Side effects during immunotherapy with purified grass pollen extracts

Side effects during subcutaneous immunotherapy in children with allergic diseases

BACKGROUND

Allergen-specific immunotherapy is the only causal form of therapy for IgE-mediated allergic diseases. Subcutaneous immunotherapy (SCIT) is considered safe and well tolerated in adults, yet there is less evidence of safety in the pediatric population.

METHODS

A non-interventional prospective observing longitudinal study was carried out to determine the incidence of local and systemic side effects by SCIT, routinely performed in pediatric patients. A total of 581 pediatric patients were observed in 18 study centers between March 2012 and October 2014, recording 8640 treatments and 10 015 injections.

RESULTS

A total of 54.6% of the patients experienced immediate local side effects at least once; delayed local side effects were seen in 56.1%. Immediate systemic adverse reactions occurred in 2.2% of patients; 7.4% experienced delayed systemic side effects. However, severe systemic side effects (grade III in the classification of Ring and Messmer) were seen in 0.03% of all treatments, all appearing within 30 minutes after the injections. No grade IV reactions were observed. In addition, many potential risk factors were investigated, yet only a few were found to be associated with the occurrence of side effects.

CONCLUSIONS

Subcutaneous immunotherapy is a safe form of therapy in pediatric patients, with similar rates of local side effects compared to adult patients and low rates of severe systemic side effects. However, local and systemic reactions occurring later than 30 minutes after injection were observed more often than expected, which makes it essential to be attentive on behalf of pediatricians, patients, and parents.

Aluminium in Allergies and Allergen immunotherapy

Aluminium is a hot topic in the current debate. Exposure occurs due to environmental, dietary and intentional exposure to aluminium, such as in vaccines where it was introduced in 1926. In spite of the fact that it is a typical Th2 adjuvant, aluminium redirects the immune response in systemic allergen immunotherapy (SIT) upon prolonged immunization. SIT in the US, and SLIT in general, are at present non-adjuvanted therapies, but in Europe aluminium is used as adjuvant in most SIT preparations. It enhances the safety of SIT by local deposition of the allergen. Undesired properties of aluminium adjuvants comprise acute and chronic inflammation at the injection site, its Th2 immune stimulatory capacity, its accumulation besides biodistribution in the body. The adjuvant and safety profile of aluminium adjuvants in allergy vaccines are discussed, as well as the need for putting modern delivery systems and adjuvants on the fast track.

Effects of different adjuvants in the context of intramuscular and intranasal routes on humoral and cellular immune responses induced by detergent-split A/H3N2 influenza vaccines in mice

Influenza A/H3N2 viruses have caused the most severe epidemics since 1968 despite current immunization programs with inactivated vaccines. We undertook a side-by-side preclinical evaluation of different adjuvants (Alum, AS03, and Protollin) and routes of administration (intramuscular [i.m.] and intranasal [i.n.]) for assessing their effect on the immunogenicity and cross-reactivity of inactivated split vaccines (A/H3N2/New York/55/2004). Humoral and T cell-mediated immune responses against the homologous virus and a heterologous drifted strain (A/H3N2/Wisconsin/67/2005) were measured in BALB/c mice at 2, 6, and 19 weeks postboost. The AS03- and Alum-adjuvanted i.m. vaccines induced at least an 8-fold increase over the nonadjuvanted vaccine in functional antibody titers against both the homotypic and heterotypic strains and low IgG2a and high IgG1 levels, suggesting a mixed Th1/Th2 response with a Th2 trend. The Protollin-adjuvanted i.n. vaccine induced the lowest IgG1/IgG2a ratio, which is indicative of a mixed Th1/Th2-type profile with a Th1 trend. This adjuvanted vaccine was the only vaccine to stimulate a mucosal IgA response. Whatever the timing after the boost, both hemagglutination inhibition (HAI) and microneutralization (MN) titers were higher with the AS03-adjuvanted i.m. vaccine than with the protollin-adjuvanted i.n. vaccine. Finally, the Alum-adjuvanted i.m. vaccine and the lower-dose Protollin-adjuvanted i.n. vaccine elicited significantly higher CD4(+) Th1 and Th2 responses and more gamma interferon (IFN-γ)-producing CD8(+) T cells than the nonadjuvanted vaccine. Our data indicate that the adjuvanted vaccines tested in this study can elicit stronger, more persistent, and broader immune responses against A/H3N2 strains than nonadjuvanted inactivated influenza vaccines.

Injection allergen immunotherapy for asthma

BACKGROUND

Allergen specific immunotherapy has long been a controversial treatment for asthma. Although beneficial effects upon clinically relevant outcomes have been demonstrated in randomised controlled trials, there remains a risk of severe and sometimes fatal anaphylaxis. The recommendations of professional bodies have ranged from cautious acceptance to outright dismissal. With increasing interest in new allergen preparations and methods of delivery, we updated the systematic review of allergen specific immunotherapy for asthma.

OBJECTIVES

The objective of this review was to assess the effects of allergen specific immunotherapy for asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trials Register up to 2005, Dissertation Abstracts and Current Contents.

SELECTION CRITERIA

Randomised controlled trials using various forms of allergen specific immunotherapy to treat asthma and reporting at least one clinical outcome.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed eligibility of studies for inclusion. Two authors independently performed quality assessment of studies.

MAIN RESULTS

Eighty-eight trials were included (13 new trials). There were 42 trials of immunotherapy for house mite allergy; 27 pollen allergy trials; 10 animal dander allergy trials; two Cladosporium mould allergy, two latex and six trials looking at multiple allergens. Concealment of allocation was assessed as clearly adequate in only 16 of these trials. Significant heterogeneity was present in a number of comparisons. Overall, there was a significant reduction in asthma symptoms and medication, and improvement in bronchial hyper-reactivity following immunotherapy. There was a significant improvement in asthma symptom scores (standardised mean difference -0.59, 95% confidence interval -0.83 to -0.35) and it would have been necessary to treat three patients (95% CI 3 to 5) with immunotherapy to avoid one deterioration in asthma symptoms. Overall it would have been necessary to treat four patients (95% CI 3 to 6) with immunotherapy to avoid one requiring increased medication. Allergen immunotherapy significantly reduced allergen specific bronchial hyper-reactivity, with some reduction in non-specific bronchial hyper-reactivity as well. There was no consistent effect on lung function. If 16 patients were treated with immunotherapy, one would be expected to develop a local adverse reaction. If nine patients were treated with immunotherapy, one would be expected to develop a systemic reaction (of any severity).

AUTHORS' CONCLUSIONS

Immunotherapy reduces asthma symptoms and use of asthma medications and improves bronchial hyper-reactivity. One trial found that the size of the benefit is possibly comparable to inhaled steroids. The possibility of local or systemic adverse effects (such as anaphylaxis) must be considered.

[Mast cell-rich aluminium granuloma]

Persistent subcutaneous nodules arise at the injection sites of aluminium hydroxide-absorbed hyposensitization solutions. We present a hitherto unreported phenomenon in aluminium granuloma. Two years after specific immunotherapy, a patient suffered increasingly from urticaria. Besides inflammatory infiltrates surrounding necrotic areas, microscopy of the specimen revealed numerous mast cells surrounding the necrotic tissue areas. The histological phenomenon of increased mast cell populations in aluminium granuloma might reflect the association with urticaria, which is probably more frequent than previously reported.

Allergen injection immunotherapy for seasonal allergic rhinitis

BACKGROUND

Allergic rhinitis is the most common of the allergic diseases. Despite improved understanding of the pathophysiology of allergic rhinitis and advances in its pharmacological treatment, its prevalence has increased worldwide. For patients whose symptoms remain uncontrolled despite medical treatment, allergen injection immunotherapy is advised. An allergen-based treatment may reduce symptoms, the need for medication and modify the natural course of this disease.

OBJECTIVES

To evaluate the efficacy and safety of subcutaneous specific allergen immunotherapy, compared with placebo, for reducing symptoms and medication requirements in seasonal allergic rhinitis patients.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1 2006), MEDLINE (1950 to 2006), EMBASE (1974 to 2006), Pre-MEDLINE, KOREAMED, INDMED, LILACS, PAKMEDINET, Scisearch, mRCT and the National Research Register. The date of the last search was February 2006.

SELECTION CRITERIA

All studies identified by the searches were assessed to identify randomised controlled trials involving participants with symptoms of seasonal allergic rhinitis and proven allergen sensitivity, treated with subcutaneous allergen specific immunotherapy or corresponding placebo.

DATA COLLECTION AND ANALYSIS

Two independent authors identified all studies reporting double-blind, placebo controlled randomised trials of specific immunotherapy in patients with seasonal allergic rhinitis due to tree, grass or weed pollens. Two authors independently performed quality assessment of studies. Data from identified studies were abstracted onto a standard extraction sheet and subsequently entered into RevMan 4.2.8. Analysis was performed using the Standardised Mean Difference (SMD) method and a random-effects model; P values < 0.05 were considered statistically significant. The primary outcome measures were symptom scores, medication use, quality of life and adverse events.

MAIN RESULTS

We retrieved 1111 publications of which 51 satisfied our inclusion criteria. In total there were 2871 participants (1645 active, 1226 placebo), each receiving on average 18 injections. Duration of immunotherapy varied from three days to three years. Symptom score data from 15 trials were suitable for meta-analysis and showed an overall reduction in the immunotherapy group (SMD -0.73 (95% CI -0.97 to -0.50, P < 0.00001)). Medication score data from 13 trials showed an overall reduction in the immunotherapy group (SMD of -0.57 (95% CI -0.82 to -0.33, p<0.00001)). Clinical interpretation of the effect size is difficult. Adrenaline was given in 0.13% (19 of 14085 injections) of those on active treatment and in 0.01% (1 of 8278 injections) of the placebo group for treatment of adverse events. There were no fatalities.

AUTHORS' CONCLUSIONS

This review has shown that specific allergen injection immunotherapy in suitably selected patients with seasonal allergic rhinitis results in a significant reduction in symptom scores and medication use. Injection immunotherapy has a known and relatively low risk of severe adverse events. We found no long-term consequences from adverse events.

Aluminium hydroxide-induced granulomas in pigs

The effect of intramuscular injection of 40 mg/2 ml aluminium hydroxide in the neck of pigs was examined in a number of ways. The investigation followed repeated slaughterhouse reports, according to which 64.8% of pigs from one particular farm were found at slaughter to have one or more nodules in the muscles of the neck (group slaughtered). The pigs had been injected with a vaccine containing 40 mg/2 ml dose of aluminium hydroxide as adjuvant. Research consisted of two phases: first, an epidemiological study was carried out, aimed at determining the risk factors for the granulomas. The results indicated that the vaccine was to be held responsible for the formation of granulomas. A clinical trial was then performed to further substantiate the initial hypothesis, by comparing pigs, which were aseptically inoculated twice with either the original vaccine or the adjuvant alone (groups vaccine and adjuvant) to pigs inoculated twice with apyrogenic bi-distilled water (group water) and to pigs inoculated once with the adjuvant and once with apyrogenic bi-distilled water (group adjuvant/water). Both studies agreed in their conclusions, which indicate that the high amount of aluminium hydroxide was the cause of the granulomas.

Adjuvants for allergen immunotherapy: experimental results and clinical perspectives

PURPOSE OF REVIEW

Inclusion of adjuvants in immunotherapy vaccines are important to enhance immune responses to allergens. This article will cover the recent advances in adjuvant formulations described in published articles primarily over the past 2 years.

RECENT FINDINGS

Traditionally, allergen immunotherapy preparations utilize aluminium hydroxide as an adjuvant. These have generally proved efficacious and have a good safety profile. However, recent advances in the understanding of immunological mechanisms underlying immunotherapy and in the design of new adjuvants may allow a more rational approach to adjuvant use. One approach is to use adjuvants such as immunostimulatory sequences or monophosphoryl lipid A, which can deviate allergy-associated Th2 immune responses towards a Th1 phenotype. Both of these adjuvants have been used in pilot controlled clinical trials which have demonstrated clinical efficacy and the induction of protective IgG antibodies. Other approaches to improve immunotherapy vaccines include microencapsulation of allergen to allow delivery of the allergen directly to the gut in order to induce immunological tolerance and vaccination with heat-killed mycobacteria.

SUMMARY

There is great interest in newly designed adjuvants to improve the efficacy and safety of allergen immunotherapy. A better understanding of immunological mechanisms and further clinical trials utilizing new adjuvants are needed.

A novel adjuvant-allergen complex, CBP-rFel d 1, induces up-regulation of CD86 expression and enhances cytokine release by human dendritic cells in vitro

Allergen-specific immunotherapy is commonly performed with allergen extracts adsorbed to aluminium hydroxide (alum). The undesirable effects associated with the use of alum, including granuloma formation at the site of injection and stimulation of T helper 2 (Th2) cytokine production, has generated interest in alternative allergen carriers, one being carbohydrate-based particles (CBPs). Here, we have investigated the in vitro effects of the recombinant major cat allergen Fel d 1 (rFel d 1) coupled to CBPs (CBP-rFel d 1) on human monocyte-derived dendritic cells (MDDCs) obtained from healthy blood donors. A majority of the CD1a(+) MDDCs internalized fluorescein isothiocyanate-labelled CBP-rFel d 1, as demonstrated by flow cytometry and confocal laser-scanning microscopy. Furthermore, an up-regulation of the expression of the costimulatory molecule, CD86, on the MDDCs was induced by CBP-rFel d 1, but not by rFel d 1 or CBPs alone. Finally, three- and fourfold increases in the release of interleukin-8 and tumour necrosis factor-alpha, respectively, were observed when MDDCs were cultured in the presence of CBP-rFel d 1. Altogether, our results indicate that the use of CBPs as an allergen carrier and adjuvant is a promising candidate for the improvement of allergen-specific immunotherapy.

Systemic reactions to immunotherapy: influence of composition and manufacturer

BACKGROUND

Although immunotherapy clearly demonstrated the benefit of reducing allergic symptoms, it has the drawback of adverse events, mainly systemic reactions that could be very inconvenient for patients and even life-threatening.

OBJECTIVE

The aim of the present study was to assess the incidence of systemic reactions to immunotherapy in a large number of patients, and its potential relationship with the characteristics of therapy, such as allergen composition or manufacturing laboratory.

METHODS

This study analysed the administration of specific immunotherapy during a period of 5 years, involving 1212 patients affected by respiratory hypersensitivity or hymenoptera venom anaphylaxis. Commercial extracts were supplied by five different laboratories. All the patients were attended at an out-clinic immunotherapy unit by the same experienced staff. Immunotherapy was given following a conventional schedule, modified according the usual recommendations.

RESULTS

A total of 250 adverse reactions have been recorded, resulting in a frequency of 0.84% over the total number of injections. Seventy-nine of them (32%) were systemic reactions (0.27% SR/injection). The 79 systemic reactions were observed in 60 patients (5% of the patients). The frequency of systemic reactions was significantly lower (P < 0.01) on the group of mites than on the other groups. The frequency of systemic reactions varies according to the manufacturing laboratory. In the case of mite extracts, although one of the laboratories had a lower frequency of adverse systemic reactions, it did not reach the level of statistical significance. However, in relation to pollen extracts, preparations of one of the manufacturers had a significantly lower frequency of systemic reactions. Concerning the time of occurrence, 27% of systemic reactions were delayed, thus they appeared at least 30 min after the vaccine injection, most of them due to pollen extracts.

CONCLUSION

This is a preliminary study to evaluate the factors that could facilitate the appearance of systemic reactions demonstrating that not only the composition but also the manufacturer is connected to systemic reactions. Although further studies are needed to clearly establish the influence of manufacturer on frequency and time of appearance of systemic reactions, it seems necessary to reach a wide consensus on allergen extract standardization methods.

Allergen immunotherapy for asthma

BACKGROUND

Allergen specific immunotherapy has long been a controversial treatment for asthma. Although beneficial effects upon clinically relevant outcomes have been demonstrated in randomised controlled trials, there remains a risk of severe and sometimes fatal anaphylaxis. The recommendations of professional bodies have ranged from cautious acceptance to outright dismissal. With increasing interest in new allergen preparations and new methods of delivery, it was time to conduct another systematic review of allergen specific immunotherapy for asthma.

OBJECTIVES

The objective of this review was to assess the effects of allergen specific immunotherapy for asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register up to June 2001, MEDLINE, Dissertation Abstracts, Current Contents and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials using various forms of allergen specific immunotherapy to treat asthma and reporting at least one clinical outcome.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed eligibility of studies for inclusion. Two reviewers independently performed quality assessment of studies.

MAIN RESULTS

Seventy-five trials were included (52 of 54 previously included trials and 23 new trials). A total of 3,506 participants (3,188 with asthma) were involved. There were 36 trials of immunotherapy for house mite allergy; 20 pollen allergy trials; ten animal dander allergy trials; two Cladosporium mould allergy, one latex and six trials looking at multiple allergens. Concealment of allocation was assessed as clearly adequate in only 15 of these trials. Significant heterogeneity was present in a number of comparisons. Overall, there was a significant reduction in asthma symptoms and medication and improvement in bronchial hyper-reactivity following immunotherapy. There was a significant improvement in asthma symptom scores (standardised mean difference -0.72, 95% confidence interval -0.99 to -0.33) and it would have been necessary to treat 4 (95%CI 3 to 5) patients with immunotherapy to avoid one deterioration in asthma symptoms. Overall it would have been necessary to treat 5 (95%CI 4 to 6) patients with immunotherapy to avoid one requiring increased medication. Allergen immunotherapy significantly reduced allergen specific bronchial hyper-reactivity, with some reduction in non-specific bronchial hyper-reactivity as well. There was no consistent effect on lung function.

REVIEWER'S CONCLUSIONS

Immunotherapy reduces asthma symptoms and use of asthma medications and improves bronchial hyper-reactivity. One trial found that the size of the benefit is possibly comparable to inhaled steroids. The possibility of adverse effects (such as anaphylaxis) must be considered.

Carbohydrate-based particles: a new adjuvant for allergen-specific immunotherapy

The occurrence of systemic anaphylactic side-effects in the course of allergen-specific immunotherapy has been strongly reduced by the adsorption of allergens to aluminium hydroxide, the most frequently used adjuvant in humans. Using the major timothy grass pollen allergen, Phl p 5b, in its recombinant form for immunization of mice, we demonstrate that carbohydrate-based particles (CBP) exhibit several potential advantages over aluminium-hydroxide as adjuvant for immunotherapy. Similar to alum-bound rPhl p 5b, CBP-bound rPhl p 5b induced a stronger antibody and cytokine response than unbound rPhl p 5b after subcutaneous injection in mice. The antibodies induced by CBP-bound rPhl p 5b, exhibited potentially beneficial activities as they cross-reacted with group 5 allergens from five other grass species and inhibited the binding of grass pollen allergic patients IgE to Phl p 5b. Alum-bound rPhl p 5b induced a preferential allergen-specific Th2-response characterized by high immunoglobulin G1 (IgG1) antibody levels and elevated interleukin (IL)-4 and IL-5 production in cultured splenocytes. By contrast, CBP-bound rPhl p 5b, but not rPhl p 5b alone or coadministered with CBP, induced a mixed allergen-specific T helper 1 (Th1)/Th2 immune response characterized by the additional production of allergen-specific IgG2a/b antibody responses and elevated interferon-gamma production. Conjugation of rPhl p 5b to CBP yielded a stable vaccine formulation with preserved immunogenic features of the allergen and, in contrast to alum, induced no granulomatous tissue reactions. Based on these results, CBP is suggested as a potentially useful adjuvant for specific immunotherapy of IgE-mediated allergies.

Systemic reactions and fatalities associated with allergen immunotherapy

OBJECTIVE

The primary objective of this review is to discuss systemic allergic reactions and risk factors associated with the injection of allergen vaccines.

DATA SOURCES

A review of the literature on anaphylactic reaction, adverse effects, and fatalities associated with allergen immunotherapy (IT) was conducted.

STUDY SELECTION

The expert opinion of the author was used to select relevant data.

RESULTS

Systemic allergic reactions associated with the injection of allergen vaccines usually begin within 20 minutes. However, on occasion, they begin 20 to 30 minutes or longer after an injection. Such reactions can also occur after allergen skin testing. Most reactions associated with skin testing and allergen IT are mild and readily respond to appropriate treatment. However, severe and even fatal reactions have been reported with both skin testing and IT.

CONCLUSIONS

Risk factors for skin testing and allergen IT include: 1) patients, particularly asthmatic patients, suffering with seasonal exacerbation of their symptoms; 2) patients who demonstrate exquisite sensitivity to particular allergen(s); 3) patients on beta-blockers; 4) patients with asthma, especially if their asthma is unstable; 5) patients in whom rush IT is used; and 6) patients in whom high doses of potent standardized allergen vaccines are used. It is essential that strict attention be paid to the risk factors for systemic reactions, and that techniques and management be initiated both before and after skin testing or IT to minimize these risks. Done properly, the risk of skin testing and IT is minimal.

Minimising the risks of allergen-specific injection immunotherapy

The clinical advantages of allergen-specific immunotherapy are counterbalanced by the risk of inducing systemic adverse effects. Although the frequency of life-threatening systemic reactions is low, the treatment carries a risk of inducing anaphylactic reactions. A fundamental point in risk assessment is to use a clinically meaningful and internationally accepted grading system for reactions. Of importance in minimising the risk of systemic adverse effects is the identification of at-risk patients and factors, the institution of procedures for monitoring patients before injections, and the adjustment of dosages in accordance with defined rules. Asthma, especially uncontrolled asthma, is a significant risk factor for the induction of systemic reactions. Likewise, dose escalation during allergen exposure, i.e. during pollen seasons, increases the risk of adverse effects. It is recommended that standardised extracts with a documented potency and consistency between production batches are used in order to prevent overdose when changing to a new vial. The intensity of the induction regimen is a balance between the risk of inducing systemic reactions and the time required to administer the regimen. Single injections once a week are generally well tolerated, in contrast to rush immunotherapy which may carry an increased frequency of adverse effects. A clustered induction regimen (2 to 4 injections per visit) represents a compromise of a patient-friendly fast regimen without an unacceptably high frequency of systemic reactions. A major issue in improving the safety of allergen injections is minimising the human factor, e.g. mistakes of patient identification, allergen extracts and dosages. Meticulous care in monitoring every patient before the injection, which requires education and training of the staff in the dosage decision process, is the cornerstone in reducing adverse effects. Involving the patient actively in the safety monitoring process might be helpful and improves patient compliance by allowing the patient to be an active partner in the treatment. Finally, if anaphylactic reactions are induced, a successful outcome is related to the staff being able to identify the early signs and to institute immediate rescue treatment. A quality assurance programme is the optimal way to minimise the risk of immunotherapy-associated systemic reactions.

Safety of allergen-specific immunotherapy. Relation between dosage regimen, allergen extract, disease and systemic side-effects during induction treatment

BACKGROUND

Allergen-specific immunotherapy is a well-documented treatment for allergic rhinitis, asthma, and allergy to Hymenoptera venoms. The drawbacks of injection immunotherapy are related to the risk of inducing systemic side-effects (especially during the induction phase), the time used to reach the maintenance dose, and the percentage of patients completing the induction phase).

OBJECTIVE

To investigate the practicability and safety of three different patient-friendly induction regimens of clustered immunotherapy (several injections administered during each visit).

METHODS

Since 1990, three different clustered induction regimens (regimen 1 = exclusively aqueous extracts; regimen 2 = a combination of aqueous and alum depot extracts; and regimen 3 = induction using exclusively alum depot extracts) have been investigated in 657 patients (10 369 injections).

RESULTS

A total of 454 systemic (immediate and late) reactions were observed in 257 patients corresponding to 4.4% of the injections and 39.1% of the patients. Most of the systemic reactions were of little or no clinical importance (93% grade 1 and grade 2) and < 1% anaphylactic reactions. The 8-week induction regimen using exclusively alum depot extracts showed a statistical significant lower frequency and severity of systemic side-effects. Immunotherapy with cat and mite allergen extracts showed the highest frequency of severe side-effects, which may be related to these extracts being used predominantly in asthmatic patients. The lowest frequency of systemic side-effects was observed in patients allergic to Hymenoptera venoms and these patients furthermore showed the highest number of patients (97%) completing the induction phase.

CONCLUSION

An 8-week clustered induction regimen using alum depot extract seems an acceptable compromise in relation to a reduction in the time used to reach maintenance dose and the risk of inducing clinically relevant systemic side-effects, and consequently imply a reduction in the costs of the treatment.

Allergen-specific immunotherapy in birch- and grass-pollen-allergic rhinitis. II. Side-effects

BACKGROUND

Allergen-specific immunotherapy (IT) involves the risk of side-effects. Different side-effect profiles have been reported for different allergens, and it would be of great benefit to be able more precisely to predict patient- and allergen-related risk factors.

METHODS

Fifty-two patients with rhinoconjunctivitis and allergy to birch as well as grass pollen participated in a 3-year IT study, with a baseline year followed by 2 years of treatment. During the first treatment year, the patients received double-blinded IT with either birch (Betula verrucosa) or grass (Phleum pratense) pollen extracts adsorbed to aluminum hydroxide. The following year, the other allergen extract was added. Assessment of systemic reactions (SRs) was performed, and related to patient pretreatment parameters such as seasonal symptoms and medication requirement, skin prick test (SPT), conjunctival provocation test (CPT), nasal provocation test (NPT), total and specific IgE, basophil histamine release (HR), eosinophil count (EOS), eosinophil cationic protein (ECP), and eosinophil protein X (EPX).

RESULTS

In total, 44 and 47 patients started IT with birch- and grass-pollen extracts, respectively. All SRs occurred during the dose-increase phase. No life-threatening SRs were observed. There were a higher number of patients with SRs during IT with grass pollen than IT with birch pollen, 21 vs five patients (P<0.001), with SRs to 3.3% of grass-pollen injections compared to 0.7% of birch-pollen injections (P<0.0001). The SRs of birch-pollen IT were mild, consisting of rhinoconjunctivitis and oral-pharyngeal itching, whereas asthma and urticaria episodes were observed in the grass-pollen IT. No difference was found in sensitivity to birch and grass, when measured by SPT, CPT, NPT, specific IgE, or HR, and no difference was found in age, duration of allergic symptoms, prevalence of asthma, mean seasonal birch/grass symptom score, eye-drop use, or antihistamine or prednisolone intake between the group with and without subsequent SRs to IT. No difference was found in EOS, serum ECP, or EPX, between the group with and without subsequent SRs to IT.

CONCLUSIONS

IT with grass-pollen extract seems to be associated with a higher number and more severe SRs than birch-pollen IT. Neither demographic data nor diagnostic tests of allergy such as specific IgE, HR, SPT, CPT, and NPT could identify the patients with subsequent SRs.

A tumour in the breast: vaccination granuloma as a differential diagnosis

AIMS

Breast cancer is the most frequent type of cancer in women; special attention is therefore paid to tumours in the breast region. Vaccination granuloma is a differential diagnosis of tumours in the upper part of the breast.

METHODS

All granulomatous lesions in the breast region since 1970 were retrieved from the files of the Departments of Pathology at Odense University Hospital and Svendborg Hospital.

RESULTS

Fourteen cases with a histology compatible with vaccination granuloma were found. Eight patients had a known history of tetanus vaccination. The tumours were ovoid, or even rod-shaped, and measured between 8x3 mm and 12x10 mm. Histologically, there were necrotic foci surrounded by histiocytes, lymphocytes, and plasma cells. Aluminium was detected by staining with solochrome azurine.

CONCLUSIONS

The possibility of a vaccination granuloma should be kept in mind in patients with a palpable tumour in the upper part of the breast, as well as in mammography screening conditions and in follow-up patients after previous treatment for breast cancer.

Antihistamine premedication in specific cluster immunotherapy: a double-blind, placebo-controlled study

BACKGROUND

Specific immunotherapy treatment in allergic diseases involves a risk of systemic side effects. A double-blind, placebo-controlled study was performed in 45 patients allergic to pollen to determine whether pretreatment with loratadine could reduce the number and severity of systemic reactions during the dose-increase phase of cluster immunotherapy.

METHODS

The patients received cluster immunotherapy with a standardized birch (Betula verrucosa) or grass (Phleum pratense) pollen extract adsorbed to aluminum hydroxide. The immunotherapy schedule involved seven visits and 14 injections to reach a maintenance dose of 100,000 standardized quality units. Loratadine, 10 mg, or placebo tablets were administered 2 hours before the first injection at each visit.

RESULTS

A total of 720 injections were given (309 injections in 21 patients receiving loratadine and 411 injections in 24 patients receiving placebo). The median numbers of injections to reach maintenance dose were 15 (range, 14 to 18) in the loratadine group and 16 (range, 14 to 23) in the placebo group (p = 0.037). The numbers of patients with systemic reactions were seven (33%) and 19 (79%) in the loratadine and placebo groups, respectively (p = 0.002). Twenty-five reductions caused by systemic reactions were observed in the placebo group in contrast to nine in the loratadine group (p = 0.047). No life-threatening systemic reactions were observed in either group. Systemic reactions were, however, more severe in the placebo group, mainly because of a significantly higher incidence of urticaria (10 vs 1, p = 0.022).

CONCLUSION

Pretreatment with loratadine seems to reduce both the number and severity of systemic reactions in specific cluster immunotherapy.

Aluminium allergy in patients hyposensitized with aluminium-precipitated antigen extracts

During hyposensitization therapy with aluminium-precipitated antigen solutions, a small % of patients develop persistent subcutaneous nodules at the injection site; the existence of delayed sensitivity to aluminium has been implicated in the pathogenesis of these nodules. We studied the prevalence of aluminium sensitivity (using patch, prick and intradermal tests) and common contact allergens (TRUE Test) in 20 healthy subjects, and in 40 patients treated with aluminium-containing extracts, 20 of whom had persistent subcutaneous nodules that remained for more than 2 months, the other half having no nodular reactions or nodules that remained for less than 2 months. Aluminium sensitivity was found only in those patients of the treated group who had persistent nodular reactions, 4 cases of positivity to an aluminium chloride patch test being found. All 4 cases were women, nodules remained for more than 6 months, and intracutaneous tests were negative. 3 of them also had contact sensitivity to nickel. In 2 cases, nodules were removed for histological and histochemical examination, showing non-specific inflammatory granulomas, and aluminium crystals being found in only 1 case. It is concluded that delayed sensitivity to aluminium appears to be implicated in the pathogenesis of persistent nodular reactions, but sensitivity to aluminium was not found in patients treated with aluminium-precipitated extracts without persistent nodular reactions.

Immunotherapy with aluminum hydroxide adsorbed insect venom extracts (Alutard SQ): immunologic and clinical results of a prospective study over 3 years

This prospective study over 3 years investigated the safety, immunogenicity, and effectiveness of immunotherapy (IT) with aluminum hydroxide adsorbed insect venom extracts (Alutard SQ, ALK Laboratories) in patients with previous, severe, systemic, IgE-mediated, anaphylactic reactions to Hymenoptera stings. Seventeen patients were treated with honeybee venom (BV), 13 with yellow-jacket venom (YJV), and 5 with both. No severe reactions to IT were noted. Only 3 BV-allergic patients experienced mild systemic reactions of grades I or II (1 per 139 injections) during the increase phase. As for the immunologic data, there was a significant decrease in specific IgE antibodies after 1 year, and a significant increase in specific IgG and IgG4 antibodies on reaching the maintenance dose, with a further rise after 1, 2, and 3 years. Moreover, a significant decrease in anti-IgE autoantibodies was observed in the BV group. Out of the 11 patients that were occasionally restung by the relevant insect (totaling 19 stings in all), only one patient developed mild systemic allergic symptoms after a third sting. In view of these results, we consider IT with aluminum hydroxide adsorbed insect venom extracts to be safe, immunogenic, and effective. The low rate of side-effects may be due to the slow release of the venom in the aluminum hydroxide adsorbed form.

The development of scar sarcoidosis at the site of desensitization injections

Tender nodules may develop at the site of injection of allergen extracts. Some cases can be related to the aluminium contained in the preparation. We report a case where scar sarcoidosis developed at the site of desensitization injections. At presentation, there were no other cutaneous signs of sarcoidosis; systemic signs only developed 2 years later. We suggest that sarcoidosis be considered as a cause of granulomata developing at sites of desensitizing injections, particularly when aluminium is not involved.

Adverse reactions after injection of adsorbed diphtheria-pertussis-tetanus (DPT) vaccine are not due only to pertussis organisms or pertussis components in the vaccine

Reactions to adsorbed diphtheria-pertussis-tetanus (DPT) vaccine have mostly been attributed to the pertussis organisms or pertussis components in the vaccine. Nevertheless reactions may also be due to other factors such as sensitization induced by aluminium adjuvants and impurities present in crude toxoids that cannot be removed by purification of toxoids after formalinization. Aluminium compounds such as aluminium phosphate and aluminium hydroxide are the most commonly used adjuvants with vaccines for human use. Due to the increasing concern about the toxicity of aluminium, other adjuvants like calcium phosphate may be evaluated as an alternative to aluminium adjuvants. To minimize reactions after immunization with DPT vaccine due to impurities in the toxoids, the use of toxoided purified toxins is suggested.

Effects of one-year hyposensitization in allergic rhinitis. Comparison of two house dust mite extracts

In an open study, 21 patients suffering from chronic non-seasonal rhinitis and allergic to house mites (HDM) have been treated for 1 year with either a new extract (Pharmalagen; n = 10) or an allergoid, pyridine denatured, extract (Alavac; n = 11), both precipitated with AlOH3 (depot). The following investigations were performed before and after therapy: clinical scoring (for 4 weeks), quantified skin prick tests (SPT) and nasal provocation tests (NPT) with HDM, and determination in serum of HDM-specific IgE and IgG. Both groups were compared with six patients who remained untreated and underwent the same investigations. Hyposensitization with either extract induced an improvement in clinical scores (P less than 0.05), a decrease in SPT reactivity (Pharmalgen: P less than 0.001; Alavac: P less than 0.01), a marked increase in the nasal tolerance to HDM (P less than 0.001) and in HDM-specific IgG (P less than 0.001). In the group of untreated patients, all these parameters remained unchanged. Compared with the Alavac extract, the Pharmalgen extract was more active in decreasing SPT reactions (P less than 0.05) and inducing a HDM-specific IgG rise (P less than 0.05). Although both extracts induced some untoward allergic reactions, no adrenaline was used at any time during the study. These data suggest that hyposensitization with depot extracts of HDM can be considered a safe and active adjunct to the treatment of allergic rhinitis.

Hyposensitization in asthmatics with mPEG-modified and unmodified house dust mite extract. IV. Occurrence and prediction of side effects

A double-blind study on hyposensitization (HS) with two extracts prepared from the house dust mite Dermatophagoides pteronyssinus (Dp) was performed on a group of asthmatics with bronchial sensitivity to Dp. In 18 patients, aluminium-hydroxide was added to the Dp-extract to give a depot effect (Dp-group). Nineteen patients were treated with a similar extract in which allergenicity had been reduced by coupling to monomethoxypolyethylene glycol (mPEG-Dp-group). This extract had previously been shown to have less effect on clinical symptoms and skin sensitivity compared to the Dp-extract. In the Dp- and mPEG-Dp-groups, 778 and 675 injections were administered. Fifteen and 12 patients in the Dp- and mPEG-Dp-groups had systemic reactions (P greater than 0.05). The frequency of injections giving systemic reactions was reduced in the mPEG-Dp-group: 5.1% compared to 9.0% in the Dp-group (P less than 0.01). In the mPEG-Dp-group, reactions were mild to moderate, mainly late-occurring asthma and urticaria, whereas two episodes of anaphylaxis and four of severe asthma occurred in the Dp-group. The reduction in side effects seems promising, but a further dose increase in the mPEG-Dp-group would be necessary to compare the side effects of doses with equal therapeutic effectiveness. High frequency of late local reactions made dose increase impossible with the present slightly modified extract. The systemic side effects occurred more frequently in patients highly skin test-sensitive to Dp prior to treatment. All patients skin test-positive to less than or equal to 100 BU had systemic reactions. Systemic side effects could not be predicted from the size of previous local reactions.

Immunotherapy with partially purified and standardized tree pollen extracts. I. Clinical results from a three-year double-blind study of patients treated with pollen extracts either of birch or combinations of alder, birch and hazel

Fifty-four adult patients with tree pollen-induced rhinitis (28), asthma (1), or rhinitis and asthma (25) were selected for immunotherapy with standardized and partly purified tree pollen extracts using a double blind protocol. The selection was based on clinical history, results of nasal or bronchial challenge, skin prick tests and RAST. Further, based on crossed radio-immunoelectrophoresis, sex, age and severity of symptoms, the patients were allocated in matched pairs and the treatment alternatives were randomly distributed within the pairs. Twenty-three patients treated with extracts composed of any combination of alder, birch and hazel pollen which matched their IgE response in CRIE (Group 1 (ABC)) and 22 patients receiving birch pollen extracts (Group 2 (B)) completed all 3 years of treatment. The in vivo results comprising symptom and medicine consumption scores are given here. Changes in specific skin and nasal reactivity as well as in immunological parameters are presented separately. No significant differences were demonstrated between the treatment groups in the two parameters. Both extracts were effective and reduced in general the symptom scores to one tenth of the starting level. Expressed another way, at the end of the study, the patients tolerated 30 times more pollen until symptoms of the same severity were elicited, compared to before. In the Nordic countries, spring-time asthma and rhino-conjunctivitis caused by pollen from deciduous trees can be effectively treated with an extract of birch pollen alone.

Diagnosis and immunotherapy of mould allergy. VI. IgE-mediated parameters during a one-year placebo-controlled study of immunotherapy with Cladosporium

The IgE-response was evaluated by skin prick test, bronchial provocation test and RAST in a 1-year placebo-controlled double-blind immunotherapy study. Eleven adult asthmatics were treated with a Cladosporium allergen preparation and 11 comparable patients received histamine placebo. The bronchial sensitivity (PC20) decrease greater than 0.5 log step in 8/11 (73%) Cladosporium-treated versus 3/11 (27%) in the placebo group. Corresponding figures for skin prick test sensitivity was 10/11 (91%) and 1/11 (9%) respectively. Circulating IgE showed a temporary boost in the Cladosporium group and then values approaching the pretreatment value. Only minimal and insignificant changes were found in the placebo-treated patients. Changes in IgE-reactivity were not related to allergen dose, clinical efficacy or to the occurrence of side effects. Some interrelation between changes in skin prick test, bronchial provocation test and RAST was found indicating a differentiated effect of immunotherapy on various IgE compartments. In spite of the pathogenetic role of IgE in allergic diseases, changes in IgE-reactivity do not seem directly involved in the mechanisms underlying the clinical efficacy of immunotherapy but might be of importance in a complex interaction with other immunological parameters.

A prospective study on the safety of immunotherapy in children with severe asthma

One hundred and six of 503 (21%) consecutive children with asthma, who from 1979 to 1983 commenced hyposensitization therapy, were prospectively studied on the safety of immunotherapy. More than 80% of the patients completed therapy without side effects. Thirteen patients were withdrawn from hyposensitization due to moderate and predictable, but intolerable, side effects such as asthma/rhinitis, urticaria and subcutaneous nodules and hypersensitivity to aluminium. However, more alarming was the outcome in six children, who after an uneventful course of immunotherapy and after several months on maintenance therapy, suddenly, 5 to 20 min (mean 10 min) following an earlier tolerable allergen injection, developed severe, anaphylactic reactions, in three of them nearly fatal. Mould extracts were responsible for the most frequent and serious side effects (Alternaria iridis/alternata, 3 patients, Cladosporium herbarum, 8 patients). Furthermore, serious, but not immediately life-threatening, anaphylactic reactions occurred in two children treated with Phleum pratense. On the other hand, hyposensitization with Dermatophagoides pteronyssinus was very well tolerated.

Diagnosis and immunotherapy of mould allergy. V. Clinical efficacy and side effects of immunotherapy with Cladosporium herbarum

A placebo-controlled, double-blind study of immunotherapy with the mould species Cladosporium was performed in 22 adult asthmatics. The diagnosis of Cladosporium allergy was based on a combination of bronchial provocation test and daily symptom score in the Cladosporium season. An aqueous preparation of a potent, biologically standardized and purified extract was used in a clustered dose-increase regimen. The clinical efficacy was evaluated by a combination of symptoms (asthma score + peak flow) and consumption of antiasthmatic medication. The mean changes in symptoms and medication consumption over a 10-week registration period (peak Cladosporium season) in 1982 after 5-7 months of immunotherapy were compared with the corresponding 1981 pretreatment 10-week period. A significant (P = 0.03) difference in terms of "improved", "unchanged" and "deteriorated" patients in favour of Cladosporium treatment was found. Approximately 80% in the Cladosporium group showed improved/unchanged symptoms contrary to 30% of the placebo treated. Side effects were observed frequently but only in the Cladosporium-treated. About 70% experienced a large local reaction and 100% had episodes of asthma during dose-increase phase. Only a few severe systemic reactions occurred. Based on the clinical efficacy of the treatment we consider immunotherapy with Cladosporium feasible for highly specialized clinics.

Persistent subcutaneous nodules in children hyposensitized with aluminium-containing allergen extracts

A follow-up study of 202 children who had received hyposensitization with aluminium-containing allergens showed that 1-3 years after cessation of hyposensitization 13 children still had severely pruiginous treatment-resistant subcutaneous nodules in their forearms. Because of their long persistence the nodules of six children were studied in detail. Histologically, the nodules showed infiltration with lymphocytes (forming germinal centres), macrophages, plasma cells, mast cells and a few eosinophils. In five patients aluminium crystals were found scattered between the cells and, in addition, the phagosomes of the macrophages contained aluminium. Patch tests for aluminium were positive in four of the six patients. It is concluded that persisting nodules during hyposensitization with aluminium-containing allergens may indicate development of aluminium hypersensitivity, and if this is confirmed hyposensitization should be discontinued.

Comparison between rush immunotherapy with a standardized allergen and an alum adjuved pyridine extracted material in grass pollen allergy

Rush immunotherapy with a standardized and lyophilized cocksfoot pollen extract was performed in twenty-three allergic subjects and compared with classical immunotherapy done with an alum adjuved, pyridine extracted cocksfoot pollen extract (fifteen subjects) and a control group of ten patients. The three groups were perfectly matched. Clinical benefits were analysed by means of symptom scores. It was shown that rush immunotherapy gave significantly better results when asthma or rhinitis was considered than either classical immunotherapy (P less than 0.02) or in the control group (P less than 0.01 and 0.02). Skin tests were significantly reduced after rush immunotherapy and did not change in the two other groups. After the pollen season the skin test reactivity was increased in the rush immunotherapy group. Cocksfoot pollen specific IgE did not vary significantly in the three groups. Cocksfoot pollen specific IgG was significantly (P less than 0.05) increased in the rush immunotherapy group before the pollen season and did not vary significantly in the other groups.

Immunotherapy with alginate-conjugated and alum-precipitated grass pollen extracts in patients with allergic rhinoconjunctivitis

In order to compare the safety and the efficacy of two grass pollen extracts made from the same starting material, i.e. equal proportions of cocksfoot and timothy, a 3-year study was made on patients with hay fever. One product was a dialysed aqueous extract of pollens which was chemically conjugated to activated sodium alginate ( Conjuvac ). The other was a pyridine-extracted alum-precipitated crude extract (Allpyral). Forty patients with classical hay fever were admitted to the study. All gave positive result to prick and nasal/conjunctival testing with extracts of both cocksfoot and timothy grass. Thirty-five patients completed all 3 years of the study. Seventeen/eighteen Allpyral-treated and 17/17 Conjuvac -treated patients were subjectively improved. There was no significant difference in symptom scores between the two groups. Challenge tests showed a tendency to reduced sensitivity to allergen in the Conjuvac -treated but not in the Allpyral-treated group. The median values for specific IgG and IgE showed the same pattern of reaction as seen in earlier studies of pollen hyposensitization. There was, however, a greater increase of grass-specific IgG in the Conjuvac -treated patients. No serious adverse effects were seen in any of the treatment groups, but there were slightly fewer side effects in the Conjuvac group.

Immunotherapy with grass pollen major allergens

Perennial hyposensitization with a partially purified timothy extract resulted in a statistically significantly higher degree of clinical protection than treatment with the two timothy major allergens (Nos. 19 and 25) and protected better from the second--than during the first grass pollen season. The extracts were standardized biologically and adsorbed to aluminium hydroxide for administration. The therapy had a more beneficial influence on sneezing than on rhinorrhoea and blockage of nasal airways, and an excellent effect on grass pollen asthma was obtained with the partially purified timothy extract. Associated birch pollen allergy was not influenced by hyposensitization with grass pollen.