiotiu
- Department of Pulmonology, University Hospital of Nancy, Nancy, France.,EA3450 DevAH - Development, Adaptation and Disadvantage. Cardio-Respiratory Regulations and Motor Control, University of Lorraine, Nancy, France.,Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
| | - Ilaria Baiardini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Borislava Krusheva
- Department of Allergology and Asthma, Aleksandrovska University Hospital, Sofia, Bulgaria
| | - Herberto Chong-Neto
- Division of Allergy and Immunology, Department of Pediatrics, Federal University of Paraná, Curitiba, Brazil
| | - Silviya Novakova
- Allergy Unit, Internal Consulting Department, University Hospital "St. George", Plovdiv, Bulgaria
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17
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Agache I, Lau S, Akdis CA, Smolinska S, Bonini M, Cavkaytar O, Flood B, Gajdanowicz P, Izuhara K, Kalayci O, Mosges R, Palomares O, Papadopoulos NG, Sokolowska M, Angier E, Fernandez‐Rivas M, Pajno G, Pfaar O, Roberts G, Ryan D, Sturm GJ, Ree R, Varga EM, Wijk RG, Yepes‐Nuñez J, Jutel M. EAACI Guidelines on Allergen Immunotherapy: House dust mite-driven allergic asthma. Allergy 2019; 74:855-873. [PMID: 31095767 DOI: 10.1111/all.13749] [Citation(s) in RCA: 168] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/12/2019] [Indexed: 12/14/2022]
Abstract
Allergen immunotherapy (AIT) has been in use for the treatment of allergic disease for more than 100 years. Asthma treatment relies mainly on corticosteroids and other controllers recommended to achieve and maintain asthma control, prevent exacerbations, and improve quality of life. AIT is underused in asthma, both in children and in adults. Notably, patients with allergic asthma not adequately controlled on pharmacotherapy (including biologics) represent an unmet health need. The European Academy of Allergy and Clinical Immunology has developed a clinical practice guideline providing evidence-based recommendations for the use of house dust mites (HDM) AIT as add-on treatment for HDM-driven allergic asthma. This guideline was developed by a multi-disciplinary working group using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. HDM AIT was separately evaluated by route of administration and children and adults: subcutaneous (SCIT) and sublingual AIT (SLIT), drops, and tablets. Recommendations were formulated for each. The important prerequisites for successful treatment with HDM AIT are (a) selection of patients most likely to respond to AIT and (b) use of allergen extracts and desensitization protocols of proven efficacy. To date, only AIT with HDM SLIT-tablet has demonstrated a robust effect in adults for critical end points (exacerbations, asthma control, and safety). Thus, it is recommended as an add-on to regular asthma therapy for adults with controlled or partially controlled HDM-driven allergic asthma (conditional recommendation, moderate-quality evidence). HDM SCIT is recommended for adults and children, and SLIT drops are recommended for children with controlled HDM-driven allergic asthma as the add-on to regular asthma therapy to decrease symptoms and medication needs (conditional recommendation, low-quality evidence).
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Affiliation(s)
- Ioana Agache
- Faculty of Medicine Department of Allergy and Clinical Immunology Transylvania University Brasov Brasov Romania
| | - Susanne Lau
- Department for Pediatric Pneumology, Immunology and Intensive Care Charité Universität Medizin Berlin Germany
| | - Cezmi A. Akdis
- University of Zürich Swiss Institute of Allergy and Asthma Research (SIAF) Davos Switzerland
- Christine Kühne‐Center for Allergy Research and Education (CK‐CARE) Davos Switzerland
| | - Sylwia Smolinska
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- “ALL‐MED” Medical Research Institute Wroclaw Poland
| | - Matteo Bonini
- National Heart and Lung Institute (NHLI) Royal Brompton Hospital & Imperial College London UK
| | - Ozlem Cavkaytar
- Faculty of Medicine Department of Pediatric Allergy Istanbul Medeniyet University Goztepe Training and Research Hospital Istanbul Turkey
| | - Breda Flood
- European Federation of Allergy and Airways Diseases, Patients Association Brussels Belgium
| | - Pawe Gajdanowicz
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
| | | | - Omer Kalayci
- Hacettepe University School of Medicine Ankara Turkey
| | - Ralph Mosges
- Universität zu Koln Institute of Medical Statistics, Informatics and Epidemiology (IMSIE) Koln Germany
| | - Oscar Palomares
- Department of Biochemistry and Molecular Biology Complutense University of Madrid Madrid Spain
| | - Nikolaos G. Papadopoulos
- Division of Infection, Immunity and respiratory medicine University of Manchester Manchester UK
- Allergy Department 2nd Pediatric Clinic University of Athens Athens Greece
| | - Milena Sokolowska
- University of Zürich Swiss Institute of Allergy and Asthma Research (SIAF) Davos Switzerland
- Christine Kühne‐Center for Allergy Research and Education (CK‐CARE) Davos Switzerland
| | | | | | - Giovanni Pajno
- Allergy Unit Department of Pediatrics University of Messina Messina Italy
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital Marburg Philipps‐Universität Marburg Marburg Germany
| | - Graham C. Roberts
- The David Hide Asthma and Allergy Research Centre St Mary's Hospital Newport Isle of Wight UK
- NIHR Biomedical Research Centre University Hospital Southampton NHS Foundation Trust Southampton UK
- Faculty of Medicine University of Southampton Southampton UK
| | - Dermot Ryan
- Usher Institute of Population Health Sciences and Informatics University of Edinburgh Edinburgh UK
- Asthma UK Centre for Applied Research The University of Edinburgh Edinburgh UK
| | - Gunter J. Sturm
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
- Outpatient Allergy Clinic Reumannplaz Vienna Austria
| | - Ronald Ree
- Department of Experimental Immunology Academic Medical Center University of Amsterdam Amsterdam The Netherlands
- Department of Otorhinolaryngology Academic Medical Center University of Amsterdam Amsterdam The Netherlands
| | - Eva M. Varga
- Department of Pediatric and Adolescent Medicine Respiratory and Allergic Disease Division Medical University of Graz Graz Austria
| | - Roy Gerth Wijk
- Section of Allergology Department of Internal Medicine Erasmus Medical Center Rotterdam The Netherlands
| | | | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- “ALL‐MED” Medical Research Institute Wroclaw Poland
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Pfaar O, Lou H, Zhang Y, Klimek L, Zhang L. Recent developments and highlights in allergen immunotherapy. Allergy 2018; 73:2274-2289. [PMID: 30372537 DOI: 10.1111/all.13652] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 10/22/2018] [Accepted: 10/22/2018] [Indexed: 12/30/2022]
Abstract
Allergen immunotherapy (AIT) is the only disease-modifying treatment option for patients with IgE-mediated inhalant allergies. Though used in clinical practice for more than 100 years, most innovations in AIT efficacy and safety have been developed in the last two decades. This expert review aimed to highlight the recent progress in AIT for both application routes, the sublingual (SLIT) and subcutaneous (SCIT) forms. As such, it covers recent aspects regarding efficacy and safety in clinical trials and real-life data and outlines new concepts in consensus and position papers as well as in guidelines for AIT. Potential clinical and nonclinical biomarkers are discussed. This review also focuses on potential future perspectives in AIT, such as alternative application routes, immune-modulating adjuvants, and recombinant vaccines. In conclusion, this state of the art review provides a comprehensive overview of AIT and highlights unmet needs for the future.
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Affiliation(s)
- Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery; Section of Rhinology and Allergy; University Hospital Marburg; Philipps-Universität Marburg; Marburg Germany
| | - Hongfei Lou
- Department of Otolaryngology; Head and Neck Surgery; Beijing TongRen Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Nasal Diseases; Beijing Institute of Otolaryngology; Beijing China
- Department of Allergy; Beijing TongRen Hospital; Capital Medical University; Beijing China
| | - Yuan Zhang
- Department of Otolaryngology; Head and Neck Surgery; Beijing TongRen Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Nasal Diseases; Beijing Institute of Otolaryngology; Beijing China
- Department of Allergy; Beijing TongRen Hospital; Capital Medical University; Beijing China
| | - Ludger Klimek
- Center for Rhinology and Allergology; Wiesbaden Germany
| | - Luo Zhang
- Department of Otolaryngology; Head and Neck Surgery; Beijing TongRen Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Nasal Diseases; Beijing Institute of Otolaryngology; Beijing China
- Department of Allergy; Beijing TongRen Hospital; Capital Medical University; Beijing China
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19
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Blanco C, Bazire R, Argiz L, Hernández-Peña J. Sublingual allergen immunotherapy for respiratory allergy: a systematic review. Drugs Context 2018; 7:212552. [PMID: 30416528 PMCID: PMC6220898 DOI: 10.7573/dic.212552] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 01/01/2023] Open
Abstract
The objective of the systematic review is to provide complete and updated information on efficacy and safety of sublingual immunotherapy (SLIT) formulations for the treatment of allergic respiratory diseases (ARDs). The literature search was conducted on PubMed database, involving double-blind, randomized clinical trials published between January 1992 and 2018, written in English, and performed in humans. The number of articles finally selected for review was 112. Data from the majority of properly controlled clinical trials demonstrate that SLIT is effective not only with short-term use (first year) but also with long-term use (up to the third year of active therapy), for treating ARDs in children and adults. Both continuous and discontinuous schemes of administration showed significant reductions in symptom and medication scores. Moreover, a SLIT-induced disease-modifying effect has been documented mainly with grass pollen extracts, since improvement is maintained during at least 2 years of follow-up after a 3-year treatment period. Additionally, allergen immunotherapy should also be considered a preventive strategy, especially for decreasing bronchial asthma incidence in children and adolescents with allergic rhinitis treated with SLIT. This therapy is also safe, producing only a few mainly local and mild-to-moderate adverse events, and usually self-limited in time. The registration and authorization of allergen SLIT preparations (grasses and house-dust mite tablets) as drugs by regulatory agencies, such as the United States Food and Drug Administration (FDA) and the European Medicines Agency (EMA), has represented a landmark in allergy immunotherapy research. Further long-term studies, specially designed with allergens other than grass pollen or house-dust mites, not only in allergic rhinoconjunctivitis but also on asthmatic subjects, as well as studies comparing different administration schedules and/or routes, are required in order to continue the progress in the modern development of this particularly promising therapy.
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Affiliation(s)
- Carlos Blanco
- Allergy Service, University Hospital La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
- RETIC ARADYAL RD16/0006/0015, Instituto de Salud Carlos III, Madrid, Spain
| | - Raphaelle Bazire
- Allergy Service, University Hospital La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
| | - Laura Argiz
- Allergy Service, University Hospital La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
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20
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Abstract
PURPOSE OF REVIEW The review provides an overview of the results of asthma clinical trials published in peer review journals in the last 18 months that evaluated patient-reported outcomes (PROs). RECENT FINDINGS In the last 10 years, health care moved toward a patient-centered approach, which includes patients' perspectives reflecting the impact of a disease and its treatment. SUMMARY Surprisingly, among the almost 300 clinical trials published in the last one and a half year, PRO evaluation was performed in only 20 studies, and none of them held in a real-life setting. The effort of applying the scientific methods of PRO investigations in asthma clinical trials following a rigorous and systematic approach needs to be highly improved to allow better understanding of patient reported factors. Some recommendations are drawn particularly about PRO assessment in personalized medicine research. The ability of an individual PRO to evaluate choice of treatment and its effectiveness remains to be achieved.
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Abstract
House dust mite (HDM) is a predominant source of indoor aeroallergen worldwide, which induces allergic diseases including allergic rhinoconjunctivitis, allergic asthma, atopic eczema and other allergic skin diseases. Allergen specific immunotherapy (AIT) is the only potential disease-modifying treatment of HDM allergic subjects. However, AIT remains underused due to no universally accepted allergen standardization and a shortage of rigorous clinical studies to confirm safety and efficacy. With the effort of doctors and researchers in allergy field, efficacy, safety, standardization and strategy of AIT are being continuously developed. This review presents the updated research based on recently published trials and meta-analyses.
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Affiliation(s)
- Lin Yang
- a Department of Allergy , Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology , Wuhan , China
| | - Rongfei Zhu
- a Department of Allergy , Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology , Wuhan , China
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22
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Lin SY, Azar A, Suarez-Cuervo C, Diette GB, Brigham E, Rice J, Ramanathan M, Robinson KA. Role of sublingual immunotherapy in the treatment of asthma: An updated systematic review. Int Forum Allergy Rhinol 2018; 8:982-992. [PMID: 29885036 DOI: 10.1002/alr.22152] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 04/21/2018] [Accepted: 05/08/2018] [Indexed: 11/05/2022]
Abstract
BACKGROUND The purpose of the systematic review is to evaluate the efficacy and safety of sublingual immunotherapy (SLIT) for the treatment of allergic asthma. METHODS PubMed, Embase, and CENTRAL databases were searched, updating an earlier review (January 1, 2005 through May 8, 2017). Randomized, controlled studies (RCTs) were included, which reported one of the prespecified outcomes: asthma symptoms measured by control composite scores; quality of life; medication use; pulmonary physiology; and health-care utilization. For safety outcomes, RCTs and observational studies were included. Two independent reviewers extracted data, assessed risk of bias, and graded strength of evidence (SOE) for each outcome. RESULTS Fourteen RCTs (n = 2585) assessed the efficacy of SLIT for asthma. The RCTs utilized house dust mite (HDM), birch, or grass allergen. SLIT improved asthma symptoms (high SOE), decreased use of long-term control medication, and improved forced expiratory volume in 1 second (FEV1 ) (moderate SOE). SLIT may decrease quick-relief medication use, and improve disease-specific quality of life (low SOE). For safety, 20 RCTs and 10 observational studies (n = 3621) were identified. Local (risk differences ranged from -0.03 to +0.765) and systemic allergic reactions (risk differences ranged from -0.03 to +0.06) were a common occurrence in SLIT and control groups. Life-threatening reactions were uncommon, with 3 cases of anaphylaxis and no deaths reported. CONCLUSION There is moderate-to-high strength evidence that SLIT improves allergic asthma symptoms, reduces long-term control medication use, and improves FEV1 based on studies of HDM, birch, and grass. SLIT rarely is associated with life-threatening adverse events.
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Affiliation(s)
- Sandra Y Lin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Antoine Azar
- Department of Medicine, Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Catalina Suarez-Cuervo
- School of Public Health-Health and Policy Management, EPC, Johns Hopkins University, Baltimore, MD
| | - Gregory B Diette
- Department of Medicine, Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emily Brigham
- Department of Medicine, Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jessica Rice
- Department of Pediatrics, Pediatric Pulmonology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Murugappan Ramanathan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Karen A Robinson
- Department of Medicine, General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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23
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Feng M, Su Q, Lai X, Xian M, Shi X, Wurtzen PA, Qin R, Zeng X, Li J. Functional and Immunoreactive Levels of IgG4 Correlate with Clinical Responses during the Maintenance Phase of House Dust Mite Immunotherapy. THE JOURNAL OF IMMUNOLOGY 2018; 200:3897-3904. [DOI: 10.4049/jimmunol.1701690] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 04/04/2018] [Indexed: 12/24/2022]
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24
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Zhang W, Lin C, Sampath V, Nadeau K. Impact of allergen immunotherapy in allergic asthma. Immunotherapy 2018; 10:579-593. [PMID: 29569506 DOI: 10.2217/imt-2017-0138] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Although traditional pharmacological approaches improve outcomes in disease management for allergic asthma, these fail to modify the underlying immune responses. Allergen immunotherapy remains the only etiological therapy for the treatment of respiratory allergies for which clinical efficacy has been demonstrated through several well-controlled studies. In this review, we examine evidence from the past 5 years regarding the impact of allergen immunotherapy on allergic asthma to inform practitioners and stimulate further discussion and research.
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Affiliation(s)
- Wenming Zhang
- Sean N. Parker Center for Allergy & Asthma Research, Stanford University, Stanford, CA 94305, USA
| | - Chunrong Lin
- Sean N. Parker Center for Allergy & Asthma Research, Stanford University, Stanford, CA 94305, USA
| | - Vanitha Sampath
- Sean N. Parker Center for Allergy & Asthma Research, Stanford University, Stanford, CA 94305, USA
| | - Kari Nadeau
- Sean N. Parker Center for Allergy & Asthma Research, Stanford University, Stanford, CA 94305, USA
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25
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Dhami S, Kakourou A, Asamoah F, Agache I, Lau S, Jutel M, Muraro A, Roberts G, Akdis CA, Bonini M, Cavkaytar O, Flood B, Gajdanowicz P, Izuhara K, Kalayci Ö, Mosges R, Palomares O, Pfaar O, Smolinska S, Sokolowska M, Asaria M, Netuveli G, Zaman H, Akhlaq A, Sheikh A. Allergen immunotherapy for allergic asthma: A systematic review and meta-analysis. Allergy 2017; 72:1825-1848. [PMID: 28543086 DOI: 10.1111/all.13208] [Citation(s) in RCA: 205] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND To inform the development of the European Academy of Allergy and Clinical Immunology's (EAACI) Guidelines on Allergen Immunotherapy (AIT) for allergic asthma, we assessed the evidence on the effectiveness, cost-effectiveness and safety of AIT. METHODS We performed a systematic review, which involved searching nine databases. Studies were screened against predefined eligibility criteria and critically appraised using established instruments. Data were synthesized using random-effects meta-analyses. RESULTS 98 studies satisfied the inclusion criteria. Short-term symptom scores were reduced with a standardized mean difference (SMD) of -1.11 (95% CI -1.66, -0.56). This was robust to a prespecified sensitivity analyses, but there was evidence suggestive of publication bias. Short-term medication scores were reduced SMD -1.21 (95% CI -1.87, -0.54), again with evidence of potential publication bias. There was no reduction in short-term combined medication and symptom scores SMD 0.17 (95% CI -0.23, 0.58), but one study showed a beneficial long-term effect. For secondary outcomes, subcutaneous immunotherapy (SCIT) improved quality of life and decreased allergen-specific airway hyperreactivity (AHR), but this was not the case for sublingual immunotherapy (SLIT). There were no consistent effects on asthma control, exacerbations, lung function, and nonspecific AHR. AIT resulted in a modest increased risk of adverse events (AEs). Although relatively uncommon, systemic AEs were more frequent with SCIT; however no fatalities were reported. The limited evidence on cost-effectiveness was mainly available for sublingual immunotherapy (SLIT) and this suggested that SLIT is likely to be cost-effective. CONCLUSIONS AIT can achieve substantial reductions in short-term symptom and medication scores in allergic asthma. It was however associated with a modest increased risk of systemic and local AEs. More data are needed in relation to secondary outcomes, longer-term effectiveness and cost-effectiveness.
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Affiliation(s)
- S. Dhami
- Evidence-Based Health Care Ltd; Edinburgh UK
| | - A. Kakourou
- Department of Hygiene and Epidemiology; University of Ioannina School of Medicine; Ioannina Greece
| | - F. Asamoah
- Centre for Environmental and Preventive Medicine; Wolfson Institute of Preventive Medicine Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
| | - I. Agache
- Faculty of Medicine; Department of Allergy and Clinical Immunology; Transylvania University Brasov; Brasov Romania
| | - S. Lau
- Department of Pediatric Pneumology and Immunology; Charité Universitätsmedizin; Berlin Germany
| | - M. Jutel
- Wroclaw Medical University; Wroclaw Poland
- ALL-MED Medical Research Institute; Wroclaw Poland
| | - A. Muraro
- Food Allergy Referral Centre Veneto Region; University Hospital of Padua; Padua Italy
| | - G. Roberts
- The David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Newport UK
- NIHR Biomedical Research Centre; University Hospital Southampton NHS Foundation Trust; Southampton UK
- Faculty of Medicine; University of Southampton; Southampton UK
| | - C. A. Akdis
- Swiss Institute for Allergy and Asthma Research; Christine Kühne-Center for Allergy Research and Education (CK-CARE); Davos Switzerland
| | - M. Bonini
- National Heart and Lung Institute; Imperial College London; London UK
| | - O. Cavkaytar
- Department of Allergy and Clinical Immunology; Sami Ulus Women's & Children's Diseases Training and Research Hospital; Ankara Turkey
- Department of Pediatric Allergy and Immunology; Ulus Women's & Children's Diseases Training and Research Hospital; Ankara Turkey
| | - B. Flood
- European Federation of Allergy and Airways Diseases Patients Association; Brussels Belgium
| | | | | | | | - R. Mosges
- Institute of Medical Statistics, Informatics and Epidemiology (IMSIE); University of Cologne; Köln Germany
| | - O. Palomares
- Department of Biochemistry and Molecular Biology; Complutense University of Madrid; Madrid Spain
| | - 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
| | - S. Smolinska
- Wroclaw Medical University; Wroclaw Poland
- ALL-MED Medical Research Institute; Wroclaw Poland
| | - M. Sokolowska
- Swiss Institute for Allergy and Asthma Research; Christine Kühne-Center for Allergy Research and Education (CK-CARE); Davos Switzerland
| | - M. Asaria
- Centre for Health Economics; University of York; York UK
| | - G. Netuveli
- Institute for Health and Human Development; University of East London; London UK
| | - H. Zaman
- Bradford School of Pharmacy; Bradford UK
| | - A. Akhlaq
- Health and Hospital Management; Institute of Business Management; Karachi Pakistan
| | - A. Sheikh
- Asthma UK Centre for Applied Research; The University of Edinburgh; Edinburgh UK
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26
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Bieber T, Vieths S, Broich K. New opportunities and challenges in the assessment of drugs for atopic diseases. Allergy 2016; 71:1662-1665. [PMID: 27716946 DOI: 10.1111/all.13063] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2016] [Indexed: 01/10/2023]
Abstract
Atopic conditions (atopic dermatitis, rhinitis, and asthma) belong to the most common noncommunicable diseases and are driven by chronic inflammatory reactions. They have a strong impact on the quality of life and represent a substantial and growing socio-economic burden. Interestingly, there is an increasing interest in the development of new therapeutic options with a number of biologics and small molecules targeting potential key mechanisms in atopic conditions. However, besides the safety issue, most of the new active substances are still evaluated according to the traditional efficacy paradigm focusing on the success in treating exacerbations and flares. Instead, the future approaches in drug development and assessment should rather concentrate on the long-term control of these diseases and consider their potential as disease-modifying strategies in the era of precision medicine. To reach this goal, a number of unsolved issues have to be addressed and consensually accepted by the stakeholders in this field. Thus, a successful and rapid development of new treatments requests a paradigm shift and a new way of thinking in the mind of physicians, pharmaceutical industry, regulators, and HTAs. This seems mandatory in order to optimize drug development and to facilitate the accessibility of new therapies to the growing population of patients suffering from atopic conditions on a global level.
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Affiliation(s)
- T. Bieber
- Department of Dermatology and Allergy; Christine Kühne-Center for Allergy Research and Education; University Medical Center; Bonn Germany
- Center for Translational Medicine; Medical Faculty; University of Bonn; Bonn Germany
| | - S. Vieths
- Paul-Ehrlich-Institute; Federal Institute for Vaccines and Biomedicines; Langen Germany
| | - K. Broich
- Center for Translational Medicine; Medical Faculty; University of Bonn; Bonn Germany
- Federal Institute of Drug and Medical Devices (BfArM); Bonn Germany
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27
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Zellweger F, Eggel A. IgE-associated allergic disorders: recent advances in etiology, diagnosis, and treatment. Allergy 2016; 71:1652-1661. [PMID: 27709638 DOI: 10.1111/all.13059] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2016] [Indexed: 12/11/2022]
Abstract
IgE-associated allergic diseases belong to the most common inflammatory conditions. Their clinical manifestation ranges from mild symptoms to life-threatening episodes. Often patients experience a reduction in physical and psychologic well-being and suffer from a decreased quality of life due to disease activity. The continuously rising number of people that are affected by an allergic condition indicates an urgent need for better diagnostics and more efficient treatment options. Recent progress in the understanding of pathophysiologic mechanisms underlying IgE-associated allergic disorders has led to the identification of novel therapeutic targets and the development of drug candidates that are currently under evaluation. In this review, we highlight studies and clinical trials, which have helped to gain further insight in the etiology of IgE-associated allergic conditions as well as advances in the development of diagnostic tools and therapeutic approaches recently published in Allergy (European Journal of Allergy and Clinical Immunology).
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Affiliation(s)
- F. Zellweger
- Department of Rheumatology, Immunology and Allergology; University Hospital Bern; Bern Switzerland
- Department of Clinical Research; University of Bern; Bern Switzerland
| | - A. Eggel
- Department of Rheumatology, Immunology and Allergology; University Hospital Bern; Bern Switzerland
- Department of Clinical Research; University of Bern; Bern Switzerland
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28
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An evidence-based analysis of house dust mite allergen immunotherapy: a call for more rigorous clinical studies. J Allergy Clin Immunol 2013; 132:1322-36. [PMID: 24139829 DOI: 10.1016/j.jaci.2013.09.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 09/05/2013] [Accepted: 09/09/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND According to meta-analyses and reviews, subcutaneous allergen immunotherapy (SCIT) and sublingual allergen immunotherapy (SLIT) are beneficial in patients with allergic rhinitis (AR) and allergic asthma (AA) induced by house dust mites (HDMs). However, the reported effect sizes have varied greatly from one study to another. OBJECTIVE We sought to perform an evidence-based medicine assessment of commercially available SCIT and SLIT formulations in patients with HDM-induced AA and HDM-induced AR. METHODS We searched for double-blind, placebo-controlled randomized clinical trials and analyzed study designs, doses, regimens, patient-reported outcomes, safety reporting, and compliance. RESULTS Forty-four studies met our inclusion criteria. Some studies tested both SLIT and SCIT or scored both AA and AR outcomes; therefore we reviewed 35 treatment arms in patients with AA (20 for SCIT and 15 for SLIT) and 23 treatment arms in patients with AR (7 for SCIT and 16 for SLIT). The treatment duration ranged from 6 weeks to 3 years. For SCIT, the dose of Der p 1 major allergen (when reported) ranged from 7 to 30 μg for maintenance doses and 60 to 420 μg for cumulative doses. For SLIT, the doses of Der p 1 (when reported) were 0.8 to 70 μg for maintenance doses and 60 to 23,695 μg for cumulative doses. Safety data were often absent or poorly reported. A statistically significant active versus placebo symptom score was observed more frequently for SCIT than for SLIT. CONCLUSION There is no consensus on basic treatment parameters (eg, dose and duration) in HDM SCIT and SLIT. There is an urgent need for rigorous, long-term, double-blind, placebo-controlled randomized clinical trials with an efficacy criterion that reflects the particular features of HDM-induced allergic disease.
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