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Layhadi JA, Moya R, Tan TJ, Lenormand MM, Sharif H, Parkin RV, Vila-Nadal G, Fedina O, Zhu R, Laisuan W, Durham SR, Carnés J, Shamji MH. Single-cell RNA sequencing identifies precise tolerogenic cellular and molecular pathways induced by depigmented-polymerized grass pollen allergen extract. J Allergy Clin Immunol 2023; 151:1357-1370.e9. [PMID: 36649758 DOI: 10.1016/j.jaci.2022.11.030] [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: 04/12/2022] [Revised: 11/04/2022] [Accepted: 11/28/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Immunologic mechanism of action of allergoids remains poorly understood. Previous models of allergenicity and immunogenicity have yielded suboptimal knowledge of these immunotherapeutic vaccine products. Novel single-cell RNA sequencing technology offers a bridge to this gap in knowledge. OBJECTIVE We sought to identify the underpinning tolerogenic molecular and cellular mechanisms of depigmented-polymerized Phleum pratense (Phl p) extract. METHODS The molecular mechanisms underlying native Phl p, depigmented Phl p (DPG-Phl p), and depigmented-polymerized (DPG-POL-Phl p) allergoid were investigated by single-cell RNA sequencing. Allergen-specific TH2A, T follicular helper (Tfh), and IL-10+ regulatory B cells were quantified by flow cytometry in peripheral blood mononuclear cells from 16 grass pollen-allergic and 8 nonatopic control subjects. The ability of Phl p, DPG-Phl p, and DPG-POL-Phl p to elicit FcεRI- and FcεRII-mediated IgE responses was measured by basophil activation test and IgE-facilitated allergen binding assay. RESULTS Analysis revealed that DPG-POL-Phl p downregulated genes associated with TH2 signaling, induced functional regulatory T cells exhibiting immunosuppressive roles through CD52 and Siglec-10, modulated genes encoding immunoproteasome that dysregulate the processing and presentation of antigens to T cells and promoted a shift from IgE toward an IgA1 and IgG responses. In grass pollen-allergic subjects, DPG-POL-Phl p exhibited reduced capacity to elicit proliferation of TH2A, IL-4+ Tfh and IL-21+ Tfh cells while being the most prominent at inducing IL-10+CD19+CD5hi and IL-10+CD19+CD5hiCD38intCD24int regulatory B-cell subsets compared to Phl p (all P < .05). Furthermore, DPG-POL-Phl p demonstrated a hypoallergenic profile through basophil activation and histamine release compared to Phl p (31.54-fold, P < .001). CONCLUSIONS Single-cell RNA sequencing provides an in-depth resolution of the mechanisms underlying the tolerogenic profile of DPG-POL-Phl p.
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Affiliation(s)
- Janice A Layhadi
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Raquel Moya
- R&D Allergy & Immunology Unit, LETI Pharma SL, Tres Cantos, Madrid, Spain
| | - Tiak Ju Tan
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Madison M Lenormand
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Hanisah Sharif
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, Brunei
| | - Rebecca V Parkin
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Gemma Vila-Nadal
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Oleksandra Fedina
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Rongfei Zhu
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Wannada Laisuan
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Stephen R Durham
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Jerónimo Carnés
- R&D Allergy & Immunology Unit, LETI Pharma SL, Tres Cantos, Madrid, Spain
| | - Mohamed H Shamji
- National Heart and Lung Institute, Imperial College London, London, United Kingdom.
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Porcaro F, Cutrera R, Pajno GB. Options of immunotherapeutic treatments for children with asthma. Expert Rev Respir Med 2019; 13:937-949. [PMID: 31414917 DOI: 10.1080/17476348.2019.1656533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Asthma is the most common chronic disease in children. Avoiding triggers, and pharmacologic treatment with short acting beta-agonist, inhaler corticosteroids and anti-leukotriene are often enough to obtain symptoms control. Nevertheless, there is a subset of children with severe asthma and poor symptom control despite maximal therapy. In these patients, anti-IgE and anti-IL5 monoclonal antibodies are suggested as the fifth step of Global Initiative for Asthma guidelines. Area covered: Immunotherapeutic treatments are now suggested for asthma management. This article will discuss the available evidence on allergen immunotherapy and biologic drugs in pediatric asthma treatment. Expert opinion: Previously published studies demonstrated a good efficacy and safety profile of Allergen Immunotherapy in patients with mild-moderate asthma and sensitization to one main allergen. New understanding of mechanisms underlying severe asthma inflammation has allowed the identifications of specific biomarkers guiding the clinician in the choice of patient specific drug. Among the suggested immunotherapeutic options, omalizumab (blocking IgE) remains the first choice for atopic 'early onset' asthma in patients aged over 6 years. Instead, mepolizumab (blocking the IL5 ligand) should be considered for 'eosinophilic' asthma. Other biologic drugs are under consideration but data on the pediatric population are still lacking.
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Affiliation(s)
- Federica Porcaro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Department of Pediatrics, Bambino Gesù Children's Hospital , Rome , Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Department of Pediatrics, Bambino Gesù Children's Hospital , Rome , Italy
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Rauber MM, Wu HK, Adams B, Pickert J, Bohle B, Shamji MH, Pfützner W, Möbs C. Birch pollen allergen-specific immunotherapy with glutaraldehyde-modified allergoid induces IL-10 secretion and protective antibody responses. Allergy 2019; 74:1575-1579. [PMID: 30866053 DOI: 10.1111/all.13774] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Michèle Myriam Rauber
- Clinical & Experimental Allergology Department of Dermatology and Allergology Philipps University Marburg Marburg Germany
- Experimental Dermatology and Allergy Research Group Department of Dermatology and Allergology Justus‐Liebig University Giessen Giessen Germany
| | - Hoi Ka Wu
- Allergy and Clinical Immunology National Heart and Lung InstituteImperial College London London UK
| | - Britta Adams
- Clinical & Experimental Allergology Department of Dermatology and Allergology Philipps University Marburg Marburg Germany
| | - Julia Pickert
- Clinical & Experimental Allergology Department of Dermatology and Allergology Philipps University Marburg Marburg Germany
| | - Barbara Bohle
- Department of Pathophysiology and Allergy Research Medical University of Vienna Vienna Austria
| | - Mohamed H. Shamji
- Allergy and Clinical Immunology National Heart and Lung InstituteImperial College London London UK
| | - Wolfgang Pfützner
- Clinical & Experimental Allergology Department of Dermatology and Allergology Philipps University Marburg Marburg Germany
| | - Christian Möbs
- Clinical & Experimental Allergology Department of Dermatology and Allergology Philipps University Marburg Marburg Germany
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Mösges R, Valero Santiago A, Allekotte S, Jahed N, Astvatsatourov A, Sager A, Sánchez-López J. Subcutaneous immunotherapy with depigmented-polymerized allergen extracts: a systematic review and meta-analysis. Clin Transl Allergy 2019; 9:29. [PMID: 31171962 PMCID: PMC6549305 DOI: 10.1186/s13601-019-0268-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 05/21/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Double-blind, placebo-controlled trials (DBPCTs) have confirmed the efficacy of allergen-specific immunotherapy (AIT) with depigmented-polymerized allergen extracts (DPAEs). This systematic review evaluates the efficacy of AIT using different allergens in different severity stages of rhinoconjunctivitis with or without asthma in the pollen studies and asthma and rhinitis in the house dust mite studies in comparison to placebo. METHODS We used MEDLINE, Embase, CENTRAL and LILACS databases to review DBPCTs published until July 2016. The combined symptom and medication score (cSMS) served as primary endpoint. The total rhinoconjunctivitis symptom score (RCSS) and total score in Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) were secondary efficacy endpoints. Solicited local and systemic adverse events were secondary safety endpoints. We assumed a random effects model with standardized mean differences (SMDs) or mean differences as summary statistics. In a subgroup analysis, we classified the studies following the GINA (Global Initiative for Asthma) and ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines for rhinoconjunctivitis and asthma severity. RESULTS Six DBPCTs in pollen and 2 trials in house dust mites (HDM) were selected. Patients (N = 915) with intermittent or mild persistent asthma were included in 3 (37.5%) and 5 (62.5%) trials, respectively. Two (25%) HDM studies included patients with moderate persistent asthma, 4 trials patients with moderate-to-severe rhinoconjunctivitis. Treatment periods ranged from 12 to 24 months. AIT with DPAEs yielded significantly lower cSMS (SMD: 1.9, 95% CI: 0.9-2.8) and RQLQ (SMD: 0.3, 95% CI: 0.1-0.5) values than did placebo. An exploratory analysis of cSMS and RCSS suggested that the efficacy of AIT treatment with DPAEs was higher in trials including patients with more severe rhinoconjunctivitis and asthma. A publication bias was not detected. Heterogeneity between individual studies was explained by differences in severity. Patients receiving DPAEs did not experience a significantly higher risk of local (OR: 1.55, 95% CI: 0.86-2.79) or systemic reactions (OR: 1.94, 95% CI: 0.98-3.84). CONCLUSIONS Compared to placebo, AIT with DPAEs is effective in patients with pollen- or HDM-induced rhinoconjunctivitis with or without allergic asthma and improves health-related quality of life. It does not differ significantly in safety and tolerability.
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Affiliation(s)
- Ralph Mösges
- CRI – Clinical Research International Ltd, Cologne, Germany
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Antonio Valero Santiago
- Department of Pulmonology and Respiratory Allergy, Hospital Clinic Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigaciones Biomedicas en Red de Enfermedades Respiratorias (CIBERES), Universitat de Barcelona, Barcelona, Spain
| | | | - Nilufar Jahed
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Anatoli Astvatsatourov
- Clinical Trials Centre Cologne, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Angelika Sager
- Laboratorios LETI, Gran Via de les Corts Catalanes 184, 08038 Barcelona, Spain
| | - Jaime Sánchez-López
- Laboratorios LETI, Gran Via de les Corts Catalanes 184, 08038 Barcelona, Spain
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Klimek L, Brehler R, Hamelmann E, Kopp M, Ring J, Treudler R, Jakob T, Worm M, Pfaar O. Entwicklung der subkutanen Allergen-Immuntherapie (Teil 1): von den Anfängen zu immunologisch orientierten Therapiekonzepten. ALLERGO JOURNAL 2019. [DOI: 10.1007/s15007-019-1819-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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6
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Evolution of subcutaneous allergen immunotherapy (part 1): from first developments to mechanism-driven therapy concepts. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s40629-019-0092-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Worm M, Rak S, Samoliński B, Antila J, Höiby AS, Kruse B, Lipiec A, Rudert M, Valovirta E. Efficacy and safety of birch pollen allergoid subcutaneous immunotherapy: A 2-year double-blind, placebo-controlled, randomized trial plus 1-year open-label extension. Clin Exp Allergy 2019; 49:516-525. [PMID: 30570787 PMCID: PMC6849700 DOI: 10.1111/cea.13331] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 10/02/2018] [Accepted: 10/16/2018] [Indexed: 01/12/2023]
Abstract
Background Previous clinical trials with birch pollen subcutaneous immunotherapy have been conducted over a 1‐ to 2‐year treatment period and involved mostly a single geographic location. Objective This study (EudraCT‐Number: 2005‐000025‐35) intended to evaluate the effect of subcutaneous immunotherapy with high‐dose hypoallergenic birch pollen allergoid in patients with confirmed moderate to severe seasonal allergic rhinitis/rhinoconjunctivitis over a 3‐year course in 19 European centres. Methods Adults with confirmed birch pollen allergy (n = 253) were randomized to preseasonal placebo (n = 129) or active treatment (n = 124). Primary endpoint was change in Symptom Medication Score after 2 years treatment (2007). Results The change in Symptom Medication Score of active‐ vs placebo‐treated patients for the Full Analysis Set (n = 227, 15.2% reduction, P = 0.0710) and Per‐Protocol Set (n = 216, 16.7% reduction, P = 0.0523) showed a positive trend, although significance was not achieved. The primary endpoint, assessed in 2007, coincided with the lowest pollination during the study period. In a subgroup analysis of patients in the north‐eastern region (n = 102), where birch is the major tree and consequently patients’ exposure is higher, changes in Symptom Medication Score (32.7% reduction, P = 0.0034) and median number of well days (P = 0.0232) were highly significant in favour of the active group. During the open‐label third year of treatment, the mean Symptom Medication Score of active‐treated patients was further reduced despite an increased pollen count. Subcutaneous immunotherapy was well tolerated and consistent with the known safety profile. Conclusions and clinical relevance Although the primary endpoint was not reached for the Full Analysis Set, a significant and clinically relevant effect on Symptom Medication Score was clearly demonstrated for the subgroup of patients in the north‐eastern region of Europe, where birch is the predominant tree species. Proving efficacy of birch allergen subcutaneous immunotherapy is challenging due to the numerous factors influencing birch pollen allergen exposure in field studies.
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Affiliation(s)
- Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Allergy and Venerology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sabina Rak
- Asthma and Allergy Research Group, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Boleslaw Samoliński
- Department of the Prevention of Environmental Hazards and Allergology, Medical University of Warsaw, Warsaw, Poland
| | - Jukka Antila
- Ear, Nose and Throat Clinic, Terveystalo Hospital, Turku, Finland
| | - Ann-Sofi Höiby
- Asthma and Allergy Research Group, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Agnieszka Lipiec
- Department of the Prevention of Environmental Hazards and Allergology, Medical University of Warsaw, Warsaw, Poland
| | | | - Erkka Valovirta
- Department of Lung Diseases and Clinical Allergology, University of Turku, Turku, Finland.,Allergy Clinic, Terveystalo Hospital, Turku, Finland
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8
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Watts AM, Cox AJ, Smith PK, Besseling-van der Vaart I, Cripps AW, West NP. A Specifically Designed Multispecies Probiotic Supplement Relieves Seasonal Allergic Rhinitis Symptoms. J Altern Complement Med 2018; 24:833-840. [DOI: 10.1089/acm.2017.0342] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Annabelle M. Watts
- Menzies Health Institute of Queensland, School of Medical Science, Griffith University, Gold Coast, Queensland, Australia
| | - Amanda J. Cox
- Menzies Health Institute of Queensland, School of Medical Science, Griffith University, Gold Coast, Queensland, Australia
| | - Peter K. Smith
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- Queensland Allergy Services Clinic Southport, Gold Coast, Queensland, Australia
| | | | - Allan W. Cripps
- Menzies Health Institute of Queensland, School of Medical Science, Griffith University, Gold Coast, Queensland, Australia
| | - Nicholas P. West
- Menzies Health Institute of Queensland, School of Medical Science, Griffith University, Gold Coast, Queensland, Australia
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9
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Wise SK, Lin SY, Toskala E, Orlandi RR, Akdis CA, Alt JA, Azar A, Baroody FM, Bachert C, Canonica GW, Chacko T, Cingi C, Ciprandi G, Corey J, Cox LS, Creticos PS, Custovic A, Damask C, DeConde A, DelGaudio JM, Ebert CS, Eloy JA, Flanagan CE, Fokkens WJ, Franzese C, Gosepath J, Halderman A, Hamilton RG, Hoffman HJ, Hohlfeld JM, Houser SM, Hwang PH, Incorvaia C, Jarvis D, Khalid AN, Kilpeläinen M, Kingdom TT, Krouse H, Larenas-Linnemann D, Laury AM, Lee SE, Levy JM, Luong AU, Marple BF, McCoul ED, McMains KC, Melén E, Mims JW, Moscato G, Mullol J, Nelson HS, Patadia M, Pawankar R, Pfaar O, Platt MP, Reisacher W, Rondón C, Rudmik L, Ryan M, Sastre J, Schlosser RJ, Settipane RA, Sharma HP, Sheikh A, Smith TL, Tantilipikorn P, Tversky JR, Veling MC, Wang DY, Westman M, Wickman M, Zacharek M. International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis. Int Forum Allergy Rhinol 2018; 8:108-352. [PMID: 29438602 PMCID: PMC7286723 DOI: 10.1002/alr.22073] [Citation(s) in RCA: 218] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR). METHODS Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR. CONCLUSION This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.
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Affiliation(s)
| | | | | | | | - Cezmi A. Akdis
- Allergy/Asthma, Swiss Institute of Allergy and Asthma Research, Switzerland
| | | | - Antoine Azar
- Allergy/Immunology, Johns Hopkins University, USA
| | | | | | | | | | - Cemal Cingi
- Otolaryngology, Eskisehir Osmangazi University, Turkey
| | | | | | | | | | | | | | - Adam DeConde
- Otolaryngology, University of California San Diego, USA
| | | | | | | | | | | | | | - Jan Gosepath
- Otorhinolaryngology, Helios Kliniken Wiesbaden, Germany
| | | | | | | | - Jens M. Hohlfeld
- Respiratory Medicine, Hannover Medical School, Airway Research Fraunhofer Institute for Toxicology and Experimental Medicine, German Center for Lung Research, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | - Amber U. Luong
- Otolaryngology, McGovern Medical School at the University of Texas Health Science Center Houston, USA
| | | | | | | | - Erik Melén
- Pediatric Allergy, Karolinska Institutet, Sweden
| | | | | | - Joaquim Mullol
- Otolaryngology, Universitat de Barcelona, Hospital Clinic, IDIBAPS, Spain
| | | | | | | | - Oliver Pfaar
- Rhinology/Allergy, Medical Faculty Mannheim, Heidelberg University, Center for Rhinology and Allergology, Wiesbaden, Germany
| | | | | | - Carmen Rondón
- Allergy, Regional University Hospital of Málaga, Spain
| | - Luke Rudmik
- Otolaryngology, University of Calgary, Canada
| | - Matthew Ryan
- Otolaryngology, University of Texas Southwestern, USA
| | - Joaquin Sastre
- Allergology, Hospital Universitario Fundacion Jiminez Diaz, Spain
| | | | | | - Hemant P. Sharma
- Allergy/Immunology, Children's National Health System, George Washington University School of Medicine, USA
| | | | | | | | | | | | - De Yun Wang
- Otolaryngology, National University of Singapore, Singapore
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Dhami S, Nurmatov U, Arasi S, Khan T, Asaria M, Zaman H, Agarwal A, Netuveli G, Roberts G, Pfaar O, Muraro A, Ansotegui IJ, Calderon M, Cingi C, Durham S, Wijk RG, Halken S, Hamelmann E, Hellings P, Jacobsen L, Knol E, Larenas‐Linnemann D, Lin S, Maggina P, Mösges R, Oude Elberink H, Pajno G, Panwankar R, Pastorello E, Penagos M, Pitsios C, Rotiroti G, Timmermans F, Tsilochristou O, Varga E, Schmidt‐Weber C, Wilkinson J, Williams A, Worm M, Zhang L, Sheikh A. Allergen immunotherapy for allergic rhinoconjunctivitis: A systematic review and meta-analysis. Allergy 2017; 72:1597-1631. [PMID: 28493631 DOI: 10.1111/all.13201] [Citation(s) in RCA: 201] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing Guidelines on Allergen Immunotherapy (AIT) for Allergic Rhinoconjunctivitis. To inform the development of clinical recommendations, we undertook a systematic review to assess the effectiveness, cost-effectiveness, and safety of AIT in the management of allergic rhinoconjunctivitis. METHODS We searched nine international biomedical databases for published, in-progress, and unpublished evidence. Studies were independently screened by two reviewers against predefined eligibility criteria and critically appraised using established instruments. Our primary outcomes of interest were symptom, medication, and combined symptom and medication scores. Secondary outcomes of interest included cost-effectiveness and safety. Data were descriptively summarized and then quantitatively synthesized using random-effects meta-analyses. RESULTS We identified 5960 studies of which 160 studies satisfied our eligibility criteria. There was a substantial body of evidence demonstrating significant reductions in standardized mean differences (SMD) of symptom (SMD -0.53, 95% CI -0.63, -0.42), medication (SMD -0.37, 95% CI -0.49, -0.26), and combined symptom and medication (SMD -0.49, 95% CI -0.69, -0.30) scores while on treatment that were robust to prespecified sensitivity analyses. There was in comparison a more modest body of evidence on effectiveness post-discontinuation of AIT, suggesting a benefit in relation to symptom scores. CONCLUSIONS AIT is effective in improving symptom, medication, and combined symptom and medication scores in patients with allergic rhinoconjunctivitis while on treatment, and there is some evidence suggesting that these benefits are maintained in relation to symptom scores after discontinuation of therapy.
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Shamji MH, Kappen JH, Akdis M, Jensen-Jarolim E, Knol EF, Kleine-Tebbe J, Bohle B, Chaker AM, Till SJ, Valenta R, Poulsen LK, Calderon MA, Demoly P, Pfaar O, Jacobsen L, Durham SR, Schmidt-Weber CB. Biomarkers for monitoring clinical efficacy of allergen immunotherapy for allergic rhinoconjunctivitis and allergic asthma: an EAACI Position Paper. Allergy 2017; 72:1156-1173. [PMID: 28152201 DOI: 10.1111/all.13138] [Citation(s) in RCA: 235] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Allergen immunotherapy (AIT) is an effective treatment for allergic rhinoconjunctivitis (AR) with or without asthma. It is important to note that due to the complex interaction between patient, allergy triggers, symptomatology and vaccines used for AIT, some patients do not respond optimally to the treatment. Furthermore, there are no validated or generally accepted candidate biomarkers that are predictive of the clinical response to AIT. Clinical management of patients receiving AIT and efficacy in randomised controlled trials for drug development could be enhanced by predictive biomarkers. METHOD The EAACI taskforce reviewed all candidate biomarkers used in clinical trials of AR patients with/without asthma in a literature review. Biomarkers were grouped into seven domains: (i) IgE (total IgE, specific IgE and sIgE/Total IgE ratio), (ii) IgG-subclasses (sIgG1, sIgG4 including SIgE/IgG4 ratio), (iii) Serum inhibitory activity for IgE (IgE-FAB and IgE-BF), (iv) Basophil activation, (v) Cytokines and Chemokines, (vi) Cellular markers (T regulatory cells, B regulatory cells and dendritic cells) and (vii) In vivo biomarkers (including provocation tests?). RESULTS All biomarkers were reviewed in the light of their potential advantages as well as their respective drawbacks. Unmet needs and specific recommendations on all seven domains were addressed. CONCLUSIONS It is recommended to explore the use of allergen-specific IgG4 as a biomarker for compliance. sIgE/tIgE and IgE-FAB are considered as potential surrogate candidate biomarkers. Cytokine/chemokines and cellular reponses provided insight into the mechanisms of AIT. More studies for confirmation and interpretation of the possible association with the clinical response to AIT are needed.
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Affiliation(s)
- M. H. Shamji
- Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College London; London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; London UK
- Allergy and Clinical Immunology; Immunomodulation and Tolerance Group; Imperial College London; London UK
| | - J. H. Kappen
- Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College London; London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; London UK
- Allergy and Clinical Immunology; Immunomodulation and Tolerance Group; Imperial College London; London UK
- Department of Pulmonology; STZ Centre of Excellence for Asthma & COPD; Sint Franciscus Vlietland Group; Rotterdam The Netherlands
| | - M. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF); University of Zürich; Davos Switzerland
| | - E. Jensen-Jarolim
- Department of Pathophysiology and Allergy Research; Center of Pathophysiology, Infectiology and Immunology; Medical University Vienna; Vienna Austria
- The interuniversity Messerli Research Institute; University of Veterinary Medicine Vienna; Medical University Vienna; Vienna Austria
| | - E. F. Knol
- Departments Immunology and Dermatology/Allergology; University Medical Center Utrecht; Utrecht The Netherlands
| | - J. Kleine-Tebbe
- Allergy & Asthma Center Westend; Outpatient Clinic and Research Center Hanf, Ackermann & Kleine-Tebbe; Berlin Germany
| | - B. Bohle
- Department of Pathophysiology and Allergy Research; Medical University of Vienna; Vienna Austria
| | - A. M. Chaker
- Center of Allergy and Environment (ZAUM); Technische Universität and Helmholtz Center Munich; Munich Germany
- Department of Otolaryngology; Allergy Section; Klinikum rechts der Isar; Technische Universität; Munich Germany
| | - S. J. Till
- Division of Asthma, Allergy and Lung Biology; King's College London; London UK
- Department of Allergy; Guy's and St. Thomas’ NHS Foundation Trust; London UK
| | - R. Valenta
- Division of Immunopathology; Department of Pathophysiology and Allergy Research; Center for Pathophysiology, Infectiology and Immunology; Medical University of Vienna; Vienna Austria
| | - L. K. Poulsen
- Allergy Clinic; Copenhagen University Hospital at Gentofte; Copenhagen Denmark
| | - M. A. Calderon
- Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College London; London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; London UK
- Allergy and Clinical Immunology; Immunomodulation and Tolerance Group; Imperial College London; London UK
| | - P. Demoly
- Division of Allergy; Department of Pulmonology; Arnaud de Villeneuve Hospital; University Hospital of Montpellier and Sorbonne University; Paris France
| | - O. Pfaar
- Department of Otorhinolaryngology; Head and Neck Surgery; Universitätsmedizin Mannheim; Medical Faculty Mannheim; Heidelberg University; Mannheim Germany
- Center for Rhinology and Allergology; Wiesbaden Germany
| | - L. Jacobsen
- Allergy Learning and Consulting; Copenhagen Denmark
| | - S. R. Durham
- Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College London; London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; London UK
- Allergy and Clinical Immunology; Immunomodulation and Tolerance Group; Imperial College London; London UK
| | - C. B. Schmidt-Weber
- Center of Allergy and Environment (ZAUM); Technische Universität and Helmholtz Center Munich; Munich Germany
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Linneberg A, Dam Petersen K, Hahn-Pedersen J, Hammerby E, Serup-Hansen N, Boxall N. Burden of allergic respiratory disease: a systematic review. Clin Mol Allergy 2016; 14:12. [PMID: 27708552 PMCID: PMC5041537 DOI: 10.1186/s12948-016-0049-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/22/2016] [Indexed: 11/22/2022] Open
Abstract
This meta-analysis compared the health-related quality of life (HRQL) of patients with allergic rhinitis (AR) and/or allergic asthma (AA) caused by perennial house dust mite (HDM) versus AR and/or AA caused by seasonal pollen allergy. Following a systematic search, the identified studies used the disease-specific rhinitis quality of life questionnaire or generic instruments (SF-36 and SF-12). Summary estimates obtained by meta-analysis showed that HRQL in patients with perennial HDM allergy was significantly worse than that of patients with seasonal pollen allergy, when measured by both disease-specific and generic HRQL instruments, and was reflected by an impact on both physical and mental health. A systematic review of cost data on AR and AA in selected European countries demonstrated that the majority of the economic burden was indirectly caused by high levels of absenteeism and presenteeism; there was little or no evidence of increasing or decreasing cost trends. Increased awareness of the detrimental effects of AR and/or AA on patients’ HRQL and its considerable cost burden might encourage early diagnosis and treatment, in order to minimize the disease burden and ensure beneficial and cost-effective outcomes.
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Affiliation(s)
- A Linneberg
- Research Centre for Prevention and Health, The Capital Region of Denmark, Copenhagen, Denmark ; Department of Clinical Experimental Research, Rigshospitalet, Copenhagen, Denmark ; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - K Dam Petersen
- Department of Business and Management, Faculty of Social Sciences, Aalborg University, Aalborg, Denmark
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Shandilya UK, Sharma A, Kapila R, Kansal VK. Probiotic Dahi containing Lactobacillus acidophilus and Bifidobacterium bifidum modulates immunoglobulin levels and cytokines expression in whey proteins sensitised mice. JOURNAL OF THE SCIENCE OF FOOD AND AGRICULTURE 2016; 96:3180-3187. [PMID: 26459934 DOI: 10.1002/jsfa.7497] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 09/14/2015] [Accepted: 10/09/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Cow milk allergy is the most common food allergy in children. So far, no effective treatment is available to prevent or cure food allergy. This study investigated whether orally administrated probiotics could suppress sensitisation in whey proteins (WP)-induced allergy mouse model. Two types of probiotic Dahi were prepared by co-culturing Dahi bacteria (Lactococcus lactis ssp. cremoris NCDC-86 and Lactococcus lactis ssp. lactis biovar diacetylactis NCDC-60) along with selected strain of Lactobacillus acidophilus LaVK2 and Bifidobacterium bifidum BbVK3. Mice were fed with probiotic Dahi (La-Dahi and LaBb-Dahi) from 7 days before sensitisation with WP, respectively, in addition to milk protein-free basal diet, and control group received no supplements. RESULTS Feeding of probiotic Dahi suppressed the elevation of whey proteins-specific IgE and IgG response of WP-sensitised mice. In addition, sIgA levels were significantly (P < 0.001) increased in intestinal fluid collected from mice fed with La-Dahi. Production of T helper (Th)-1 cell-specific cytokines, i.e. interferon-γ (IFN-γ), interleukin (IL)-12, and IL-10 increased, while Th2-specific cytokines, i.e. IL-4 decreased in the supernatant of cultured splenocytes collected from mice fed with probiotic Dahi as compared to the other groups. Moreover, the splenic mRNA levels of IFN-γ, interleukin-10 were found to be significantly increased, while that of IL-4 decreased significantly in La-Dahi groups, as compared to control groups. CONCLUSION Results of the present study indicate that probiotic Dahi skewed Th2-specific immune response towards Th1-specific response and suppressed IgE in serum. Collectively, this study shows the potential use of probiotics intervention in reducing the allergic response to whey proteins in mice. © 2015 Society of Chemical Industry.
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Affiliation(s)
- Umesh Kumar Shandilya
- Animal Biochemistry Division, National Dairy Research Institute, Karnal, 132001, India
| | | | - Rajeev Kapila
- Animal Biochemistry Division, National Dairy Research Institute, Karnal, 132001, India
| | - Vinod Kumar Kansal
- Animal Biochemistry Division, National Dairy Research Institute, Karnal, 132001, India
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Morais-Almeida M, Arêde C, Sampaio G, Borrego LM. Ultrarush schedule of subcutaneous immunotherapy with modified allergen extracts is safe in paediatric age. Asia Pac Allergy 2016; 6:35-42. [PMID: 26844218 PMCID: PMC4731479 DOI: 10.5415/apallergy.2016.6.1.35] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 01/19/2016] [Indexed: 11/13/2022] Open
Abstract
Background Traditional subcutaneous immunotherapy up dosing with allergenic extracts has been shown to be associated with frequent adverse reactions. In recent studies it has been demonstrated that using modified extracts, namely allergoids, it is a safe and effective procedure particularly on accelerated schedules. However data assessing its safety in paediatric age is scarce. Objective To evaluate the safety profile in paediatric population of using modified allergen extracts, in an ultrarush schedule, to reach the maintenance dose in the first day. Methods We included children undergoing treatment with subcutaneous immunotherapy during a five-year period, using modified aeroallergen extracts, depigmented, polymerized with glutaraldehyde and adsorbed on aluminium hydroxide using an ultrarush induction phase. The type of adverse reactions during the ultrarush protocol was recorded. Results We studied 100 paediatric patients (57 males) with a mean age of 11.6 years (5 to 18 years; standard deviation, 3.3), all with moderate to severe persistent rhinitis, with or without allergic conjunctivitis, asthma and atopic eczema, sensitized to mites and/or pollens. All reached the maintenance dose of 0.5 mL in the first day, except 1 child. During the ultrarush protocol the total number of injections was 199. There were 21 local adverse reactions in 11 patients, 11 immediate and 10 delayed; from those, had clinical relevance 1 immediate and 4 delayed. Systemic reactions were recorded in 2 cases, both immediate and mild. Conclusion The ultrarush protocol, without premedication, was a safe alternative to be used in paediatric age during the induction phase of subcutaneous immunotherapy using allergoid depigmented extracts.
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Affiliation(s)
- Mário Morais-Almeida
- Allergy Center, CUF Descobertas Hospital, 1998-018 Lisbon, Portugal.; CINTESIS, Center for Research in Health Technologies and Information Systems, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
| | - Cristina Arêde
- Allergy Center, CUF Descobertas Hospital, 1998-018 Lisbon, Portugal
| | - Graça Sampaio
- Allergy Center, CUF Descobertas Hospital, 1998-018 Lisbon, Portugal
| | - Luis Miguel Borrego
- Allergy Center, CUF Descobertas Hospital, 1998-018 Lisbon, Portugal.; CEDOC, Chronic Diseases Research Center, Immunology Department, NOVA Medical School, 1169-056 Lisboa, Portugal
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Pfaar O, Sager A, Robinson DS. Safety and effect on reported symptoms of depigmented polymerized allergen immunotherapy: a retrospective study of 2927 paediatric patients. Pediatr Allergy Immunol 2015; 26:280-286. [PMID: 25640879 PMCID: PMC4576817 DOI: 10.1111/pai.12347] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Allergen immunotherapy (AIT) is effective treatment for allergic diseases, and subcutaneous use of depigmented polymerized extracts may allow rapid up-dosing and safe therapy. To date, there is little information on their safety and clinical effects for children and adolescents with allergic disease. METHODS We performed a retrospective survey of patient notes of 2927 children and adolescents across 136 centres who had received subcutaneous AIT (SCIT) with depigmented polymerized extracts to pollen or mite allergens for at least 1 yr to collect documentation on safety and clinical symptoms. RESULTS 16.3% percent of patients had local reactions, of these 148 were larger than 12 cm in diameter. Systemic reactions were documented in 1.6% of children and in 0.8% of adolescents. There were no documented cases of anaphylactic shock. There were significant reductions in the frequency of patients with recorded nasal symptoms over time of treatment. Moreover, the prescribing rate of rescue medication was reduced over the course of SCIT. CONCLUSION These 'real-life' data from a large retrospective analysis including 2927 children and adolescents with pollen- and/or mite-induced allergic rhinoconjunctivitis with/or without allergic asthma indicate that AIT with depigmented polymerized extracts is well tolerated, and they are compatible with clinical response.
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Affiliation(s)
- Oliver Pfaar
- Center for Rhinology and Allergology, Wiesbaden, Germany.,Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Douglas S Robinson
- Leukocyte Biology Section, National Heart and Lung Institute, Imperial College London, London, UK.,Department of Allergy, Royal National Throat Nose and Ear Hospital, University College London Hospital NHS Trust, London, UK
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Leitlinie zur (allergen-)spezifischen Immuntherapie bei IgE-vermittelten allergischen Erkrankungen. ALLERGO JOURNAL 2014. [DOI: 10.1007/s15007-014-0707-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Cingi C, Muluk NB, Hanci D, Ulusoy S, Sahin F. Updating the role played by immunotherapy for allergic rhinitis: meta-analysis. Int Forum Allergy Rhinol 2014; 5:132-42. [DOI: 10.1002/alr.21447] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 10/08/2014] [Accepted: 10/10/2014] [Indexed: 12/15/2022]
Affiliation(s)
- Cemal Cingi
- Department of Otorhinolaryngology; Medical Faculty, Eskisehir Osmangazi University; Eskisehir Turkey
| | - Nuray Bayar Muluk
- Department of Otorhinolaryngology; Medical Faculty, Kirikkale University; Kirikkale Turkey
| | - Deniz Hanci
- Ear Nose and Throat (ENT) Department; Liv Hospital; Istanbul Turkey
| | - Seckin Ulusoy
- ENT Clinics; Gaziosmanpaşa Taksim Education and Research Hospital; Istanbul Turkey
| | - Fezan Sahin
- Department of Biostatistics, Medical Faculty; Eskisehir Osmangazi University; Eskisehir Turkey
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Urry ZL, Richards DF, Black C, Morales M, Carnés J, Hawrylowicz CM, Robinson DS. Depigmented-polymerised allergoids favour regulatory over effector T cells: enhancement by 1α, 25-dihydroxyvitamin D3. BMC Immunol 2014; 15:21. [PMID: 24884430 PMCID: PMC4051145 DOI: 10.1186/1471-2172-15-21] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 05/16/2014] [Indexed: 02/03/2023] Open
Abstract
Background Allergen immunotherapy (SIT) is the only treatment for allergic disease capable of modifying disease long term. To reduce the risk of anaphylaxis from SIT, allergen-extracts have been modified by polymerisation with glutaraldehyde to reduce IgE binding. It is suggested that these allergoid extracts also have reduced T cell activity, which could compromise clinical efficacy. Effective SIT is thought to act through regulatory T cells (Tregs) rather than activation of effector T cells. There is no published data on the activity of modified extracts on Tregs. Results We compared the capacity of modified (depigmented-polymerised) versus unmodified (native) allergen extracts of grass pollen and house dust mite to stimulate proliferation/cytokine production and to modulate Treg/effector T cell frequency in cultures of peripheral blood mononuclear cells (PBMC), from volunteers sensitised to both allergens in vitro. Depigmented-polymerised allergen extracts stimulated less proliferation of PBMC, and reduced effector cell numbers after 7 days in culture than did native extracts. However, the frequency of Foxp3+ Tregs in cultures were similar to those seen with native extract so that ratios of regulatory to effector T cells were significantly increased in cultures stimulated with depigmented-polymerised extracts. Addition of 1α, 25-dihydroxyvitamin D3 further favoured Treg, and reduced effector cytokine production, but not interleukin-10. Conclusions Depigmented-polymerised allergen extracts appear to favour Treg expansion over activation of effector T cells and this may relate to their demonstrated efficacy and safety in SIT. 1α, 25-dihydroxyvitamin D3 further reduces effector T cell activation by allergen extracts and may be a useful adjuvant for SIT.
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Affiliation(s)
| | | | | | | | | | - Catherine M Hawrylowicz
- Department of Allergy and Asthma, MRC and Asthma UK Centre for Mechanisms of Allergic Asthma, Guy's Campus, King's College London, London, UK.
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Casale TB, Stokes JR. Immunotherapy: what lies beyond. J Allergy Clin Immunol 2014; 133:612-9: quiz 620. [PMID: 24581428 DOI: 10.1016/j.jaci.2014.01.007] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 12/19/2013] [Accepted: 01/14/2014] [Indexed: 10/25/2022]
Abstract
Allergen immunotherapy has been used to treat allergic diseases, such as asthma, allergic rhinitis, and venom allergy, since first described over a century ago. The current standard of care in the United States involves subcutaneous administration of clinically relevant allergens for several months, building up to eventual monthly injections for typically 3 to 5 years. Recent advances have improved the safety and efficacy of immunotherapy. The addition of omalizumab or Toll-like receptor agonists to standard subcutaneous immunotherapy has proved beneficial. Altering the extract itself, either through chemical manipulation producing allergoids or directly producing recombinant proteins or significant peptides, has been evaluated with promising results. The use of different administration techniques, such as sublingual immunotherapy, is common in Europe and is on the immediate horizon in the United States. Other methods of administering allergen immunotherapy have been studied, including epicutaneous, intralymphatic, intranasal, and oral immunotherapy. In this review we focus on new types and routes of immunotherapy, exploring recent human clinical trial data. The promise of better immunotherapies appears closer than ever before, but much work is still needed to develop novel immunotherapies that induce immunologic tolerance and enhanced clinical efficacy and safety over that noted for subcutaneous allergen immunotherapy.
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Affiliation(s)
- Thomas B Casale
- Division of Allergy/Immunology, University of South Florida, Tampa, Fla.
| | - Jeffrey R Stokes
- Division of Allergy/Immunology, Creighton University, Omaha, Neb
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Exley C. Aluminium adjuvants and adverse events in sub-cutaneous allergy immunotherapy. Allergy Asthma Clin Immunol 2014; 10:4. [PMID: 24444186 PMCID: PMC3898727 DOI: 10.1186/1710-1492-10-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 01/15/2014] [Indexed: 01/20/2023] Open
Abstract
Sub-cutaneous immunotherapy is an effective treatment for allergy. It works by helping to modify or re-balance an individual’s immune response to allergens and its efficacy is greatly improved by the use of adjuvants, most commonly, aluminium hydroxide. Aluminium salts have been used in allergy therapy for many decades and are assumed to be safe with few established side-effects. This assumption belies their potency as adjuvants and their potential for biological reactivity both at injection sites and elsewhere in the body. There are very few data purporting to the safety of aluminium adjuvants in allergy immunotherapy and particularly so in relation to longer term health effects. There are, if only few, published reports of adverse events following allergy immunotherapy and aluminium adjuvants are the prime suspects in the majority of such incidents. Aluminium adjuvants are clearly capable of initiating unwanted side effects in recipients of immunotherapy and while there is as yet no evidence that such are commonplace it is complacent to consider aluminium salts as harmless constituents of allergy therapies. Future research should establish the safety of the use of aluminium adjuvants in sub-cutaneous allergy immunotherapy.
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Affiliation(s)
- Christopher Exley
- The Birchall Centre, Lennard-Jones Laboratories, Keele University, Staffordshire, UK.
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Pfaar O, Bachert C, Bufe A, Buhl R, Ebner C, Eng P, Friedrichs F, Fuchs T, Hamelmann E, Hartwig-Bade D, Hering T, Huttegger I, Jung K, Klimek L, Kopp MV, Merk H, Rabe U, Saloga J, Schmid-Grendelmeier P, Schuster A, Schwerk N, Sitter H, Umpfenbach U, Wedi B, Wöhrl S, Worm M, Kleine-Tebbe J, Kaul S, Schwalfenberg A. Guideline on allergen-specific immunotherapy in IgE-mediated allergic diseases: S2k Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Society for Pediatric Allergy and Environmental Medicine (GPA), the Medical Association of German Allergologists (AeDA), the Austrian Society for Allergy and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Dermatology (DDG), the German Society of Oto- Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), the German Society of Pediatrics and Adolescent Medicine (DGKJ), the Society for Pediatric Pneumology (GPP), the German Respiratory Society (DGP), the German Association of ENT Surgeons (BV-HNO), the Professional Federation of Paediatricians and Youth Doctors (BVKJ), the Federal Association of Pulmonologists (BDP) and the German Dermatologists Association (BVDD). ALLERGO JOURNAL INTERNATIONAL 2014; 23:282-319. [PMID: 26120539 PMCID: PMC4479478 DOI: 10.1007/s40629-014-0032-2] [Citation(s) in RCA: 247] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The present guideline (S2k) on allergen-specific immunotherapy (AIT) was established by the German, Austrian and Swiss professional associations for allergy in consensus with the scientific specialist societies and professional associations in the fields of otolaryngology, dermatology and venereology, pediatric and adolescent medicine, pneumology as well as a German patient organization (German Allergy and Asthma Association; Deutscher Allergie- und Asthmabund, DAAB) according to the criteria of the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). AIT is a therapy with disease-modifying effects. By administering allergen extracts, specific blocking antibodies, toler-ance-inducing cells and mediators are activated. These prevent further exacerbation of the allergen-triggered immune response, block the specific immune response and attenuate the inflammatory response in tissue. Products for SCIT or SLIT cannot be compared at present due to their heterogeneous composition, nor can allergen concentrations given by different manufacturers be compared meaningfully due to the varying methods used to measure their active ingredients. Non-modified allergens are used for SCIT in the form of aqueous or physically adsorbed (depot) extracts, as well as chemically modified allergens (allergoids) as depot extracts. Allergen extracts for SLIT are used in the form of aqueous solutions or tablets. The clinical efficacy of AIT is measured using various scores as primary and secondary study endpoints. The EMA stipulates combined symptom and medication scores as primary endpoint. A harmonization of clinical endpoints, e. g., by using the combined symptom and medication scores (CSMS) recommended by the EAACI, is desirable in the future in order to permit the comparison of results from different studies. The current CONSORT recommendations from the ARIA/GA2LEN group specify standards for the evaluation, presentation and publication of study results. According to the Therapy allergen ordinance (TAV), preparations containing common allergen sources (pollen from grasses, birch, alder, hazel, house dust mites, as well as bee and wasp venom) need a marketing authorization in Germany. During the marketing authorization process, these preparations are examined regarding quality, safety and efficacy. In the opinion of the authors, authorized allergen preparations with documented efficacy and safety, or preparations tradeable under the TAV for which efficacy and safety have already been documented in clinical trials meeting WAO or EMA standards, should be preferentially used. Individual formulations (NPP) enable the prescription of rare allergen sources (e.g., pollen from ash, mugwort or ambrosia, mold Alternaria, animal allergens) for specific immunotherapy. Mixing these allergens with TAV allergens is not permitted. Allergic rhinitis and its associated co-morbidities (e. g., bronchial asthma) generate substantial direct and indirect costs. Treatment options, in particular AIT, are therefore evaluated using cost-benefit and cost-effectiveness analyses. From a long-term perspective, AIT is considered to be significantly more cost effective in allergic rhinitis and allergic asthma than pharmacotherapy, but is heavily dependent on patient compliance. Meta-analyses provide unequivocal evidence of the efficacy of SCIT and SLIT for certain allergen sources and age groups. Data from controlled studies differ in terms of scope, quality and dosing regimens and require product-specific evaluation. Therefore, evaluating individual preparations according to clearly defined criteria is recommended. A broad transfer of the efficacy of certain preparations to all preparations administered in the same way is not endorsed. The website of the German Society for Allergology and Clinical Immunology (www.dgaki.de/leitlinien/s2k-leitlinie-sit; DGAKI: Deutsche Gesellschaft für Allergologie und klinische Immunologie) provides tables with specific information on available products for AIT in Germany, Switzerland and Austria. The tables contain the number of clinical studies per product in adults and children, the year of market authorization, underlying scoring systems, number of randomized and analyzed subjects and the method of evaluation (ITT, FAS, PP), separately given for grass pollen, birch pollen and house dust mite allergens, and the status of approval for the conduct of clinical studies with these products. Strong evidence of the efficacy of SCIT in pollen allergy-induced allergic rhinoconjunctivitis in adulthood is well-documented in numerous trials and, in childhood and adolescence, in a few trials. Efficacy in house dust mite allergy is documented by a number of controlled trials in adults and few controlled trials in children. Only a few controlled trials, independent of age, are available for mold allergy (in particular Alternaria). With regard to animal dander allergies (primarily to cat allergens), only small studies, some with methodological deficiencies are available. Only a moderate and inconsistent therapeutic effect in atopic dermatitis has been observed in the quite heterogeneous studies conducted to date. SCIT has been well investigated for individual preparations in controlled bronchial asthma as defined by the Global Initiative for Asthma (GINA) 2007 and intermittent and mild persistent asthma (GINA 2005) and it is recommended as a treatment option, in addition to allergen avoidance and pharmacotherapy, provided there is a clear causal link between respiratory symptoms and the relevant allergen. The efficacy of SLIT in grass pollen-induced allergic rhinoconjunctivitis is extensively documented in adults and children, whilst its efficacy in tree pollen allergy has only been shown in adults. New controlled trials (some with high patient numbers) on house dust mite allergy provide evidence of efficacy of SLIT in adults. Compared with allergic rhinoconjunctivitis, there are only few studies on the efficacy of SLIT in allergic asthma. In this context, newer studies show an efficacy for SLIT on asthma symptoms in the subgroup of grass pollen allergic children, adolescents and adults with asthma and efficacy in primary house dust mite allergy-induced asthma in adolescents aged from 14 years and in adults. Aspects of secondary prevention, in particular the reduction of new sensitizations and reduced asthma risk, are important rationales for choosing to initiate treatment early in childhood and adolescence. In this context, those products for which the appropriate effects have been demonstrated should be considered. SCIT or SLIT with pollen or mite allergens can be performed in patients with allergic rhinoconjunctivitis using allergen extracts that have been proven to be effective in at least one double-blind placebo-controlled (DBPC) study. At present, clinical trials are underway for the indication in asthma due to house dust mite allergy, some of the results of which have already been published, whilst others are still awaited (see the DGAKI table "Approved/potentially completed studies" via www.dgaki.de/Leitlinien/s2k-Leitlinie-sit (according to www.clinicaltrialsregister.eu)). When establishing the indication for AIT, factors that favour clinical efficacy should be taken into consideration. Differences between SCIT and SLIT are to be considered primarily in terms of contraindications. In individual cases, AIT may be justifiably indicated despite the presence of contraindications. SCIT injections and the initiation of SLIT are performed by a physician experienced in this type of treatment and who is able to administer emergency treatment in the case of an allergic reaction. Patients must be fully informed about the procedure and risks of possible adverse events, and the details of this process must be documented (see "Treatment information sheet"; available as a handout via www.dgaki.de/Leitlinien/s2k-Leitlinie-sit). Treatment should be performed according to the manufacturer's product information leaflet. In cases where AIT is to be performed or continued by a different physician to the one who established the indication, close cooperation is required in order to ensure that treatment is implemented consistently and at low risk. In general, it is recommended that SCIT and SLIT should only be performed using preparations for which adequate proof of efficacy is available from clinical trials. Treatment adherence among AIT patients is lower than assumed by physicians, irrespective of the form of administration. Clearly, adherence is of vital importance for treatment success. Improving AIT adherence is one of the most important future goals, in order to ensure efficacy of the therapy. Severe, potentially life-threatening systemic reactions during SCIT are possible, but - providing all safety measures are adhered to - these events are very rare. Most adverse events are mild to moderate and can be treated well. Dose-dependent adverse local reactions occur frequently in the mouth and throat in SLIT. Systemic reactions have been described in SLIT, but are seen far less often than with SCIT. In terms of anaphylaxis and other severe systemic reactions, SLIT has a better safety profile than SCIT. The risk and effects of adverse systemic reactions in the setting of AIT can be effectively reduced by training of personnel, adhering to safety standards and prompt use of emergency measures, including early administration of i. m. epinephrine. Details on the acute management of anaphylactic reactions can be found in the current S2 guideline on anaphylaxis issued by the AWMF (S2-AWMF-LL Registry Number 061-025). AIT is undergoing some innovative developments in many areas (e. g., allergen characterization, new administration routes, adjuvants, faster and safer dose escalation protocols), some of which are already being investigated in clinical trials. Cite this as Pfaar O, Bachert C, Bufe A, Buhl R, Ebner C, Eng P, Friedrichs F, Fuchs T, Hamelmann E, Hartwig-Bade D, Hering T, Huttegger I, Jung K, Klimek L, Kopp MV, Merk H, Rabe U, Saloga J, Schmid-Grendelmeier P, Schuster A, Schwerk N, Sitter H, Umpfenbach U, Wedi B, Wöhrl S, Worm M, Kleine-Tebbe J. Guideline on allergen-specific immunotherapy in IgE-mediated allergic diseases - S2k Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Society for Pediatric Allergy and Environmental Medicine (GPA), the Medical Association of German Allergologists (AeDA), the Austrian Society for Allergy and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Dermatology (DDG), the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), the German Society of Pediatrics and Adolescent Medicine (DGKJ), the Society for Pediatric Pneumology (GPP), the German Respiratory Society (DGP), the German Association of ENT Surgeons (BV-HNO), the Professional Federation of Paediatricians and Youth Doctors (BVKJ), the Federal Association of Pulmonologists (BDP) and the German Dermatologists Association (BVDD). Allergo J Int 2014;23:282-319.
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Affiliation(s)
- Oliver Pfaar
- />Center for Rhinology and Allergology, Wiesbaden, Germany
- />Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany
- />Center for Rhinology and Allergology Wiesbaden, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, An den Quellen 10, 65189 Wiesbaden, Germany
| | - Claus Bachert
- />Department of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
| | - Albrecht Bufe
- />Department of Experimental Pneumology, Ruhr-University Bochum, Bochum, Germany
| | - Roland Buhl
- />Pulmonary Department, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Christof Ebner
- />Outpatient Clinic for Allergy and Clinical Immunology, Vienna, Austria
| | - Peter Eng
- />Department of Children and Adolescent Medicine, Aarau and Children‘s Hospital Lucerne, Lucerne, Switzerland
| | - Frank Friedrichs
- />Pediatric and Adolescent Medicine Practice, Laurensberg, Germany
| | - Thomas Fuchs
- />Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Eckard Hamelmann
- />Department of Pediatric and Adolescent Medicine, Pediatric Center Bethel, Evangelical Hospital, Bielefeld, Germany
| | | | - Thomas Hering
- />Pulmonary Outpatient Practice, Tegel, Berlin, Germany
| | - Isidor Huttegger
- />Department of Pediatric and Adolescent Medicine, Paracelsus Private Medical University, Salzburg Regional Hospitals, Salzburg, Austria
| | | | - Ludger Klimek
- />Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Matthias Volkmar Kopp
- />Clinic of Pediatric and Adolescent Medicine, Lübeck University, Airway Research Center North (ARCN), Member of the German Lung Center (DZL), Lübeck, Germany
| | - Hans Merk
- />Department of Dermatology and Allergology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Uta Rabe
- />Department of Allergology, Johanniter-Krankenhaus im Fläming Treuenbrietzen GmbH, Treuenbrietzen Germany, Treuenbrietzen, Germany
| | - Joachim Saloga
- />Department of Dermatology, University Medical Center, Johannes-Gutenberg University, Mainz, Germany
| | | | - Antje Schuster
- />Center for Pediatric and Adolescent Medicine, University Medical Center, Düsseldorf, Germany
| | - Nicolaus Schwerk
- />University Children’s hospital, Department of Pediatric Pneumology, Allergology and Neonatology, Hanover Medical University, Hannover, Germany
| | - Helmut Sitter
- />Institute for Theoretical Surgery, Marburg University, Marburg, Germany
| | | | - Bettina Wedi
- />Department of Dermatology, Allergology and Venereology, Hannover Medical University, Hannover, Germany
| | | | - Margitta Worm
- />Allergy-Centre-Charité, Department of Dermatology, Venereology, and Allergology, Charité University Hospital, Berlin, Germany
| | | | - Susanne Kaul
- />Division of Allergology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
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Lavaud F, Fore M, Fontaine JF, Pérotin JM, de Blay F. [Birch pollen allergy]. Rev Mal Respir 2013; 31:150-61. [PMID: 24602682 DOI: 10.1016/j.rmr.2013.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 08/17/2013] [Indexed: 12/16/2022]
Abstract
In the North-East of France, birch is the main tree responsible of spring pollen allergy. However, the epidemiology of sensitization to birch pollen remains unclear. Monosensitization to birch pollen seems rare because of the frequency of cross-reactions with other pollens of the same botanical family via the major allergen Bet v 1. Around one third of patients with allergic rhinoconjunctivitis due to birch pollen are also asthmatics and a half suffer from a food allergy, essentially an oral syndrome due to rosaceae fruits eaten raw. The molecular allergens of birch pollen are well-known and have been cloned. They are available for use in in vitro diagnostic tests and also in clinical trials of specific immunotherapy.
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Affiliation(s)
- F Lavaud
- Service des maladies respiratoires et allergiques, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France.
| | - M Fore
- Département des maladies respiratoires, CHU de Strasbourg, BP 426, 67091 Strasbourg cedex, France
| | - J-F Fontaine
- Service des maladies respiratoires et allergiques, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France
| | - J M Pérotin
- Service des maladies respiratoires et allergiques, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France
| | - F de Blay
- Département des maladies respiratoires, CHU de Strasbourg, BP 426, 67091 Strasbourg cedex, France
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Depigmented allergoids reveal new epitopes with capacity to induce IgG blocking antibodies. BIOMED RESEARCH INTERNATIONAL 2013; 2013:284615. [PMID: 24222901 PMCID: PMC3816019 DOI: 10.1155/2013/284615] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 08/01/2013] [Accepted: 08/12/2013] [Indexed: 02/03/2023]
Abstract
Background. The synthesis of allergen-specific blocking IgGs that interact with IgE after allergen immunotherapy (SIT) has been related to clinical efficacy. The objectives were to investigate the epitope specificity of IgG-antibodies induced by depigmented-polymerized (Dpg-Pol) allergoids and unmodified allergen extracts, and examine IgE-blocking activity of induced IgG-antibodies. Methods. Rabbits were immunized with native and Dpg-Pol extracts of birch pollen, and serum samples were obtained. Recognition of linear IgG-epitopes of Bet v 1 and Bet v 2 and the capacity of these IgG-antibodies to block binding of human-IgE was determined. Results. Serum from rabbits immunized with native extracts recognised 11 linear epitopes from Bet v 1, while that from Dpg-Pol-immunized animals recognised 8. For Bet v 2, 8 epitopes were recognized by IgG from native immunized animals, and 9 from Dpg-Pol immunized one. Dpg-Pol and native immunized serum did not always recognise the same epitopes, but specific-IgG from both could block human-IgE binding sites for native extract. Conclusions. Depigmented-polymerized birch extract stimulates the synthesis of specific IgG-antibodies which recognize common but also novel epitopes compared with native extracts. IgG-antibodies induced by Dpg-Pol effectively inhibit human-IgE binding to allergens which may be part of the mechanism of action of SIT.
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Pfaar O, Biedermann T, Klimek L, Sager A, Robinson DS. Depigmented-polymerized mixed grass/birch pollen extract immunotherapy is effective in polysensitized patients. Allergy 2013; 68:1306-13. [PMID: 23991896 DOI: 10.1111/all.12219] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although many patients with allergic rhinoconjunctivitis have symptoms due to sensitization with more than one pollen allergen, and mixed pollen extracts are widely used for allergen immunotherapy in practice, there are few published trials. METHODS We performed a 2-year multicentre, double-blind, placebo-controlled trial of subcutaneous immunotherapy with mixed depigmented-polymerized birch and grass pollen extract in 285 patients with allergic rhinoconjunctivitis symptomatic during both birch and grass pollen seasons. Primary outcome was combined symptom and medication score (SMS) assessed by daily visual analogue scales (VAS). Analysis included a placebo-based analysis examining the effect of treatment only on days when placebo patients were symptomatic. RESULTS There was a significant reduction in median SMS for actively treated patients (median 5.70 (interquartile range 2.62-10.02) compared with 7.07 (3.47-10.71) for placebo, P = 0.0385). Rhinitis quality-of-life scores were significantly better for active compared with placebo, and other secondary endpoints were not significantly different. Placebo-based analysis showed a 33.7% reduced SMS at year 2 for active treatment compared with placebo on days when placebo patients were symptomatic. Both birch pollen- and grass pollen-specific IgG4 increased with active treatment. CONCLUSIONS This study shows efficacy of mixed pollen extracts for immunotherapy for patients symptomatic to both birch and grass pollen allergens. The relatively modest effect may reflect 50% dose reduction for each allergen in the mixture. It supports VAS for symptom assessment and placebo-based analysis as useful for the analysis of immunotherapy trials. The safety of modified extracts may allow study of mixed extracts without dose reduction to improve efficacy.
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Affiliation(s)
- O. Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery; Center for Rhinology and Allergology; University Hospital Mannheim; Wiesbaden; Germany
| | - T. Biedermann
- Clinic for Dermatology; University Hospital Tübingen; Tübingen; Germany
| | - L. Klimek
- Department of Otorhinolaryngology, Head and Neck Surgery; Center for Rhinology and Allergology; University Hospital Mannheim; Wiesbaden; Germany
| | | | - D. S. Robinson
- Leukocyte Biology Section; National Heart and Lung Institute; Imperial College London; London; UK
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26
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Meyer W, Narkus A, Salapatek AM, Häfner D. Double-blind, placebo-controlled, dose-ranging study of new recombinant hypoallergenic Bet v 1 in an environmental exposure chamber. Allergy 2013; 68:724-31. [PMID: 23621350 DOI: 10.1111/all.12148] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recombinant allergens offer a tool for improving specific immunotherapy (SIT). OBJECTIVE To find the optimal dose of a new hypoallergenic folding variant of recombinant Bet v 1 (rBet v 1-FV) as SIT for patients with birch pollen allergy. METHODS Before SIT, thirty-seven adult patients were exposed for eight hours in an environmental exposure chamber (EEC) to birch pollen at an average concentration of 3500 ± 500 grains/m(3) , then randomized to four maintenance dose groups of rBet v 1-FV and one placebo group: 20 μg (n = 7), 80 μg (n = 8), 160 μg (n = 7), 320 μg (n = 8), and placebo (n = 7). Patients were treated for 10 weeks with weekly injections and then re-exposed in the EEC. The optimal dose for SIT was assessed using efficacy results from the EEC, IgG responses, and tolerability. RESULTS Thirty-six patients were evaluable for efficacy assessment. The total symptom score significantly decreased in all active groups compared with placebo (-18.8% for placebo patients; -71.9%, P = 0.0022 for 20 μg; -75.6%, P = 0.0007 for 80 μg; -81.8%, P = 0.0009 for 160 μg; -78.3%, P = 0.0003 for 320 μg). IgG1 increased significantly in all active groups compared to placebo. All four active doses were well tolerated, no serious adverse event occurred; two Grade II reactions, according to EAACI classification, were observed, one in each of the 160- and 320-μg groups. CONCLUSIONS Considering efficacy, immunological response, and tolerability, a maintenance dose of 80 μg of rBet v 1-FV appears to be the ideal dose for allergen immunotherapy in birch pollen allergic patients.
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Affiliation(s)
- W. Meyer
- Medical Department Allergopharma GmbH & Co. KG; Reinbek; Germany
| | - A. Narkus
- Medical Department Allergopharma GmbH & Co. KG; Reinbek; Germany
| | | | - D. Häfner
- Medical Department Allergopharma GmbH & Co. KG; Reinbek; Germany
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27
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Meechan P, Tungtrongchitr A, Chaisri U, Maklon K, Indrawattana N, Chaicumpa W, Sookrung N. Intranasal, liposome-adjuvanted cockroach allergy vaccines made of refined major allergen and whole-body extract of Periplaneta americana. Int Arch Allergy Immunol 2013; 161:351-62. [PMID: 23689057 DOI: 10.1159/000348314] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 01/18/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cockroach (CR) allergens frequently cause severe asthma in CR-sensitized subjects. Allergen-specific immunotherapy causes a shift of allergic Th2 responses towards Th1 and/or regulatory T cell (Treg) responses which reduce airway inflammation and prevent disease progression. Data are relatively limited on immunotherapy via CR allergy vaccine. METHODS The therapeutic efficacy of an intranasal liposome-adjuvant vaccine made of a refined Periplaneta americana arginine kinase (AK) was compared to the liposome-entrapped P. americana crude extract (CRE) vaccine. Adult BALB/c mice were rendered allergic to CRE. Three allergic mouse groups were immunized intranasally on alternate days with 8 doses of liposome-entrapped CRE (L-CRE), liposome-entrapped AK and placebo, respectively. One week later, all mice received a nebulized CRE provocation. Evaluation of vaccine efficacy was performed 1 day after provocation. RESULTS Liposome-entrapped native AK attenuated airway inflammation after the CRE provocation and caused a shift of allergic Th2 to Th1 and Treg responses. The L-CRE also induced a shift from the Th2 to the Th1 response but did not induce a Treg response and could not attenuate the airway inflammation upon allergen reexposure. CONCLUSIONS Intranasal liposome-adjuvant CR allergy vaccine containing native AK (Per a 9) is better than L-CRE in attenuating allergic airway inflammation. The findings of this study not only document a more comprehensive and beneficial immune response induced by the refined allergen vaccine but also raise the point that the shift from the Th2 to the Th1 response alone might not correlate with improved airway histopathology, clinical outcome and quality of life.
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Affiliation(s)
- Panissara Meechan
- Graduate Program in Immunology, Department of Immunology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Purkey MT, Smith TL, Ferguson BJ, Luong A, Reisacher WR, Pillsbury HC, Toskala E. Subcutaneous immunotherapy for allergic rhinitis: an evidence based review of the recent literature with recommendations. Int Forum Allergy Rhinol 2013; 3:519-31. [PMID: 23315962 DOI: 10.1002/alr.21141] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Revised: 10/22/2012] [Accepted: 11/01/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND Allergic rhinitis is a common allergic disease with increasing prevalence in Western Societies. Medical therapy is first line treatment, and is aimed at reducing symptoms of immunoglobulin E (IgE)-mediated inflammation of the nasal passages. In patients with disease refractory to medical therapy, subcutaneous immunotherapy is an option. The aim of this study is to update a recent Cochrane review with available level 1 evidence for seasonal and perennial allergic rhinitis. METHODS A systematic review of the literature was performed from 2006 to 2011 and compared with data from a 2007 Cochrane review on immunotherapy for seasonal allergic rhinitis. We included all studies of level 1 evidence. All forms of single extract immunotherapy were considered. Studies with primary asthma related end-points were excluded. Primary end-points were instruments of clinical efficacy (ie, symptom-medication scores) and adverse events. RESULTS We retrieved 12 level 1 studies for review. In total, 1512 patients were randomized into treatment groups, alternative study groups (alternative duration of therapy or sublingual immunotherapy [SLIT]), or placebo. Efficacy was evaluated based on reported symptom and/or medication score, validated quality of life instruments, immunological assays, challenge testing, and adverse events. CONCLUSION Subcutaneous immunotherapy improves symptom and/or medication scores and validated quality of life measures. In addition, associated changes in surrogate markers of immunologic protection are observed. Subcutaneous immunotherapy is safe when administered to carefully selected patients and in settings capable of responding to systemic reactions. Subcutaneous immunotherapy is recommended for patients with seasonal or perennial allergic rhinitis not responsive to conservative medical therapy, and whose symptoms significantly affect quality of life.
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Affiliation(s)
- Michael T Purkey
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Abstract
PURPOSE OF REVIEW The purpose of the review is to summarize and comment on recent developments regarding the safety of engineered immunotherapy vaccines. RECENT FINDINGS In the last 2 years, several studies were published in which allergy vaccines were developed on the basis of chemical modification of natural allergen extracts, the engineering of allergen molecules by recombinant DNA technology and synthetic peptide chemistry, allergen genes, new application routes and conjugation with immune modulatory molecules. Several studies exemplified the general applicability of hypoallergenic vaccines on the basis of recombinant fusion proteins consisting of nonallergenic allergen-derived peptides fused to allergen-unrelated carrier molecules. These vaccines are engineered to reduce both, immunoglobulin E (IgE) as well as allergen-specific T cell epitopes in the vaccines, and thus should provoke less IgE and T-cell-mediated side-effects. They are made to induce allergen-specific IgG antibodies against the IgE-binding sites of allergens with the T-cell help of the carrier molecule. SUMMARY Several interesting examples of allergy vaccines with potentially increased safety profiles have been published. The concept of fusion proteins consisting of allergen-derived hypoallergenic peptides fused to allergen-unrelated proteins that seems to be broadly applicable for a variety of allergens appears to be of particular interest because it promises not only to reduce side-effects but also to increase efficacy and convenience of allergy vaccines.
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30
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Jacobsen L, Wahn U, Bilo MB. Allergen-specific immunotherapy provides immediate, long-term and preventive clinical effects in children and adults: the effects of immunotherapy can be categorised by level of benefit -the centenary of allergen specific subcutaneous immunotherapy. Clin Transl Allergy 2012; 2:8. [PMID: 22500494 PMCID: PMC3348084 DOI: 10.1186/2045-7022-2-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 04/13/2012] [Indexed: 12/24/2022] Open
Abstract
Allergen Specific Immunotherapy (SIT) for respiratory allergic diseases is able to significantly improve symptoms as well as reduce the need for symptomatic medication, but SIT also has the capacity for long-term clinical effects and plays a protective role against the development of further allergies and symptoms. The treatment acts on basic immunological mechanisms, and has the potential to change the pathological allergic immune response. In this paper we discuss some of the most important achievements in the documentation of the benefits of immunotherapy, over the last 2 decades, which have marked a period of extensive research on the clinical effects and immunological background of the mechanisms involved. The outcome of immunotherapy is described as different levels of benefit from early reduction in symptoms over progressive clinical effects during treatment to long-term effects after discontinuation of the treatment and prevention of asthma. The efficacy of SIT increases the longer it is continued and immunological changes lead to potential long-term benefits. SIT alone and not the symptomatic treatment nor other avoidance measures has so far been documented as the therapy with long-term or preventive potential. The allergic condition is driven by a subset of T-helper lymphocytes (Th2), which are characterised by the production of cytokines like IL-4, and IL-5. Immunological changes following SIT lead to potential curative effects. One mechanism whereby immunotherapy suppresses the allergic response is through increased production of IgG4 antibodies. Induction of specific IgG4 is able to influence the allergic response in different ways and is related to immunological effector mechanisms, also responsible for the reduced late phase hyperreactivity and ongoing allergic inflammation. SIT is the only treatment which interferes with the basic pathophysiological mechanisms of the allergic disease, thereby creating the potential for changes in the long-term prognosis of respiratory allergy. SIT should not only be recognised as first-line therapeutic treatment for allergic rhinoconjunctivitis but also as secondary preventive treatment for respiratory allergic diseases.
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Affiliation(s)
- Lars Jacobsen
- Research Centre for Prevention and Health, Glostrup University Hospital, Copenhagen, Denmark.
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31
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Pfaar O, Urry Z, Robinson DS, Sager A, Richards D, Hawrylowicz CM, Bräutigam M, Klimek L. A randomized placebo-controlled trial of rush preseasonal depigmented polymerized grass pollen immunotherapy. Allergy 2012; 67:272-9. [PMID: 22107266 DOI: 10.1111/j.1398-9995.2011.02736.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Specific subcutaneous immunotherapy (SCIT) for seasonal rhinoconjunctivitis with unmodified allergen extracts is effective, but limited by risk of side-effects and involves treatment over 3 years. We examined a depigmented polymerized grass pollen extract for immunogenicity and for clinical efficacy in a rush preseasonal regimen. METHODS Depigmented polymerized grass pollen extract was tested for proliferation and cytokine production by peripheral blood mononuclear cells. A prospective, double-blind, placebo-controlled trial of 195 grass pollen allergic patients treated with preseasonal rush immunotherapy using depigmented polymerized allergenic extract of mixed grass pollen was performed over 2 years. Primary outcome was combined symptom and medication score (SMS) during the peak of the second grass pollen season. Secondary outcomes included combined score over the whole season, during the first grass pollen season, individual symptom and medication scores, quality of life, well days/hell days and responder analysis. Adverse events were classified using the EAACI scale. Grass pollen-specific IgE and IgG4 were measured before and during treatment. RESULTS Depigmented polymerized extract stimulated dose-dependent T-cell proliferation and cytokine production. Patients treated with preseasonal SCIT showed improved combined scores during peak season at year 2 (median 3.93, interquartile range 0.77-6.27 vs median 5.86 for placebo, 3.11-8.36, P < 0.01). Most secondary outcomes were significantly better for active treatment. Side-effects were minimal, with no grade 3 or 4 reactions. CONCLUSIONS Depigmented polymerized grass pollen extract is immunogenic and clinically effective in rush preseasonal SCIT. This form of immunotherapy may be an attractive option for some patients.
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Affiliation(s)
- O Pfaar
- Center for Rhinology and Allergology Wiesbaden, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Germany.
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Oral administration of allergen extracts from mugwort pollen desensitizes specific allergen-induced allergy in mice. Vaccine 2012; 30:1437-44. [PMID: 22240342 DOI: 10.1016/j.vaccine.2012.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 12/04/2011] [Accepted: 01/02/2012] [Indexed: 11/23/2022]
Abstract
Clinically, sublingual immunotherapy (SLIT) using allergen extracts effectively alleviates the symptoms of allergic rhinitis and asthma. We hypothesized that oral administration of a high-dose of allergen extracts imitates SLIT, which may prevent IgE-related responses in allergic diseases. In the present study, we investigated the effects of oral administration of allergen extracts from mugwort pollen (MP) on allergen-induced inflammation and airway hyperresponsiveness (AHR) in an allergic mouse model. After administration of MPdrop containing Art v 1 and Art v 4 extracts derived from MP specifically in MP-sensitized mice, the effects of MPdrop on AHR, inflammatory cell accumulation, cytokine production in the bronchoalveolar lavage fluid and lung tissue, and serum IgE and IgG levels were investigated. The results indicated that MPdrop not only prevented the AHR in response to methacholine in a dose-dependent manner but also significantly reduced the total serum and allergen-specific IgE levels. All of the maximal effects were achieved at a dose of 100μg/(kgd) and were comparable to the effects of dexamethasone at a dose of 0.5mg/(kgd). Furthermore, oral administration of MPdrop dose-dependently elevated allergen-specific serum IgG2a levels, reduced total and allergen-specific IgE levels and normalized the imbalance between the Th1 cytokine IL-12 and Th2 cytokines IL-4 and IL-5. Finally, oral administration of MPdrop significantly reduced goblet cell hyperplasia and eosinophilia in the MP-sensitized allergic mouse model. These data suggest that MPdrop effectively improves specific allergen-induced inflammation and AHR in MP-sensitized and -challenged mice and provides the rationale for clinical use of MPdrop in the specific allergen-induced asthma.
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