Local immunotherapy is not documented for clinical use

Strategies of mucosal immunotherapy for allergic diseases

Incidences of allergic disease have recently increased worldwide. Allergen-specific immunotherapy (SIT) has long been a controversial treatment for allergic diseases. Although beneficial effects on clinically relevant outcomes have been demonstrated in clinical trials by subcutaneous immunotherapy (SCIT), there remains a risk of severe and sometimes fatal anaphylaxis. Mucosal immunotherapy is one advantageous choice because of its non-injection routes of administration and lower side-effect profile. This study reviews recent progress in mucosal immunotherapy for allergic diseases. Administration routes, antigen quality and quantity, and adjuvants used are major considerations in this field. Also, direct uses of unique probiotics, or specific cytokines, have been discussed. Furthermore, some researchers have reported new therapeutic ideas that combine two or more strategies. The most important strategy for development of mucosal therapies for allergic diseases is the improvement of antigen formulation, which includes continuous searching for efficient adjuvants, collecting more information about dominant T-cell epitopes of allergens, and having the proper combination of each. In clinics, when compared to other mucosal routes, sublingual immunotherapy (SLIT) is a preferred choice for therapeutic administration, although local and systemic side effects have been reported. Additionally, not every allergen has the same beneficial effect. Further studies are needed to determine the benefits of mucosal immunotherapy for different allergic diseases after comparison of the different administration routes in children and adults. Data collected from large, well-designed, double-blind, placebo-controlled, and randomized trials, with post-treatment follow-up, can provide robust substantiation of current evidence.

Sublingual immunotherapy of allergic diseases

The only disease-modifying treatment that is available for allergic patients is allergen-specific immunotherapy. Two competing application forms are used: subcutaneous immunotherapy, which has been used for > 90 years, and a relatively new immunotherapy where the allergen is applied sublingually. Numerous studies have shown efficacy for subcutaneous immunotherapy and have identified possible mechanisms that are responsible for the observed reduction in allergic responses. In contrast, the efficacy of sublingual immunotherapy has not been documented to the same degree and the responsible immunological mechanisms have not yet been clearly defined. This review focuses on the published clinical and experimental data on sublingual immunotherapy and points at possible mechanisms of how sublingual immunotherapy may differ from subcutaneous immunotherapy in its mode of action, and also discusses the potential advantages and pit falls of both therapies.

Local nasal specific immunotherapy for allergic rhinitis

The possibility of producing local hyposensitization by administering allergens via mucosal routes was envisaged at the beginning of 1900, and local nasal immunotherapy has been extensively studied since the 1970s. Presently, there are 21 randomized controlled trials being conducted with the most common allergens, consistently showing the clinical efficacy of local nasal immunotherapy for rhinitis. Other advantages are that it has an optimal safety profile and can be self-administered at home by the patient. Moreover, there are several data from animal models and from humans that confirm the immunomodulatory effect of intranasally administered antigens. On the other hand, local nasal immunotherapy seems to be effective only on rhinitis symptoms and requires a particular technique of administration. For these reasons, its clinical use is progressively declining in favour of the sublingual route although nasal immunotherapy is validated in official documents and remains a viable alternative to injection.

Production of salivary immunoglobulin A and suppression of Dermatophagoides pteronyssinus-induced airway inflammation by local nasal immunotherapy

BACKGROUND

Local nasal immunotherapy (LNIT) is an effective immunotherapeutic modality, especially when targeting a single immunodominant peptide from an allergen. However, the working mechanisms of LNIT are poorly understood. We hypothesized that LNIT with a mixture of group 2 allergens of Dermatophagoides pteronyssinus (Der p 2) protein and fungal immunomodulatory peptide (FIP) would generate suppression of Der p-induced airway inflammation through immunoglobulin (Ig) A secretion in the airways.

METHOD

Mice were sensitized with recombinant Der p 2 (rDer p 2) and Der p followed by LNIT with rDer p 2 in conjunction with FIP. After intratracheal challenge with rDer p 2 and Der p, the airway inflammation was determined by analyzing the cell subpopulation and cytokine concentration in the bronchoalveolar lavage fluid. The allergen-specific IgE, IgG2a and IgG in the sera and IgA in the saliva were measured by ELISA.

RESULTS

LNIT with rDer p 2 in conjunction with FIP could downregulate the lymphocyte infiltration in both rDer p 2- and Der p-induced airway inflammation. Both total and specific IgA in the saliva were increased after LNIT. Serum levels of IL-4, IL-10 and specific IgE were reduced and the specific IgG2a and IgG increased after LNIT. After LNIT, there was a reduction of airway hypersensitivity at 30 min after allergen challenge in the rDer p 2-and Der p-sensitized mice, with a significant decrease only in rDer p 2-sensitized mice.

CONCLUSION

LNIT with rDer p 2 in conjunction with FIP was not only able to suppress rDer p 2-induced airway inflammation but also generate suppression of Der p-induced airway inflammation. The simultaneous reduction of IL-4 and IL-10 indicated that IL-10-producing cells were not activated by LNIT. The increment of IgA in the airway might play a role in the prevention of airway inflammation.

Efficacy of local nasal immunotherapy for Dp2-induced airway inflammation in mice: Using Dp2 peptide and fungal immunomodulatory peptide

BACKGROUND

Local nasal immunotherapy (LNIT) is an effective immunotherapy. Peptides derived from the group 2 allergen of Dermatophagoides pteronyssinus, Dp2 28-40 and Dp2 28-40A, and fungal immunomodulatory peptide (FIP) have been shown to act as T(H)1 potential and response-inducing adjuvant. LNIT by the use of Dp2 peptides in conjunction with FIP were investigated.

OBJECTIVE

We sought to determine whether Dp2-induced airway inflammation in mice could be downregulated by Dp2 peptides or a mixture of Dp2 peptides with FIP.

METHOD

Mice were sensitized with rDp2 followed by LNIT with Dp2 peptides, FIP, or FIP and a mixture of Dp2 peptides. After intratracheal challenge with rDp2, the airway inflammation and hyperresponsiveness were determined by bronchoalveolar lavage fluid (BALF) analysis and methacholine challenge.

RESULTS

Both Dp2 peptides and FIP were able to inhibit rDp2-induced airway inflammation and airway hyperresponsiveness. An increase in IFN-gamma and a decrease in IL-5 in BALF and sera were found after LNIT with Dp2 peptides, FIP, and mixtures of both. Serum levels of TGF-beta were reduced after LNIT with FIP and Dp2 28-40. Penh values were significantly decreased after methacholine challenge in both the early and late phase.

CONCLUSIONS

LNIT with allergen-derived peptides and FIP can produce an anti-inflammatory effect on allergen-induced airway inflammation. LNIT with selected peptides and FIP might be a good alternative therapy for allergic airway disease.

Noninjection routes for immunotherapy

Allergen specific immunotherapy, together with drugs and allergen avoidance, is a cornerstone in the management of respiratory allergy. The traditional subcutaneous route is burdened with the risk of severe adverse events; therefore, safer routes of administration (noninjection or local routes) have been investigated and developed. Controlled trials failed to demonstrate the clinical efficacy and the safety of oral and bronchial administration, and these routes have been abandoned. Local nasal immunotherapy proved effective and safe in 17 of 18 controlled trials; thus it is considered a viable route of immunotherapy. Nevertheless, nasal immunotherapy is effective in rhinitis only and requires a particular administration technique; therefore its use is slowly declining. The sublingual route is supported by numerous controlled trials showing its efficacy in asthma and rhinitis in adults and children. The safety profile, assessed in clinical trials and postmarketing surveillance studies, is satisfactory; the most frequent side effects are gastrointestinal complaints, which can be easily managed by proper dose adjusting. Sublingual immunotherapy is now accepted by the World Health Organization as a valid alternative to the subcutaneous route also in children. Although the long-lasting efficacy has been recently documented for the sublingual route, several points still need to be elucidated, including mechanisms of action, optimal dosage, cost-effectiveness, and adherence.

Allergen immunotherapy: current and new therapeutic strategies

Allergic individuals respond to an environmental allergen encounter by producing T-cell cytokines, predominantly IL-4 and IL-5, which in turn drive the production of allergen-specific IgE antibodies and recruitment of an eosinophil-rich inflammatory infiltrate. Allergen-specific immunotherapy (SIT) involves the repeated injection of the allergen to specifically downregulate this predominantly Th2-type immune response. SIT is a clinically proven effective treatment for allergic diseases, including rhinoconjunctivitis and asthma. However, despite having been in clinical practice since early this century, its use remains empirical. Best practice protocols are based on clinical experience and include recommendations for selecting patients for treatment, SIT regimes and avoidance of adverse events. More rational and safer SIT regimes will result from new insights into the underlying immune mechanisms for allergic disease, in particular the critical role of helper T-cells in orchestrating this response. The development of recombinant techniques for producing purified allergens and allergen derivatives has led to a dramatic improvement in the ability to standardise allergen preparations and to develop novel vaccines for allergy treatment. Potential vaccines include short peptides based on dominant T-cell epitopes of allergens, allergen fragments and mutant allergens. All of these preparations are designed to target T-cells without binding IgE and inducing local and systemic side effects. Additional strategies under consideration include DNA vaccines and fusion protein constructs incorporating immunomodulatory elements such as bacterial cell proteins, cytokines and immunostimulatory sequences of DNA. Different forms of allergens are being evaluated for the more practical mucosal administration of allergy vaccines. The identification of recombinant allergens suitable for diagnostic use and the development of reliable laboratory assays, based on T-cell function to monitor clinical efficacy of SIT, are important practical outcomes from this research.

Clinical efficacy and tolerability of a steady dosage schedule of local nasal immunotherapy. Results of preseasonal treatment in grass pollen rhinitis

BACKGROUND

Local nasal immunotherapy (LNIT) is an effective and safe alternative to conventional subcutaneous immunotherapy. A specific nasal provocation test (SNPT) could be used to indicate the optimal subclinical dose to carry out LNIT.

OBJECTIVE

We hypothesize that LNIT could be carried out with only one predefined dose for all patients, so we have evaluated the efficacy and the tolerability of LNIT administered at steady dosages in patients with seasonal allergic rhinitis.

METHODS

Twenty grass pollen-sensitized patients suffering from seasonal allergic rhinitis were studied in a randomized, double-blind, placebo-controlled trial. The treatment was carried out according to a schedule based on the administration of a steady subclinical dosage of the allergenic extract, selected on the basis of the sensitivity threshold of the SNPT. The patients were divided into two groups of 10 people each, which were treated either with grass pollen extract in a hydroglyceric solution or with placebo.

RESULTS

During the peak pollen period, with regard to the placebo (P) group, in the grass treated (GT) group a significant decrease of both nasal symptoms (P = .021) and consumption of antihistamines (P = 0.047) was found. Furthermore, only in the GT group was the provocative dose assessed by the SNPT significantly lower (P = .049) at the end of the treatment. In this group of patients an inverse correlation between such provocative dose and the nasal symptom score reported during the peak pollen period was also evidenced (r = 0.708; P = .038). Adverse reactions to LNIT were mild, rare, and did not interfere with the completion of the therapeutic schedule.

CONCLUSIONS

Our study indicates that LNIT, when administered at steady dosages, may be proposed as a treatment for grass pollen seasonal allergic rhinitis as it appears to be effective and well tolerated.

Clinical efficacy and safety of local nasal immunotherapy

Local nasal immunotherapy represents an alternative route of allergen administration. It was proposed to overcome the risk of systemic reactions rarely reported during the traditional subcutaneous immunotherapy. Some studies carried out in the past generally showed good efficacy but poor tolerability. The aqueous extracts mostly used in these studies carry some drawbacks such as the volume effect, self-digestion and the difficulty of administering reproducible dosages. The recent availability of allergen extracts in powder form has led to better stability and standardization. The studies carried out with these freeze-dried allergens showed clinical efficacy and good tolerability in perennial (mite, cat) and seasonal (grass, birch, Parietaria) allergic rhinitis. According to these findings this new local nasal immunotherapy with extract in powder form represents a suitable alternative to the traditional immunotherapy in the treatment of allergic rhinitis.

Local nasal immunotherapy: experimental evidences and general considerations

The possibility of local hyposensitization in allergies was envisaged since the first decades of the century and then sporadically employed, whereas controlled clinical trials of local nasal immunotherapy (LNIT) were performed only during the last 20 years. Studies currently available agree on the clinical efficacy of the treatment. LNIT was demonstrated capable of reducing symptoms both in pollen- and mite-induced rhinitis, and of modifying the specific target organ responsivity. Indeed, aqueous extracts appeared to be more effective than modified ones but were also charged by troublesome local side effects, while the recently introduced powdered extracts seemed to overcome this problem, maintaining a favourable clinical effectiveness. In a recent study we demonstrated a significant effect of LNIT on local allergic inflammation. LNIT reduced both the inflammatory infiltration and ICAM-1 expression on nasal epithelial cells upon specific nasal challenge. The effects on specific challenge appeared long-lasting, but the clinical efficacy seemed to depend strictly upon preseasonal treatment. LNIT with powdered extracts appears an effective, safe and well-tolerated treatment for allergic rhinitis. Nevertheless, its particular administration technique requires a careful choice of patients. Finally, a socioeconomical analysis shows a favourable cost/benefit ratio for LNIT if compared to classic subcutaneous immunotherapy.

Local nasal immunotherapy with extract in powder form is effective and safe in grass pollen rhinitis: a double-blind study

BACKGROUND

Local nasal immunotherapy has been studied, by means of an extract in powder form, in patients with allergic rhinitis caused by grass pollen.

METHODS

Thirty-two patients allergic to grass were studied for 37 weeks in a double-blind controlled trial. Subjects were selected on the basis of a positive history, skin test result, RAST finding, and result of intranasal challenge to grass pollen. Two 16-patient groups were randomly assigned to active or placebo treatment. The treatment lasted 26 weeks (14 for the build-up phase, 12 for the maintenance period).

RESULTS

No significant differences were observed in nasal symptoms during the treatment. During the pollen season the mean weekly symptom and medication scores were significantly lower in the treated group, compared with the control group, even considering each allergic symptom separately. Moreover, only in the treated group was a significant increase of specific nasal threshold to grass pollen observed after treatment.

CONCLUSIONS

This study indicates that local nasal immunotherapy with allergen in powder form can be a suitable alternative to the traditional subcutaneous immunotherapy in terms of clinical efficacy and safety in grass-allergic rhinitis.