Similar biological activity in skin prick test for Oralair® (8200 BAU) and Grazax® (6200 BAU) reinforces effective SLIT dosing level

Update about Oralair® as a treatment for grass pollen allergic rhinitis

Sublingual immunotherapy (SLIT) is a well-tolerated, safe, and effective approach to treating allergic rhinitis (AR). Oralair® is a five-grass pollen SLIT tablet containing natural pollen allergens from five of the major grass species responsible for seasonal AR due to grass pollen allergy. Recommended use is in a pre-coseasonal regimen, starting daily treatment approximately 4 months before the start of the pollen season, with treatment then continued daily throughout the season; treatment should continue for 3–5 y. Clinical efficacy and safety of Oralair® in patients with grass pollen-induced AR has been demonstrated in a comprehensive clinical development program of randomized controlled trials. Effectiveness has been substantiated in subsequent observational studies with sustained efficacy following treatment cessation and a favorable level of adherence, quality of life, benefit, and satisfaction for the patients. Supportive evidence for a benefit in reducing the risk or delaying the development of allergic asthma is emerging.

Sublingual Immunotherapy Tablets Relieve Symptoms in Adults with Allergic Rhinitis: A Meta-analysis of Randomized Clinical Trials

Background:

Sublingual immunotherapy (SLIT) has been proven to be effective against house dust mite-induced allergic rhinitis. However, the efficacy in adults with allergic rhinitis has never been reported on SLIT tablets. The current meta-analysis aimed to illustrate the differentiated efficacy of SLIT tablets on allergic rhinitis.

Methods:

Our systematic review and meta-analysis were performed on allergic rhinitis patients and aimed to summarize those randomized controlled studies (RCTs). PubMed, EMBASE, Cochrane library, and MEDLINE were screened for associated articles. We included RCTs on allergic rhinitis patients undergoing SLIT therapy and reporting outcomes on symptom relief and serum-specific IgE levels. The effect of SLIT tablets on the Rhinitis Quality Life Questionnaire Score (RQLQ), Rhinitis Total Symptom Score (RTSS), and serum-specific IgE levels was evaluated using RevMan 5.3.

Results:

Seven studies were included, with 2723 patients identified. All of the studies were RCT. The included seven studies were all conducted on adults. Among the included seven articles, five researches administered patients with SLIT tablets and were eligible for meta-analysis of RTSS, consisting of 1490 patients. Overall, RTSS was significantly reduced in the SLIT tablet group compared with that in the placebo group (standard mean difference = −0.33, 95% confidence interval [−0.54, −0.13], P < 0.01). There was no significant difference in specific IgE levels between SLIT and placebo patients.

Conclusions:

SLIT tablets effectively relieve rhinitis symptoms in adults with allergic rhinitis. Nevertheless, the current evidence may be limited due to sample size and the heterogeneity between studies. Large sample size and multiple center RCTs on the efficacy of different formulations of SLIT drugs are still needed to provide further evidence and a more precise recommendation.

Recent developments and highlights in rhinitis and allergen immunotherapy

This review paper aims to provide an overview of recent developments in the field of allergic and non-allergic rhinitis, as well as allergen immunotherapy. Recent advances in phenotyping and endotyping various forms of rhinitis have brought us one step closer towards tailoring treatment more appropriately for a given patient. Updates on local allergic rhinitis are also covered. Allergen immunotherapy (AIT) is an area of significant interest, with multiple original papers and recent position papers and guidelines published. Evidence related to the application of AIT in seasonal and perennial allergic rhinitis (AR), local allergic rhinitis and novel and expanded applications is discussed in the publication.

Elevated oxytocin and noradrenaline indicate higher stress levels in allergic rhinitis patients: Implications for the skin prick diagnosis in a pilot study

BACKGROUND & AIMS

The effects of acute stress on allergic symptoms are little understood. The intention of this clinical study was to study the effects of acute stress and related mediators in allergic rhinitis (AR), taking the wheal and flare reaction in skin prick testing (SPT) as a readout.

METHODS

19 healthy and 21 AR patients were first subjected to SPTs with grass pollen-, birch pollen- and house dust mite allergen extracts, histamine and negative control. Subsequently, participants were exposed to a standardized Trier Social Stress Test (TSST), followed by SPT on the contralateral forearm. Stress responders were identified based on the salivary cortisol levels and State-subscale of State-Trait-Anxiety Inventory (STAI-S). Blood samples were collected before and after TSST and adrenaline, noradrenaline, serotonin, oxytocin, platelet activating factor and prostaglandin D2 were analyzed by enzyme immunoassay (EIA).

RESULTS

SPT results of 14/21 allergics and 11/19 healthy who responded with stress after TSST were evaluated. No significant differences regarding SPT to allergens or histamine before and after the stress test could be calculated at the group level. But, the wheal and flare sizes after TSST increased or decreased substantially in several individuals, and unmasked sensitization in one "healthy" person, which could not be correlated with any mediator tested. The most significant finding, however, was that, independent of TSST, the baseline levels of oxytocin and noradrenaline were significantly higher in allergics.

CONCLUSION

High baseline levels of noradrenaline points toward higher stress levels in allergic patients, which might be counterregulated by elevated oxytocin. Moreover, our data indicate that acute stress may have a significant influence on SPT fidelity in susceptible individuals.

Bioavailability of House Dust Mite Allergens in Sublingual Allergy Tablets Is Highly Dependent on the Formulation

BACKGROUND

In sublingual immunotherapy (SLIT), the immune system is addressed by solubilized allergen that interacts with immunocompetent cells of the oral mucosa, the efficiency of which is governed by 2 main factors of SLIT allergen bioavailability: the allergen concentration and the mucosal contact time. Recently, 3 house dust mite (HDM) SLIT tablets were developed that differ with regard to allergen content, nominal strength (maintenance doses: 6 SQ-HDM/10,000 Japanese Allergen Units [JAU], 12 SQ-HDM/ 20,000 JAU, and 300 IR/57,000 JAU), and formulation (freeze-dried/compressed). Here, the importance of the SLIT tablet formulation for HDM major allergen bioavailability is examined.

METHODS

The HDM major allergen content, tablet disintegration times, and allergen release kinetics were determined. Dissolution kinetics (allergen concentration vs. time) of Der f 1, Der p 1, and Der 2 were measured. Area under the curve (AUC) was used as a surrogate parameter for allergen bioavailability.

RESULTS

The release of HDM major allergens from the freeze-dried tablets was complete after 30 s, while only partial release was achieved with the compressed tablets, even after prolonged dissolution. At 1 min, i.e., the recommended sublingual holding time for the freeze-dried tablets, the allergen bioavailability (AUC) of the compressed 300 IR/57,000 JAU tablet was 4.7-fold (Der f 1), 10.8-fold (Der p 1), and 23.6-fold (Der 2) lower than that of the freeze-dried 12 SQ-HDM/20,000 JAU tablet and similar to (Der f 1) and 5.3-fold (Der p 1) and 12.5-fold (Der 2) lower than that of the freeze-dried 6 SQ-HDM/10,000 JAU tablet.

CONCLUSIONS

SLIT tablet allergen bioavailability depends highly on the tablet formulation. Only the fast-dissolving freeze-dried tablets provide maximal delivery of soluble allergens and achieve allergen concentrations that reflect the nominal tablet strengths within the recommended sublingual holding time.

Debates in allergy medicine: Molecular allergy diagnosis with ISAC will replace screenings by skin prick test in the future

In today's clinical practice patients' skin is used as screening organ for diagnosing type 1 allergy. According to European guidelines skin prick testing with a panel of 18 allergen extracts is recommended, in the US between 10 to 50 allergens are used. The specificity and sensitivity of skin testing is individually highly variable depending on age, body mass, and skin barrier status. In atopic inflammation skin testing gives more false positive results. Smaller skin area and strain limits prick testing in small children. Although the risk for systemic reactions in skin prick testing is very small, emergency medications must be available. Considering the fact that IgE is the only reliable biomarker for type I allergy, upfront IgE screening with ISAC, followed by fewer skin tests to approve positive sensitizations, is proposed. It is time to arrive in the age of molecular allergy diagnosis in daily patient care.