1
|
West T, Katelaris CH. The evidence for commercial house dust mite immunotherapy products: A pragmatic systematic review with narrative synthesis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100255. [PMID: 39092213 PMCID: PMC11292502 DOI: 10.1016/j.jacig.2024.100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/24/2024] [Accepted: 02/15/2024] [Indexed: 08/04/2024]
Abstract
House dust mite (HDM) allergen immunotherapy (AIT) has an established role in the treatment of perennial allergic rhinitis (AR) and allergic asthma (AA) triggered by HDM sensitization. We aimed to identify all double-blind, randomized, placebo-controlled trials of HDM AIT for the treatment of AR and AA in humans and to summarize the evidence for AIT products that are currently manufactured and available for clinical use. A total of 56 eligible double-blind, randomized, placebo-controlled trials of HDM AIT for the treatment of AA and/or AR in humans fit the inclusion criteria and investigated a total of 14 commercial AIT products; together, the 56 studies enrolled a total of 14,619 patients. Of the 56 studies, 39 studies investigated the current manufacturer-recommended maintenance dose (MRMD) of the product, and 17 investigated other doses. We identified 39 studies (12,539 patients randomized) for 8 sublingual immunotherapy (SLIT) products and 17 studies (2,080 patients randomized) for subcutaneous immunotherapy products. For AR, 3 products, the ALK 12 standardized-quality (SQ-HDM) SLIT tablet, the ALK 6 SQ-HDM tablet, and the SG 300 index of reactivity SLIT tablet, had both dose-finding studies (DFSs) and phase III definitive studies (DSs) to demonstrate efficacy of the MRMD of the product. For AA, 2 products, the ALK 12 SQ-HDM SLIT tablet and the ALK 6 SQ-HDM tablet, had both DFSs and DSs for the MRMD. No subcutaneous immunotherapy product had a paired DFS and DS supporting the MRMD. A total of 30 studies of products no longer commercially manufactured were excluded. This study will help to inform clinical care and product selection for the treatment of HDM-induced AR and AA.
Collapse
Affiliation(s)
| | - Constance H. Katelaris
- Campbelltown Hospital, Campbelltown, Australia
- Western Sydney University, Campbelltown, Australia
| |
Collapse
|
2
|
Jutel M, Klimek L, Richter H, Brüggenjürgen B, Vogelberg C. House dust mite SCIT reduces asthma risk and significantly improves long-term rhinitis and asthma control-A RWE study. Allergy 2024; 79:1042-1051. [PMID: 38429981 DOI: 10.1111/all.16052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND The German Therapy Allergen Ordinance (TAO) triggered an ongoing upheaval in the market for house dust mite (HDM) allergen immunotherapy (AIT) products. Three HDM subcutaneous AIT (SCIT) products hold approval in Germany and therefore will be available after the scheduled completion of the TAO procedure in 2026. In general, data from clinical trials on the long-term effectiveness of HDM AIT are rare. We evaluated real-world data (RWD) in a retrospective, observational cohort study based on a longitudinal claims database including 60% of all German statutory healthcare prescriptions to show the long-term effectiveness of one of these products in daily life. Aim of this analysis was to provide a per product analysis on effectiveness of mite AIT as it is demanded by international guidelines on AIT. METHODS Subjects between 5 and 70 years receiving their first (index) prescription of SCIT with a native HDM product (SCIT group) between 2009 and 2013 were included. The exactly 3:1 matched control group received prescriptions for only symptomatic AR medication (non-AIT group); the evaluation period for up to 6 years of follow-up ended in February 2017. Study endpoints were the progression of allergic rhinitis (AR) and asthma, asthma occurrence and time to the onset of asthma after at least 2 treatment years. RESULTS In total, 892 subjects (608 adults and 284 children/adolescents) were included in the SCIT group and 2676 subjects (1824 adults and 852 children/adolescents) in the non-AIT group. During the follow-up period after at least 2 years of SCIT, the number of prescriptions in the SCIT group was reduced by 62.8% (p < .0001) for AR medication and by 42.4% for asthma medication (p = .0003). New-onset asthma risk was significantly reduced in the SCIT vs non-AIT group by 27.0% (p = .0212). The asthma-preventive effect of SCIT occurred 15 months after start of the treatment. In the SCIT group, the time to onset of asthma was prolonged compared to the non-AIT group (p = .0010). CONCLUSION In this first product based RWD analysis on SCIT with a native HDM product, patients aged 5 to 70 years benefited from AIT in the long term in terms of reduced progression of AR and asthma after at least 2 years of treatment. The effects seemed to last for up to 6 years after treatment termination. A significantly reduced risk of asthma onset was observed, starting after 15 months of treatment.
Collapse
Affiliation(s)
- Marek Jutel
- ALL-MED Medical Research Institute, Wrocław, Poland
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | | | - Bernd Brüggenjürgen
- Institute for Health Services Research and Technical Orthopedics, Orthopedic Clinic of Hannover Medical School, Hannover, Germany
| | - Christian Vogelberg
- Department of Pneumology and Allergology, Carl Gustav Carus University Clinic, Dresden, Germany
| |
Collapse
|
3
|
Kappen JH, Agache I, Jutel M, Pillai P, Corrigan CJ. Allergen Immunotherapy for Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:23-30. [PMID: 38013158 DOI: 10.1016/j.jaip.2023.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 11/29/2023]
Abstract
Allergen immunotherapy is a disease-modifying treatment for IgE-mediated allergies reducing disease burden and symptoms in patients with allergic rhinitis, with or without asthma. The growing evidence that allergen immunotherapy also has the potential to facilitate achieving asthma control in patients with allergic asthma resulted in its acknowledgment by international bodies (Global Initiative for Asthma and European Academy of Allergy and Clinical Immunology) as add-on treatment for mild/moderate asthma. Although there have been promising developments in biomarkers for patient selection and for allergen immunotherapy efficacy evaluation in patients with asthma, a lot more data are still required.
Collapse
Affiliation(s)
- Jasper H Kappen
- Department of Pulmonology, STZ Centre of Excellence for Asthma, COPD and Respiratory Allergy, Franciscus & Vlietland, Rotterdam, The Netherlands; Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
| | | | - Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland; ALL-MED Medical Research Institute, Wroclaw, Poland
| | - Prathap Pillai
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; King's Centre for Lung Health, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Chris J Corrigan
- King's Centre for Lung Health, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| |
Collapse
|
4
|
Rodriguez‐Plata E, Callero Viera A, Ruiz‐Garcia M, Gomez‐Cardenosa A, Nieto E, García‐Robaina JC. House dust mite subcutaneous immunotherapy has sustained long-term effectiveness on allergic rhinitis and asthma: A 10-year follow-up. Immun Inflamm Dis 2023; 11:e1004. [PMID: 37904678 PMCID: PMC10571497 DOI: 10.1002/iid3.1004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND Maintenance doses for allergen immunotherapy (AIT) have been recommended for at least 3 years but little data on long-term efficacy is available depending on AIT duration. To show sustained efficacy 10 years after completion of treatment with depigmented-polymerized house dust mite (dpg-pol HDM) allergen extract in adults with asthma and/or rhinoconjunctivitis. METHODS Patients included in a double-blind placebo-controlled AIT study with dpg-pol HDM allergen extract were reviewed at completion of the perennial treatment and 10-year follow-up (10y-FU). Change in symptom and rescue medication score was the primary objective. Visual analog scale (VAS), asthma control test (ACT), and degree of disease control were the secondary objectives. A comparative analysis between patients who underwent AIT treatment for <3 years and ≥3 years was performed. RESULTS Data from 31 patients (mean age 38 years) were available at 10y-FU. All had asthma and 29 had rhinoconjunctivitis at baseline. Twenty-three patients were treated ≥3 years and 8 for <3 years. Seventeen (55%) patients were asymptomatic at completion of AIT, with significant differences for nasal, conjunctival, and bronchial symptoms (p < .0001) compared with baseline only in those patients treated ≥3 years. Nine (52.9%) patients remained completely asymptomatic at 10y-FU, all were treated for ≥3 years. Moreover, significant reduction in the number of patients with rhinitis (p = .0117), conjunctivitis (p < .0001), and bronchial (p = .0005) symptoms was observed at 10y-FU compared with baseline only in the ≥3 years treated. Ten (32.3%) patients did not require any rescue medication at 10y-FU, all had been treated for ≥3 years. ACT at 10y-FU showed a good control of asthma (median 23.5; 95% IC[22.0, 25.0]). No significant differences were observed between VAS at end of treatment compared with VAS at 10y-FU. CONCLUSIONS Sustained clinical efficacy is achieved 10 years after completion of depigmented-polymerized HDM, however, these findings were observed only if patients are treated for at least 3 years.
Collapse
Affiliation(s)
- Elena Rodriguez‐Plata
- Allergy DepartmentHospital Universitario Nuestra Señora de CandelariaSanta Cruz de TenerifeSpain
| | - Ariel Callero Viera
- Allergy DepartmentHospital Universitario Nuestra Señora de CandelariaSanta Cruz de TenerifeSpain
| | | | | | - Eva Nieto
- Medical Affairs and Clinical DepartmentLETI PharmaMadridSpain
| | | |
Collapse
|
5
|
Is immunotherapy safe for treatment of severe asthma. Curr Opin Allergy Clin Immunol 2022; 22:396-401. [PMID: 36305469 DOI: 10.1097/aci.0000000000000853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE OF REVIEW The benefits of allergen immunotherapy (AIT), including subcutaneous allergen immunotherapy (SCIT) and sublingual allergen immunotherapy (SLIT), for IgE-mediated asthma are well established, especially for dust mite. This review will explore whether the benefits of AIT outweigh the risks in severe asthmatic patients. RECENT FINDINGS Studies have mostly included mild and moderate asthmatic patients, but at least a few studies do show improvements in asthma symptoms and medication use in severe asthmatic patients. Asthma, and especially uncontrolled asthma, is a major risk factor for severe and fatal systemic reactions from SCIT. Uncontrolled asthma is an absolute contraindication for SCIT. It is less clear whether the benefits of SCIT and SLIT may outweigh the risks in well controlled, severe asthmatic patients, and further study is needed in this area. Asthma biologics, especially Omalizumab, may improve outcomes in severe, controlled asthmatic patients on SCIT, but further data are needed regarding timing of initiation and duration of treatment. SUMMARY Although severe asthmatic patients may benefit from AIT, significant risks exist, especially in those with uncontrolled asthma. Further study is needed regarding optimal strategies to minimize risks.
Collapse
|
6
|
Eremija J, Carr TF. Immunotherapy for Asthma. Semin Respir Crit Care Med 2022; 43:709-719. [PMID: 35714626 DOI: 10.1055/s-0042-1749454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Asthma represents one of the biggest global health concerns with increasing prevalence and influence on global health. Several distinct asthma phenotypes have been identified with one of the most common, earliest recognized, and described being the allergic asthma phenotype, in which allergens trigger asthma through mechanisms involving allergen-specific immunoglobulin E (IgE). Allergen-specific immunotherapy (AIT), in the forms of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT), has been used for many decades as a tool for reducing IgE-mediated sensitization and controlling symptoms of allergic disease, most commonly for allergic rhinitis, and it remains the only currently available disease modifying therapy in atopic patients. AIT has been studied for use in mild to moderate allergic asthma. While the data are often inconsistent, and utilize a multitude of different methods, antigens, and outcome measures, in general, AIT may have several beneficial effects on asthma disease control, quality of life, and requirement for medication. These benefits are notable when immunotherapy is used as an adjunct to pharmacologic treatment in carefully selected and monitored patients with mild to moderate persistent asthma. Patients with severe asthma are excluded from these trials. Importantly, patients with asthma, and in particular severe asthma, may have a higher rate of systemic adverse reactions to SCIT, including anaphylaxis, however, these events are overall rare. Future research in the area is needed to definitively assess the benefit of SCIT and SLIT for patients with asthma, comparing outcomes with different methods, addressing the role of AIT in severe asthma, significance of multiallergen AIT in allergic asthma, and safety concerns in asthma.
Collapse
Affiliation(s)
- Jelena Eremija
- Section of Allergy & Immunology, Department of Medicine, Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
| | - Tara F Carr
- Section of Allergy & Immunology, Department of Medicine, Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
| |
Collapse
|
7
|
de Blay F, Gherasim A, Casale TB, Doyen V, Bernstein D. Which patients with asthma are most likely to benefit from allergen immunotherapy? J Allergy Clin Immunol 2022; 149:833-843. [DOI: 10.1016/j.jaci.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
|
8
|
Nakagome K, Nagata M. Allergen Immunotherapy in Asthma. Pathogens 2021; 10:pathogens10111406. [PMID: 34832562 PMCID: PMC8618936 DOI: 10.3390/pathogens10111406] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/15/2021] [Accepted: 10/26/2021] [Indexed: 12/03/2022] Open
Abstract
Allergen immunotherapy (AIT) is a specific treatment involving the administration of relevant allergens to allergic patients, with subtypes including subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT). In asthma, AIT using the house dust mite (HDM) alleviates clinical symptoms and decreases airway hyper responsiveness and medication dose. In addition, AIT can improve the natural course of asthma. For example, the effects of AIT can be preserved for at least a few years, even after ending treatment. AIT may increase the remission rate of asthma in children and suppress sensitization to new allergens. If AIT is introduced in pollinosis, AIT may prevent the development of asthma. Moreover, AIT can control other allergic diseases complicated by asthma, such as allergic rhinitis, which also improves the control of asthma. The indication of HDM-SCIT for asthma is mild-to-moderate HDM-sensitized allergic asthma in a patient with normal respiratory function. To date, HDM-SLIT is applicable in Japan for allergic rhinitis, not for asthma. However, the effect of SLIT on asthma has been confirmed internationally, and SLIT is available for asthma in Japan if allergic rhinitis is present as a complication.
Collapse
Affiliation(s)
- Kazuyuki Nakagome
- Department of Respiratory Medicine, Saitama Medical University, Saitama 350-0495, Japan;
- Allergy Center, Saitama Medical University, Saitama 350-0495, Japan
- Correspondence: ; Tel.: +81-49-276-1319
| | - Makoto Nagata
- Department of Respiratory Medicine, Saitama Medical University, Saitama 350-0495, Japan;
- Allergy Center, Saitama Medical University, Saitama 350-0495, Japan
| |
Collapse
|
9
|
Boonpiyathad T, Lao-Araya M, Chiewchalermsri C, Sangkanjanavanich S, Morita H. Allergic Rhinitis: What Do We Know About Allergen-Specific Immunotherapy? FRONTIERS IN ALLERGY 2021; 2:747323. [PMID: 35387059 PMCID: PMC8974870 DOI: 10.3389/falgy.2021.747323] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/30/2021] [Indexed: 01/23/2023] Open
Abstract
Allergic rhinitis (AR) is an IgE-mediated disease that is characterized by Th2 joint inflammation. Allergen-specific immunotherapy (AIT) is indicated for AR when symptoms remain uncontrolled despite medication and allergen avoidance. AIT is considered to have been effective if it alleviated allergic symptoms, decreased medication use, improved the quality of life even after treatment cessation, and prevented the progression of AR to asthma and the onset of new sensitization. AIT can be administered subcutaneously or sublingually, and novel routes are still being developed, such as intra-lymphatically and epicutaneously. AIT aims at inducing allergen tolerance through modification of innate and adaptive immunologic responses. The main mechanism of AIT is control of type 2 inflammatory cells through induction of various functional regulatory cells such as regulatory T cells (Tregs), follicular T cells (Tfr), B cells (Bregs), dendritic cells (DCregs), innate lymphoid cells (IL-10+ ILCs), and natural killer cells (NKregs). However, AIT has a number of disadvantages: the long treatment period required to achieve greater efficacy, high cost, systemic allergic reactions, and the absence of a biomarker for predicting treatment responders. Currently, adjunctive therapies, vaccine adjuvants, and novel vaccine technologies are being studied to overcome the problems associated with AIT. This review presents an updated overview of AIT, with a special focus on AR.
Collapse
Affiliation(s)
- Tadech Boonpiyathad
- Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
- *Correspondence: Tadech Boonpiyathad
| | - Mongkol Lao-Araya
- Faculty of Medicine, Department of Pediatrics, Chiang Mai University, Chiang Mai, Thailand
| | - Chirawat Chiewchalermsri
- Department of Medicine, Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University, Nonthaburi, Thailand
| | - Sasipa Sangkanjanavanich
- Faculty of Medicine Ramathibodi Hospital, Department of Medicine, Mahidol University, Bangkok, Thailand
| | - Hideaki Morita
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
10
|
Chipps BE, Murphy KR, Oppenheimer J. 2020 NAEPP Guidelines Update and GINA 2021-Asthma Care Differences, Overlap, and Challenges. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:S19-S30. [PMID: 34718214 DOI: 10.1016/j.jaip.2021.10.032] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/29/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022]
Abstract
The 2020 National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group (NAEPP [2020 Focused Asthma Update]) guidelines and the Global Initiative for Asthma (GINA) 2021 strategy report are compared in this Rostrum article. The methodologies of each publication are described. Subsequently, 4 different selected pharmacological recommendations are compared in the 2 documents: step 1 for children 0 to 4 years of age with viral-induced wheezing, step 2 in ages 12 years and older with the intermittent use of inhaled corticosteroid, steps 3 and 4 with single-inhaler maintenance and reliever therapy with inhaled corticosteroids-formoterol (SMART), and steps 3, 4, and 5 with add-on long-acting muscarinic antagonist therapy. Nonpharmacological recommendations are also considered and contrasted, including for exhaled nitric oxide, environmental control, immunotherapy, and bronchial thermoplasty. Similarities and differences in these 2 documents are highlighted, and recommendations are made about harmonizing the approaches where possible.
Collapse
Affiliation(s)
- Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, Calif.
| | - Kevin R Murphy
- Boys Town National Research Hospital, Section of Adult and Pediatric Allergy and Pediatric Pulmonary, Boystown, Neb
| | - John Oppenheimer
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ
| |
Collapse
|
11
|
Cloutier MM, Dixon AE, Krishnan JA, Lemanske RF, Pace W, Schatz M. Managing Asthma in Adolescents and Adults: 2020 Asthma Guideline Update From the National Asthma Education and Prevention Program. JAMA 2020; 324:2301-2317. [PMID: 33270095 DOI: 10.1001/jama.2020.21974] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Asthma is a major public health problem worldwide and is associated with excess morbidity, mortality, and economic costs associated with lost productivity. The National Asthma Education and Prevention Program has released the 2020 Asthma Guideline Update with updated evidence-based recommendations for treatment of patients with asthma. OBJECTIVE To report updated recommendations for 6 topics for clinical management of adolescents and adults with asthma: (1) intermittent inhaled corticosteroids (ICSs); (2) add-on long-acting muscarinic antagonists; (3) fractional exhaled nitric oxide; (4) indoor allergen mitigation; (5) immunotherapy; and (6) bronchial thermoplasty. EVIDENCE REVIEW The National Heart, Lung, and Blood Advisory Council chose 6 topics to update the 2007 asthma guidelines based on results from a 2014 needs assessment. The Agency for Healthcare Research and Quality conducted systematic reviews of these 6 topics based on literature searches up to March-April 2017. Reviews were updated through October 2018 and used by an expert panel (n = 19) that included asthma content experts, primary care clinicians, dissemination and implementation experts, and health policy experts to develop 19 new recommendations using the GRADE method. The 17 recommendations for individuals aged 12 years or older are reported in this Special Communication. FINDINGS From 20 572 identified references, 475 were included in the 6 systematic reviews to form the evidence basis for these recommendations. Compared with the 2007 guideline, there was no recommended change in step 1 (intermittent asthma) therapy (as-needed short-acting β2-agonists [SABAs] for rescue therapy). In step 2 (mild persistent asthma), either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy are recommended. Formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) is recommended as the preferred therapy for moderate persistent asthma in step 3 (low-dose ICS-formoterol therapy) and step 4 (medium-dose ICS-formoterol therapy) for both daily and as-needed therapy. A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended. Add-on long-acting muscarinic antagonists are recommended in individuals whose asthma is not controlled by ICS-formoterol therapy for step 5 (moderate-severe persistent asthma). Fractional exhaled nitric oxide testing is recommended to assist in diagnosis and monitoring of symptoms, but not alone to diagnose or monitor asthma. Allergen mitigation is recommended only in individuals with exposure and relevant sensitivity or symptoms. When used, allergen mitigation should be allergen specific and include multiple allergen-specific mitigation strategies. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma. Bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort. CONCLUSIONS AND RELEVANCE Asthma is a common disease with substantial human and economic costs globally. Although there is no cure or established means of prevention, effective treatment is available. Use of the recommendations in the 2020 Asthma Guideline Update should improve the health of individuals with asthma.
Collapse
Affiliation(s)
| | | | - Jerry A Krishnan
- University of Illinois Hospital and Health Sciences System, Chicago
| | - Robert F Lemanske
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Wilson Pace
- University of Colorado School of Medicine, Aurora
| | - Michael Schatz
- Department of Allergy, Kaiser Permanente Medical Center, San Diego, California
| |
Collapse
|
12
|
Cloutier MM, Baptist AP, Blake KV, Brooks EG, Bryant-Stephens T, DiMango E, Dixon AE, Elward KS, Hartert T, Krishnan JA, Lemanske RF, Ouellette DR, Pace WD, Schatz M, Skolnik NS, Stout JW, Teach SJ, Umscheid CA, Walsh CG. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol 2020; 146:1217-1270. [PMID: 33280709 PMCID: PMC7924476 DOI: 10.1016/j.jaci.2020.10.003] [Citation(s) in RCA: 409] [Impact Index Per Article: 102.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 12/22/2022]
Abstract
The 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group was coordinated and supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. It is designed to improve patient care and support informed decision making about asthma management in the clinical setting. This update addresses six priority topic areas as determined by the state of the science at the time of a needs assessment, and input from multiple stakeholders:A rigorous process was undertaken to develop these evidence-based guidelines. The Agency for Healthcare Research and Quality's (AHRQ) Evidence-Based Practice Centers conducted systematic reviews on these topics, which were used by the Expert Panel Working Group as a basis for developing recommendations and guidance. The Expert Panel used GRADE (Grading of Recommendations, Assessment, Development and Evaluation), an internationally accepted framework, in consultation with an experienced methodology team for determining the certainty of evidence and the direction and strength of recommendations based on the evidence. Practical implementation guidance for each recommendation incorporates findings from NHLBI-led patient, caregiver, and clinician focus groups. To assist clincians in implementing these recommendations into patient care, the new recommendations have been integrated into the existing Expert Panel Report-3 (EPR-3) asthma management step diagram format.
Collapse
Affiliation(s)
- Michelle M Cloutier
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Alan P Baptist
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Kathryn V Blake
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Edward G Brooks
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Tyra Bryant-Stephens
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Emily DiMango
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Anne E Dixon
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Kurtis S Elward
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Tina Hartert
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Jerry A Krishnan
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Robert F Lemanske
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Daniel R Ouellette
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Wilson D Pace
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Michael Schatz
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Neil S Skolnik
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - James W Stout
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Stephen J Teach
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Craig A Umscheid
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| | - Colin G Walsh
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda
| |
Collapse
|
13
|
Hartmann D, Fischl A, Herrmann E, Schulze J, Schubert R, Zielen S. Prospective comparison of a nonmodified and a modified mite extract for immunotherapy in children and adolescents. Immunotherapy 2019; 11:1015-1029. [PMID: 31319714 DOI: 10.2217/imt-2019-0015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This prospective study compares nonmodified and modified house dust mite extracts for allergen immunotherapy (AIT) in pediatric patients with allergic asthma. Materials & methods: Total 95 patients underwent bronchial allergen provocation (BAP). AIT was recommended to 62 patients. Complete datasets of 54 subjects were obtained. Primary aim was the comparison of treatment success defined by BAP between two extracts after 1 year. Secondary parameters were laboratory parameters and clinical symptoms. Results: Significant improvement (p < 0.001) was measured by BAP in both treatment groups. No change was seen in the controls. Both extracts exerted comparable effects on all parameters. Conclusion: After 1 year of AIT, the extracts were equally efficient, with significant improvements in 70.0% (nonmodified) and 72.2% (modified) of patients.
Collapse
Affiliation(s)
- Desireé Hartmann
- Department for Children & Adolescents, Division of Allergology, Pulmonology & Cystic fibrosis, Goethe University, 60590 Frankfurt am Main, Germany
| | - Anna Fischl
- Department for Children & Adolescents, Division of Allergology, Pulmonology & Cystic fibrosis, Goethe University, 60590 Frankfurt am Main, Germany
| | - Eva Herrmann
- Department of Biostatistics, Goethe University, 60590 Frankfurt am Main, Germany
| | - Johannes Schulze
- Department for Children & Adolescents, Division of Allergology, Pulmonology & Cystic fibrosis, Goethe University, 60590 Frankfurt am Main, Germany
| | - Ralf Schubert
- Department for Children & Adolescents, Division of Allergology, Pulmonology & Cystic fibrosis, Goethe University, 60590 Frankfurt am Main, Germany
| | - Stefan Zielen
- Department for Children & Adolescents, Division of Allergology, Pulmonology & Cystic fibrosis, Goethe University, 60590 Frankfurt am Main, Germany
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Agache I, Lau S, Akdis CA, Smolinska S, Bonini M, Cavkaytar O, Flood B, Gajdanowicz P, Izuhara K, Kalayci O, Mosges R, Palomares O, Papadopoulos NG, Sokolowska M, Angier E, Fernandez‐Rivas M, Pajno G, Pfaar O, Roberts G, Ryan D, Sturm GJ, Ree R, Varga EM, Wijk RG, Yepes‐Nuñez J, Jutel M. EAACI Guidelines on Allergen Immunotherapy: House dust mite-driven allergic asthma. Allergy 2019; 74:855-873. [PMID: 31095767 DOI: 10.1111/all.13749] [Citation(s) in RCA: 158] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/12/2019] [Indexed: 12/14/2022]
Abstract
Allergen immunotherapy (AIT) has been in use for the treatment of allergic disease for more than 100 years. Asthma treatment relies mainly on corticosteroids and other controllers recommended to achieve and maintain asthma control, prevent exacerbations, and improve quality of life. AIT is underused in asthma, both in children and in adults. Notably, patients with allergic asthma not adequately controlled on pharmacotherapy (including biologics) represent an unmet health need. The European Academy of Allergy and Clinical Immunology has developed a clinical practice guideline providing evidence-based recommendations for the use of house dust mites (HDM) AIT as add-on treatment for HDM-driven allergic asthma. This guideline was developed by a multi-disciplinary working group using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. HDM AIT was separately evaluated by route of administration and children and adults: subcutaneous (SCIT) and sublingual AIT (SLIT), drops, and tablets. Recommendations were formulated for each. The important prerequisites for successful treatment with HDM AIT are (a) selection of patients most likely to respond to AIT and (b) use of allergen extracts and desensitization protocols of proven efficacy. To date, only AIT with HDM SLIT-tablet has demonstrated a robust effect in adults for critical end points (exacerbations, asthma control, and safety). Thus, it is recommended as an add-on to regular asthma therapy for adults with controlled or partially controlled HDM-driven allergic asthma (conditional recommendation, moderate-quality evidence). HDM SCIT is recommended for adults and children, and SLIT drops are recommended for children with controlled HDM-driven allergic asthma as the add-on to regular asthma therapy to decrease symptoms and medication needs (conditional recommendation, low-quality evidence).
Collapse
Affiliation(s)
- Ioana Agache
- Faculty of Medicine Department of Allergy and Clinical Immunology Transylvania University Brasov Brasov Romania
| | - Susanne Lau
- Department for Pediatric Pneumology, Immunology and Intensive Care Charité Universität Medizin Berlin Germany
| | - Cezmi A. Akdis
- University of Zürich Swiss Institute of Allergy and Asthma Research (SIAF) Davos Switzerland
- Christine Kühne‐Center for Allergy Research and Education (CK‐CARE) Davos Switzerland
| | - Sylwia Smolinska
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- “ALL‐MED” Medical Research Institute Wroclaw Poland
| | - Matteo Bonini
- National Heart and Lung Institute (NHLI) Royal Brompton Hospital & Imperial College London UK
| | - Ozlem Cavkaytar
- Faculty of Medicine Department of Pediatric Allergy Istanbul Medeniyet University Goztepe Training and Research Hospital Istanbul Turkey
| | - Breda Flood
- European Federation of Allergy and Airways Diseases, Patients Association Brussels Belgium
| | - Pawe Gajdanowicz
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
| | | | - Omer Kalayci
- Hacettepe University School of Medicine Ankara Turkey
| | - Ralph Mosges
- Universität zu Koln Institute of Medical Statistics, Informatics and Epidemiology (IMSIE) Koln Germany
| | - Oscar Palomares
- Department of Biochemistry and Molecular Biology Complutense University of Madrid Madrid Spain
| | - Nikolaos G. Papadopoulos
- Division of Infection, Immunity and respiratory medicine University of Manchester Manchester UK
- Allergy Department 2nd Pediatric Clinic University of Athens Athens Greece
| | - Milena Sokolowska
- University of Zürich Swiss Institute of Allergy and Asthma Research (SIAF) Davos Switzerland
- Christine Kühne‐Center for Allergy Research and Education (CK‐CARE) Davos Switzerland
| | | | | | - Giovanni Pajno
- Allergy Unit Department of Pediatrics University of Messina Messina Italy
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital Marburg Philipps‐Universität Marburg Marburg Germany
| | - Graham C. Roberts
- The David Hide Asthma and Allergy Research Centre St Mary's Hospital Newport Isle of Wight UK
- NIHR Biomedical Research Centre University Hospital Southampton NHS Foundation Trust Southampton UK
- Faculty of Medicine University of Southampton Southampton UK
| | - Dermot Ryan
- Usher Institute of Population Health Sciences and Informatics University of Edinburgh Edinburgh UK
- Asthma UK Centre for Applied Research The University of Edinburgh Edinburgh UK
| | - Gunter J. Sturm
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
- Outpatient Allergy Clinic Reumannplaz Vienna Austria
| | - Ronald Ree
- Department of Experimental Immunology Academic Medical Center University of Amsterdam Amsterdam The Netherlands
- Department of Otorhinolaryngology Academic Medical Center University of Amsterdam Amsterdam The Netherlands
| | - Eva M. Varga
- Department of Pediatric and Adolescent Medicine Respiratory and Allergic Disease Division Medical University of Graz Graz Austria
| | - Roy Gerth Wijk
- Section of Allergology Department of Internal Medicine Erasmus Medical Center Rotterdam The Netherlands
| | | | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- “ALL‐MED” Medical Research Institute Wroclaw Poland
| |
Collapse
|
16
|
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]
|
17
|
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]
|
18
|
Terada T, Kawata R. Early Intervention is Important to Prevent Sensitization to New Allergens. Med Sci (Basel) 2018; 6:E114. [PMID: 30545018 PMCID: PMC6313720 DOI: 10.3390/medsci6040114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/03/2018] [Accepted: 12/07/2018] [Indexed: 11/17/2022] Open
Abstract
We review current management for allergic rhinitis and possible new treatments for this condition. Management of allergic rhinitis includes promotion of protective factors, avoidance of allergens, and possibly immunotherapy. In recent years, the incidence of allergic rhinitis has increased in many countries. Early intervention at different stages is an important part of management. Allergic disease in infants has been described as the allergic march, commencing with atopic dermatitis accompanied by infantile asthma and progressing to perennial allergic rhinitis induced by house dust mite allergy. In order to prevent polysensitization, allergen-specific immunotherapy should probably be initiated at an earlier age, especially in children with rhinitis who show monosensitization to house dust mite antigens.
Collapse
Affiliation(s)
- Tetsuya Terada
- Department of Otolaryngology, Osaka Medical College, 2-7 Daigakumachi Takatsuki, Osaka 569-8686, Japan.
| | - Ryo Kawata
- Department of Otolaryngology, Osaka Medical College, 2-7 Daigakumachi Takatsuki, Osaka 569-8686, Japan.
| |
Collapse
|
19
|
Dhami S, Kakourou A, Asamoah F, Agache I, Lau S, Jutel M, Muraro A, Roberts G, Akdis CA, Bonini M, Cavkaytar O, Flood B, Gajdanowicz P, Izuhara K, Kalayci Ö, Mosges R, Palomares O, Pfaar O, Smolinska S, Sokolowska M, Asaria M, Netuveli G, Zaman H, Akhlaq A, Sheikh A. Allergen immunotherapy for allergic asthma: A systematic review and meta-analysis. Allergy 2017; 72:1825-1848. [PMID: 28543086 DOI: 10.1111/all.13208] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND To inform the development of the European Academy of Allergy and Clinical Immunology's (EAACI) Guidelines on Allergen Immunotherapy (AIT) for allergic asthma, we assessed the evidence on the effectiveness, cost-effectiveness and safety of AIT. METHODS We performed a systematic review, which involved searching nine databases. Studies were screened against predefined eligibility criteria and critically appraised using established instruments. Data were synthesized using random-effects meta-analyses. RESULTS 98 studies satisfied the inclusion criteria. Short-term symptom scores were reduced with a standardized mean difference (SMD) of -1.11 (95% CI -1.66, -0.56). This was robust to a prespecified sensitivity analyses, but there was evidence suggestive of publication bias. Short-term medication scores were reduced SMD -1.21 (95% CI -1.87, -0.54), again with evidence of potential publication bias. There was no reduction in short-term combined medication and symptom scores SMD 0.17 (95% CI -0.23, 0.58), but one study showed a beneficial long-term effect. For secondary outcomes, subcutaneous immunotherapy (SCIT) improved quality of life and decreased allergen-specific airway hyperreactivity (AHR), but this was not the case for sublingual immunotherapy (SLIT). There were no consistent effects on asthma control, exacerbations, lung function, and nonspecific AHR. AIT resulted in a modest increased risk of adverse events (AEs). Although relatively uncommon, systemic AEs were more frequent with SCIT; however no fatalities were reported. The limited evidence on cost-effectiveness was mainly available for sublingual immunotherapy (SLIT) and this suggested that SLIT is likely to be cost-effective. CONCLUSIONS AIT can achieve substantial reductions in short-term symptom and medication scores in allergic asthma. It was however associated with a modest increased risk of systemic and local AEs. More data are needed in relation to secondary outcomes, longer-term effectiveness and cost-effectiveness.
Collapse
Affiliation(s)
- S. Dhami
- Evidence-Based Health Care Ltd; Edinburgh UK
| | - A. Kakourou
- Department of Hygiene and Epidemiology; University of Ioannina School of Medicine; Ioannina Greece
| | - F. Asamoah
- Centre for Environmental and Preventive Medicine; Wolfson Institute of Preventive Medicine Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
| | - I. Agache
- Faculty of Medicine; Department of Allergy and Clinical Immunology; Transylvania University Brasov; Brasov Romania
| | - S. Lau
- Department of Pediatric Pneumology and Immunology; Charité Universitätsmedizin; Berlin Germany
| | - M. Jutel
- Wroclaw Medical University; Wroclaw Poland
- ALL-MED Medical Research Institute; Wroclaw Poland
| | - A. Muraro
- Food Allergy Referral Centre Veneto Region; University Hospital of Padua; Padua Italy
| | - G. Roberts
- The David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Newport UK
- NIHR Biomedical Research Centre; University Hospital Southampton NHS Foundation Trust; Southampton UK
- Faculty of Medicine; University of Southampton; Southampton UK
| | - C. A. Akdis
- Swiss Institute for Allergy and Asthma Research; Christine Kühne-Center for Allergy Research and Education (CK-CARE); Davos Switzerland
| | - M. Bonini
- National Heart and Lung Institute; Imperial College London; London UK
| | - O. Cavkaytar
- Department of Allergy and Clinical Immunology; Sami Ulus Women's & Children's Diseases Training and Research Hospital; Ankara Turkey
- Department of Pediatric Allergy and Immunology; Ulus Women's & Children's Diseases Training and Research Hospital; Ankara Turkey
| | - B. Flood
- European Federation of Allergy and Airways Diseases Patients Association; Brussels Belgium
| | | | | | | | - R. Mosges
- Institute of Medical Statistics, Informatics and Epidemiology (IMSIE); University of Cologne; Köln Germany
| | - O. Palomares
- Department of Biochemistry and Molecular Biology; Complutense University of Madrid; Madrid Spain
| | - O. Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery; Universitätsmedizin Mannheim; Medical Faculty Mannheim; Heidelberg University; Mannheim Germany
- Center for Rhinology and Allergology; Wiesbaden Germany
| | - S. Smolinska
- Wroclaw Medical University; Wroclaw Poland
- ALL-MED Medical Research Institute; Wroclaw Poland
| | - M. Sokolowska
- Swiss Institute for Allergy and Asthma Research; Christine Kühne-Center for Allergy Research and Education (CK-CARE); Davos Switzerland
| | - M. Asaria
- Centre for Health Economics; University of York; York UK
| | - G. Netuveli
- Institute for Health and Human Development; University of East London; London UK
| | - H. Zaman
- Bradford School of Pharmacy; Bradford UK
| | - A. Akhlaq
- Health and Hospital Management; Institute of Business Management; Karachi Pakistan
| | - A. Sheikh
- Asthma UK Centre for Applied Research; The University of Edinburgh; Edinburgh UK
| |
Collapse
|
20
|
Wüstenberg E, Klimek L, Bachert C, Haxel B, Hamelmann E, Pfaar O, Wagenmann M, Kleine-Tebbe J. Früher diagnostizieren, besser therapieren. ALLERGO JOURNAL 2017. [DOI: 10.1007/s15007-017-1455-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
21
|
Mahler V, Klein C, Sager A, Zimmermann J. House dust mite-specific immunotherapy with two licensed vaccines: Outcome under clinical routine conditions. IMMUNITY INFLAMMATION AND DISEASE 2017; 5:132-140. [PMID: 28474505 PMCID: PMC5418138 DOI: 10.1002/iid3.141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 10/31/2016] [Accepted: 11/02/2016] [Indexed: 11/06/2022]
Abstract
INTRODUCTION House dust mite (HDM) allergens are major causes for the development of allergic diseases. A disease modifying effect and clinical benefit of allergen immunotherapy (AIT) has been demonstrated in a number of clinical trials. Clinical trials, however, are carried out in selected populations under specific conditions based on inclusion and exclusion criteria and may not represent the entire patient population from medical practice. Objective of this study conducted in patients with HDM allergy was to systematically collect information about the benefit of AIT under clinical routine conditions. METHODS In this prospective, multi-center non-interventional study, 220 patients (117 adults, 103 children) with HDM allergy receiving subcutaneous AIT with Depigoid® were monitored for 2 years. Organ-specific key symptoms, health-related quality of life (QoL), and the use of concomitant anti-allergic medication were assessed at baseline and after 12 and 24 months. Effectiveness and tolerability of the AIT was assessed by physicians and patients. Occurrence of adverse events (AEs) was continuously monitored. RESULTS Two hundred and nineteen patients (116 adults, 103 children) were evaluated. A major improvement of the total symptom-score was observed after 24 (12) months in 76% (72%) and 80% (79%) of adults and children, respectively, accompanied by a reduction in concomitant anti-allergic medication and a pronounced improvement in QoL. The effectiveness and tolerability of the AIT was estimated as very good/good by 80-90% of physicians and patients. AEs were observed in 4/117 adults (3.4%) and in 7/103 children (6.8%). Serious AEs were reported in three adults and one child: A grade-II anaphylactic reaction (one adult) controlled by oral antihistamines (no hospitalization) classified as "definitely," three others as not (2) or possibly (1) drug-related. CONCLUSIONS The data collected from 220 patients confirm the efficacy, tolerability/safety, and acceptance of AIT with Depigoid® in adults and children with HDM allergy under routine clinical conditions.
Collapse
Affiliation(s)
- Vera Mahler
- Hautklinik Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | | |
Collapse
|
22
|
Safety of immunotherapy with glutaraldehyde modified allergen extracts in children and adults. Allergol Immunopathol (Madr) 2017; 45:198-207. [PMID: 27939406 DOI: 10.1016/j.aller.2016.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 07/28/2016] [Accepted: 08/19/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Glutaraldehyde-modified natural allergen extracts show significant reduction in the IgE-binding capacity and proteolytic activity. This allows the administration of higher doses in a shorter period of time, and to mix different allergen extracts. OBJECTIVE Evaluate the safety of different concentrations and mixtures of glutaraldehyde-modified allergen extracts in a large group of paediatric and adult patients undergoing specific immunotherapy treatment. MATERIALS AND METHODS 1855 patients (1156 adults and 699 children), suffering from rhinoconjunctivitis and/or asthma, participated in an observational multicentre cohort study, to evaluate the safety of immunotherapy using vaccines containing modified allergen extracts. Patients were monosensitised, or polysensitised, and received a therapeutic vaccine containing polymerised allergen extracts adsorbed onto aluminium hydroxide. Safety was assessed by recording all side reactions related to immunotherapy. RESULTS The clinically relevant local reactions totalled 120, (90 immediate and 30 delayed) (1.02% of injections). Of them, 31 (0.26% of injections) occurred in children (26 immediate and 5 delayed) and 89 (0.76% of injections) in adults (64 immediate and 25 delayed). There were 38 systemic reactions. Eleven reactions were immediate (9 of grade 1 and 2 of grade 2) and 27 delayed (22 of grade 1 and 5 of grade 2). There were seven grade 2 systemic reactions (0.06% of the injections). No differences (P>0.05) in the number of reactions were observed between adults and children and between treatments were found in systemic reactions. All systemic reactions were mild and resolved spontaneously without the need of medication. CONCLUSION Specific immunotherapy using natural modified allergen vaccines is safe to treat allergic patients, even at higher doses and in mixtures of unrelated allergen extracts. The percentage of adverse reactions detected is lower than those reported in the literature with native unmodified allergen extracts.
Collapse
|
23
|
Haxel BR, Huppertz T, Boessert P, Bast F, Fruth K. Correlation of skin test results and specific immunoglobulin E blood levels with nasal provocation testing for house-dust mite allergies. Am J Rhinol Allergy 2016; 30:60-4. [PMID: 26867532 DOI: 10.2500/ajra.2016.30.4262] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Allergen-specific immunotherapy for house-dust mite (HDM) allergies is associated with lower success rates when compared with similar treatments for other inhalant allergens, such as grass or birch. One reason might be the greater difficulty in diagnosing patients with assumed HDM allergies because symptoms occur perennially and may differ from those of a conventional allergic rhinitis. OBJECTIVE The aim of the study was to compare the different methods of diagnosis in patients with assumed HDM allergy. METHODS We performed a retrospective analysis of nasal provocation tests (NPT) from patients (n = 161) evaluated for Dermatophagoides pteronyssinus (n = 127) and Dermatophagoides farinae (n = 104) allergies, and compared the results with other allergen testing methods (skin-prick test [SPT], intracutaneous test, and allergen specific immunoglobulin E levels [sIgE] to detect sensitization). Receiver operating characteristic curves were used for the analyses and the areas under the curve were calculated. RESULTS For D. pteronyssinus and D. farinae, 86 and 70 complete data files, respectively, were available. For both tested HDMs, the results of the receiver operating characteristic curves showed a significant correlation for SPT and sIgE, with the results of the NPT (area under the curve, 0.742 to 0.763) but not for the intracutaneous test. In patients with a positive SPT (≥3 mm), an allergy was confirmed by the NPT in 69% of cases for D. pteronyssinus and 71% for D. farinae. A positive sIgE result (ImmunoCAP class of ≥2) was verified by the NPT in 69% of cases (D. pteronyssinus) and 70% (D. farinae). CONCLUSION The predictability value for a positive NPT result is best for SPT and sIgE. Nevertheless, even if the results of both test systems are combined, the positive predictive value that was achieved was only 0.77 for D. pteronyssinus and 0.69 for D. farinae. Therefore, in patients eligible for immunotherapy for HDM, an NPT should be performed before the start of the therapy to verify a clinically relevant allergy.
Collapse
Affiliation(s)
- Boris R Haxel
- Department of Otorhinolaryngology, Head and Neck Surgery, AMEOS Klinikum Haldensleben, Germany
| | | | | | | | | |
Collapse
|
24
|
Jirawutthiwongchai J, Klaharn IY, Hobang N, Mai-ngam K, Klaewsongkram J, Sereemaspun A, Chirachanchai S. Chitosan-phenylalanine-mPEG nanoparticles: From a single step water-based conjugation to the potential allergen delivery system. Carbohydr Polym 2016; 141:41-53. [DOI: 10.1016/j.carbpol.2015.12.076] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/21/2015] [Accepted: 12/29/2015] [Indexed: 10/22/2022]
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
Passalacqua G, Rogkakou A, Mincarini M, Canonica GW. Allergen immunotherapy in asthma; what is new? Asthma Res Pract 2015; 1:6. [PMID: 27965760 PMCID: PMC4970380 DOI: 10.1186/s40733-015-0006-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/27/2015] [Indexed: 12/29/2022] Open
Abstract
The use and role of allergen immunotherapy (AIT) in asthma is still a matter of debate, and no definite recommendation about this is made in guidelines, both for the subcutaneous and sublingual routes. This is essentially due to the fact that most controlled randomised trials were not specifically designed for asthma, and that objective measures of pulmonary function were only occasionally considered. Nonetheless, in many trials, favourable results in asthma (symptoms, medication usage, bronchial reactivity) were consistently reported. There are also several meta analyses in favour of AIT, although their validity is limited by a relevant methodological heterogeneity. In addition to the crude clinical effect, a disease modifying action of AIT (prevention of asthma onset and long-lasting effects) have been reported. The safety is an important aspect to consider in asthma. Fatalities were rare: in Europe no fatality was reported in the last three decades, as in the United States in the last 4 years. Based on previous surveys, and common sense, uncontrolled asthma is still recognized as the most important risk factor for severe adverse events. On the contrary, there is no evidence that AIT can worsen or induce asthma. According to the available evidence, AIT can be safely used as add-on treatment when asthma is associated with rhinitis (a frequent condition), provided that asthma is adequately controlled by pharmacotherapy. AIT cannot be recommended or suggested as single therapy. When asthma is the unique manifestation of respiratory allergy, its use should be evaluated case by case.
Collapse
Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital-IST-University of Genoa, Padiglione Maragliano, L.go R.Benzi 10, Genoa, 16133 Italy
| | - Anthi Rogkakou
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital-IST-University of Genoa, Padiglione Maragliano, L.go R.Benzi 10, Genoa, 16133 Italy
| | - Marcello Mincarini
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital-IST-University of Genoa, Padiglione Maragliano, L.go R.Benzi 10, Genoa, 16133 Italy
| | - Giorgio Walter Canonica
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital-IST-University of Genoa, Padiglione Maragliano, L.go R.Benzi 10, Genoa, 16133 Italy
| |
Collapse
|
27
|
Liao W, Hu Q, Shen LL, Hu Y, Tao HF, Li HF, Fan WT. Sublingual Immunotherapy for Asthmatic Children Sensitized to House Dust Mite: A Meta-Analysis. Medicine (Baltimore) 2015; 94:e701. [PMID: 26091451 PMCID: PMC4616527 DOI: 10.1097/md.0000000000000701] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The house dust mite is one of the most common allergens worldwide. There is good evidence that house dust mite subcutaneous immunotherapy is efficacious and has long-term benefit in children. However, the evidence of the benefit of house dust mite sublingual immunotherapy (SLIT) is less convincing. The purpose of this meta-analysis was to evaluate that efficacy and safety of dust mite SLIT in children with asthma. Medical Literature Analysis and Retrieval System Online, ISI Web of Knowledge, and Cochrane Central Register of Controlled Trials databases until February 2014 were searched. The primary outcome was mean change in asthma symptom score. Secondary outcomes included mean change in serum immunoglobulin G4 (sIgG4), specific Dermatophagoides pteronyssinus, immunoglobulin E (IgE) levels, and medication score. Safety was also assessed. We found that SLIT significantly decreased asthma symptom score (P = 0.007) and increased sIgG4 levels (P = 0.011) greater than control in children (<18 years of age) with asthma. There was no difference between SLIT and control groups in specific D pteronyssinus IgE levels (P = 0.076) and medication score (P = 0.408). The safety profile was similar between groups. Our study indicates that dust mite SLIT therapy was effective in reducing asthma symptoms and in increasing sIgG4 but did not significantly reduce medication scores or specific D pteronyssinus IgE levels. Our findings are not enough to support the use of dust mite SLIT in children with asthma.
Collapse
Affiliation(s)
- Wei Liao
- Department of Pediatrics, Southwest Hospital, Third Military Medical University, Chongqing, China
| | | | | | | | | | | | | |
Collapse
|
28
|
Pfaar O, Gerth van Wijk R. Mite-Allergic Rhinitis: How to Evaluate Clinical Efficacy in Allergen-Specific Immunotherapy Trials? CURRENT TREATMENT OPTIONS IN ALLERGY 2015; 2:1-9. [PMID: 25798370 PMCID: PMC4361724 DOI: 10.1007/s40521-014-0040-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
House dust mite (HDM) allergen exposure is the most important cause of perennial allergic rhinitis and/or asthma. Although allergen-specific immunotherapy (AIT) with HDM is well established, published studies have been characterized by substantial heterogeneity in clinical endpoints. Standardization in measuring clinical efficacy is required. Moreover, when designing an AIT trial with HDM allergens, several considerations have to be taken into account. The history of HDM allergy is less clear cut than the typical history of pollen allergy. In addition, clinical features of HDM allergy may differ from those of pollen allergy. Moreover, although not easily measurable, fluctuation in allergen exposure may cause variation in symptom severity and determine the timing of assessment of clinical effects of HDM AIT. Key points 1. A combined symptom and medication score (CSMS) is recommended as standard for the primary endpoint in future house dust mite (HDM) allergen-specific immunotherapy trials. 2. The diagnosis of HDM allergy is based on a carefully taken history in combination with sensitization to HDM allergens. 3. Eye symptoms are less prominent in patients with HDM-induced allergic rhinitis. Nasal symptoms, but not eye symptoms, should be included in the CSMS and in symptom scores as well. 4. As methods to determine allergen exposure vary and the efficacy of environmental control is a matter of debate, a practical approach consists of restraining patients from implementing HDM-reducing measures, such as removing carpets and introducing anti-mite covers, after the start of the study. 5. Efficacy evaluation in the period with the highest exposure to mites is recommended.
Collapse
Affiliation(s)
- Oliver Pfaar
- Center for Rhinology and Allergology Wiesbaden, Germany, An den Quellen 10, 65189 Wiesbaden, Germany ; Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Roy Gerth van Wijk
- Section of Allergology, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| |
Collapse
|
29
|
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]
|
30
|
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
| |
Collapse
|
31
|
Moingeon P. Progress in the development of specific immunotherapies for house dust mite allergies. Expert Rev Vaccines 2014; 13:1463-73. [PMID: 25187166 DOI: 10.1586/14760584.2014.948861] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Allergen-specific immunotherapy is used to treat patients exposed and co-sensitized to the two common house dust mites, Dermatophagoides pteronyssinus and Dermatophagoides farinae. Based on seroepidemiological studies and a detailed characterization of mite allergens, an optimal immunotherapeutic product should associate extracts from the two Dermatophagoides species, and include both bodies and fecal particles. Both subcutaneous and sublingual immunotherapies performed with aqueous mite extracts are safe and efficacious in children and adults with mite-induced rhinitis and/or asthma. Double-blind placebo-controlled studies are conducted to further document the efficacy of immunotherapeutic products, with promising results that were obtained already with sublingual tablets. Current developments of second-generation products relying upon recombinant allergens and peptides are reviewed.
Collapse
Affiliation(s)
- Philippe Moingeon
- Stallergenes SA, Research and Pharmaceutical Development, 6 rue Alexis de Tocqueville, 92160 Antony, France
| |
Collapse
|
32
|
Safety of immunotherapy in patients with rhinitis, asthma or atopic dermatitis using an ultra-rush buildup. A retrospective study. Allergol Immunopathol (Madr) 2014; 42:90-5. [PMID: 23265265 DOI: 10.1016/j.aller.2012.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 07/12/2012] [Accepted: 07/16/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Allergen-specific immunotherapy is a proven, highly effective treatment for IgE-mediated diseases. However, ultra-rush immunotherapy is prescribed infrequently because of the perception that accelerated immunotherapy buildup leads to a higher rate of systemic reactions. OBJECTIVE To evaluate the frequency of adverse reactions in patients with IgE-mediated diseases receiving house dust mite (HDM) ultra-rush immunotherapy. METHODS A retrospective, observational study was conducted for patients with IgE-mediated diseases receiving allergen-specific immunotherapy. Subcutaneous immunotherapy with depigmented polymerized mites extract was administered in two refracted doses of 0.2 and 0.3 ml at first injection, and in single 0.5 ml doses in subsequent monthly injections. A 30 min observation time was required after each injection. Systemic reactions were graded using the World Allergy Organisation grading system. RESULTS 575 patients were included. The age range was 1-83 years. Most patients had respiratory diseases (544) and 101 patients had atopic dermatitis. A total of 27 patients (4.6%) experienced 139 reactions (reactions/injections: 1.9%); 22 patients (3.8%) experienced 134 local reactions (local reactions/injections: 1.8%). Eight patients (1.3%) experienced eight systemic reactions (systemic reactions/injections: 0.1%). Five systemic reactions were grade 2 and three grade 1. Two systemic reactions were reported during buildup. There were no fatalities. CONCLUSION Taking into account the possible bias for the retrospective design of this study we observed that immunotherapy for patients with IgE-mediated diseases using a depigmented polymerized mites extract, with an ultra-rush buildup, has similar frequency of systemic reactions than that seen in slower buildup immunotherapy in other studies. Accelerated buildup could improve patients' adherence and reduce dropout rates.
Collapse
|
33
|
Cruz Niesvaara D, Cumplido Bonny J, Hernández Suárez H, Almeida Quintana L, Carrillo Díaz T. Short-term improvement in health-related quality of life in adult rhinitis/asthma patients treated with Acaroid®. Allergol Immunopathol (Madr) 2014; 42:169-71. [PMID: 23253690 DOI: 10.1016/j.aller.2012.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 10/22/2012] [Accepted: 10/30/2012] [Indexed: 10/27/2022]
|
34
|
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: 245] [Impact Index Per Article: 24.5] [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.
Collapse
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
| | | |
Collapse
|
35
|
An evidence-based analysis of house dust mite allergen immunotherapy: a call for more rigorous clinical studies. J Allergy Clin Immunol 2013; 132:1322-36. [PMID: 24139829 DOI: 10.1016/j.jaci.2013.09.004] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 09/05/2013] [Accepted: 09/09/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND According to meta-analyses and reviews, subcutaneous allergen immunotherapy (SCIT) and sublingual allergen immunotherapy (SLIT) are beneficial in patients with allergic rhinitis (AR) and allergic asthma (AA) induced by house dust mites (HDMs). However, the reported effect sizes have varied greatly from one study to another. OBJECTIVE We sought to perform an evidence-based medicine assessment of commercially available SCIT and SLIT formulations in patients with HDM-induced AA and HDM-induced AR. METHODS We searched for double-blind, placebo-controlled randomized clinical trials and analyzed study designs, doses, regimens, patient-reported outcomes, safety reporting, and compliance. RESULTS Forty-four studies met our inclusion criteria. Some studies tested both SLIT and SCIT or scored both AA and AR outcomes; therefore we reviewed 35 treatment arms in patients with AA (20 for SCIT and 15 for SLIT) and 23 treatment arms in patients with AR (7 for SCIT and 16 for SLIT). The treatment duration ranged from 6 weeks to 3 years. For SCIT, the dose of Der p 1 major allergen (when reported) ranged from 7 to 30 μg for maintenance doses and 60 to 420 μg for cumulative doses. For SLIT, the doses of Der p 1 (when reported) were 0.8 to 70 μg for maintenance doses and 60 to 23,695 μg for cumulative doses. Safety data were often absent or poorly reported. A statistically significant active versus placebo symptom score was observed more frequently for SCIT than for SLIT. CONCLUSION There is no consensus on basic treatment parameters (eg, dose and duration) in HDM SCIT and SLIT. There is an urgent need for rigorous, long-term, double-blind, placebo-controlled randomized clinical trials with an efficacy criterion that reflects the particular features of HDM-induced allergic disease.
Collapse
|
36
|
Eifan AO, Calderon MA, Durham SR. Allergen immunotherapy for house dust mite: clinical efficacy and immunological mechanisms in allergic rhinitis and asthma. Expert Opin Biol Ther 2013; 13:1543-56. [PMID: 24099116 DOI: 10.1517/14712598.2013.844226] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION There is an increasing prevalence of atopic diseases such as allergic rhinitis and asthma with house dust mite (HDM) being the common allergen that is highly associated with allergic rhinitis and asthma. Allergen avoidance and pharmacotherapy are part of treatment but it has proved difficult to change the course of HDM-related allergic diseases. Allergen immunotherapy (AIT) has been in use for the past century and has been shown to be effective in the treatment of allergic respiratory disease. AREAS COVERED This review exclusively focuses on HDM-AIT and discusses the differences in clinical efficacy and safety, long-term effect after discontinuation and immunological changes observed in both HDM-subcutaneous immunotherapy (SCIT) and HDM-sublingual immunotherapy (SLIT) in the treatment of allergic rhinitis and asthma in both pediatric and adult populations. EXPERT OPINION The majority of studies involved small numbers of patients, variable doses of major allergens and are of variable quality. There is good evidence for HDM-SCIT efficacy and its long-term effect in adults and children, whereas at the present time, evidence for HDM-SLIT is unconvincing, particularly in children. In carefully selected patients, HDM-SCIT is effective and safe. More definitive trials are needed before HDM-SLIT can be recommended in routine practice for rhinitis and/or asthma.
Collapse
Affiliation(s)
- Aarif O Eifan
- Imperial College London, Allergy and Clinical Immunology , NHLI, London, SW7 2AZ , UK
| | | | | |
Collapse
|
37
|
Sánchez Caraballo JM, Cardona Villa R. Clinical and immunological changes of immunotherapy in patients with atopic dermatitis: randomized controlled trial. ISRN ALLERGY 2012; 2012:183983. [PMID: 23724240 PMCID: PMC3658480 DOI: 10.5402/2012/183983] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Accepted: 01/10/2012] [Indexed: 12/03/2022]
Abstract
Background. Immunotherapy has proven to be an useful tool in the management of allergic respiratory diseases; however, little has been studied in atopic dermatitis. Objective. To evaluate the clinical and immunological impact of immunotherapy with mites allergen extracts in atopic dermatitis. Methods. Patients with atopic dermatitis were assigned with computer-generated randomization to either of the following groups: (a) controls received only topical treatment with steroids and/or tacrolimus and (b) actively treated patients received topical treatment plus immunotherapy. Levels of serum total IgE, mites-specific IgE and IgG4 were assessed at study start and after one year of immunotherapy. Results. 31 patients in the active group and 29 in the control group completed the study. Symptoms and medication scores were significantly reduced in the active group after six months. Three patients in the control group showed new sensitizations to mites, while 3 patients in the active group showed neosensitization to shrimp with negative oral food challenge. We observed significant increase of mites-specific IgG4 levels in active group. Conclusion. Specific allergen immunotherapy induced a tolerogenic IgG4 response to mite allergens associated with favorable clinical effects in atopic dermatitis patients.
Collapse
Affiliation(s)
- Jorge Mario Sánchez Caraballo
- Group of Clinical and Experimental Allergy, University of Antioquia, Medellin, Colombia ; Foundation for the Development of Medical and Biological Sciences (FUNDEMEB), Cartagena, Colombia ; Institute for Immunological Research, University of Cartagena, Cartagena, Colombia ; IPS Universitaria Sede Ambulatoria, Universidad de Antioquia Carrera 51A No. 62-42, Medellin, Colombia
| | | |
Collapse
|
38
|
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.
Collapse
Affiliation(s)
- O Pfaar
- Center for Rhinology and Allergology Wiesbaden, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Pico de Coaña Y, Carnés J, Gallego MT, Alonso C, Parody N. Modulation of the humoral response to Dermatophagoides pteronyssinus allergens in BALB/c mice by extract modification and adjuvant use. Int Arch Allergy Immunol 2011; 157:331-8. [PMID: 22123212 DOI: 10.1159/000329636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 05/25/2011] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Currently, several strategies are being used in order to improve the safety and efficacy of allergen-specific immunotherapy; these strategies include the use of modified hypoallergenic extracts as well as different adjuvants with immunomodulatory properties in combination with native or modified extracts. The objectives of this study were to investigate the humoral response generated in mice to modified Dermatophagoides pteronyssinus extracts in the presence or absence of two different adjuvants. METHODS BALB/c mice were inoculated either with native, depigmented or depigmented-polymerised D. pteronyssinus without adjuvants or combined with aluminium hydroxide or oligodeoxinucleotides containing CpG motifs. IgE concentration, specific total IgG, IgG1 and IgG2a titres were measured in mice sera and cross-reactivity inhibition experiments were performed. IgG antigenic profiles were obtained by immunoblotting for all formulations. RESULTS Inoculation of depigmented-polymerised extract induced statistically significant lower IgE levels than the native extract even when adsorbed onto aluminium hydroxide. When this extract was inoculated in the presence of oligodeoxinucleotides containing CpG motifs, it elicited high IgG levels, a high IgG2a/lgG1 ratio and low IgE production. Furthermore, the antigenic profiles observed after extract inoculation showed punctual differences between the depigmented-polymerised extract and the native or depigmented extracts. CONCLUSIONS Our results suggest that the depigmentation and polymerisation process modifies the native extract's antigenic and immunogenic properties and converts the depigmented-polymerised extract into a better choice for allergen-specific immunotherapy.
Collapse
Affiliation(s)
- Yago Pico de Coaña
- Centro de Biología Molecular Severo Ochoa, Consejo Superior de Investigaciones Científicas, Universidad Autónoma de Madrid, Madrid, Spain.
| | | | | | | | | |
Collapse
|
40
|
Yukselen A, Kendirli SG, Yilmaz M, Altintas DU, Karakoc GB. Effect of one-year subcutaneous and sublingual immunotherapy on clinical and laboratory parameters in children with rhinitis and asthma: a randomized, placebo-controlled, double-blind, double-dummy study. Int Arch Allergy Immunol 2011; 157:288-98. [PMID: 22041501 DOI: 10.1159/000327566] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 03/21/2011] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND It has been reported that both sublingual (SLIT) and subcutaneous (SCIT) allergen-specific immunotherapy have clinical efficacy, yet there are rather few comparative placebo studies of children. We aimed to investigate the clinical and immunological efficacy of mite-specific SLIT and SCIT versus a placebo in rhinitis and asthma in children. METHODS The outcomes of this 1-year, randomized, placebo-controlled, double-blind, double-dummy study were symptom and medication scores, visual analog scores (VAS), titrated skin prick tests, nasal and bronchial allergen provocation doses, serum house dust mite-specific immunglobulin E (HDM-sIgE), sIgG4, IL-10 and IFN-γ levels. RESULTS Clinical and laboratory parameters were evaluated in 30 patients. SCIT significantly diminished symptom and medication scores for rhinitis and asthma (p = 0.03 and p = 0.05 for rhinitis; p = 0.01 and p = 0.05 for asthma) and VAS. SLIT also reduced VAS, symptoms associated with rhinitis and asthma as well as medication usage for rhinitis, but this reduction was not significant when compared with the placebo. Skin reactivitiy to HDM and HDM-sIgE levels was reduced significantly in both immunotherapy groups. Serum IL-10 levels and nasal provocative doses increased significantly with both SCIT and SLIT. Nasal eosinophil increments after nasal challenge decreased with two treatment modes, but bronchial provocative doses and sputum eosinophil increments after bronchial challenge were reduced only with SCIT. In both treatment arms, there was no change in IFN-γ levels. Serum sIgG4 levels increased significantly only in the SCIT group. CONCLUSION Based on the limited number of patients at the end of the 1-year immunotherapy, the clinical efficacy of SCIT on rhinitis and asthma symptoms was more evident when compared with the placebo.
Collapse
Affiliation(s)
- Ayfer Yukselen
- Clinic of Pediatric Allergy and Immunology, Children's Hospital of Gaziantep, Gaziantep, Turkey.
| | | | | | | | | |
Collapse
|
41
|
Hernández N, Ibero M, Ridao M, Artigas R, Viñas M, Castillo MJ. Safety of specific immunotherapy using a depigmented and polymerised extract of Dermatophagoides pteronyssinus in children under five years of age. Allergol Immunopathol (Madr) 2011; 39:267-70. [PMID: 21334128 DOI: 10.1016/j.aller.2010.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Accepted: 09/01/2010] [Indexed: 11/17/2022]
Abstract
BACKGROUND Different opinion documents point to a patient age of under five years as a relative contraindication to specific immunotherapy, arguing that this age group has a greater risk of developing anaphylaxis, and that specially trained personnel are needed to deal with the problem if it occurs. However, insufficient evidence exists to support such an affirmation. PATIENTS AND METHODS A retrospective follow-up observational study was made of patients aged 60 months or younger who had been subjected to specific immunotherapy. We included 77 children with a diagnosis of extrinsic bronchial asthma (n=68), extrinsic spasmodic cough (n=5) and allergic rhinitis (n=4) confirmed by clinical criteria and prick-test, with specific IgE positivity to Dermatophagoides pteronyssinus. All patients received specific immunotherapy with an extract of depigmented D. pteronyssinus polymerised with glutaraldehyde, involving an initial cluster protocol of two weeks and monthly maintenance doses. All observed adverse reactions were recorded, and classified according to European Academy of Allergy and Clinical Immunology (EAACI) criteria. RESULTS A total of 1837 doses were administered to the 77 patients, with four adverse reactions being observed in three patients. Three reactions (0.16% of the administered doses) were local and immediate, while one was systemic and of grade 2 (0.05% of the administered doses) - consisting of an episode of nocturnal wheezing. CONCLUSIONS Specific immunotherapy in children under five years of age with the extract used is safe. We consider that further studies are needed, involving other types of extracts, to allow reconsideration of the relative contraindication of patient age for the administration of immunotherapy.
Collapse
MESH Headings
- Animals
- Antigens, Dermatophagoides/administration & dosage
- Antigens, Dermatophagoides/adverse effects
- Antigens, Dermatophagoides/chemistry
- Asthma/complications
- Asthma/drug therapy
- Asthma/immunology
- Asthma/physiopathology
- Child, Preschool
- Complex Mixtures/administration & dosage
- Complex Mixtures/adverse effects
- Complex Mixtures/chemistry
- Dermatophagoides pteronyssinus
- Desensitization, Immunologic
- Female
- Follow-Up Studies
- Glutaral/chemistry
- Humans
- Immunoglobulin E/immunology
- Infant
- Male
- Pigments, Biological/chemistry
- Pigments, Biological/metabolism
- Polymerization
- Retrospective Studies
- Rhinitis, Allergic, Perennial/complications
- Rhinitis, Allergic, Perennial/drug therapy
- Rhinitis, Allergic, Perennial/immunology
- Rhinitis, Allergic, Perennial/physiopathology
Collapse
Affiliation(s)
- N Hernández
- Allergy Unit, Terrassa Hospital, Barcelona (Spain)
| | | | | | | | | | | |
Collapse
|
42
|
Passalacqua G, Canonica GW. Specific immunotherapy in asthma: efficacy and safety. Clin Exp Allergy 2011; 41:1247-55. [PMID: 21255159 DOI: 10.1111/j.1365-2222.2010.03688.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The use of specific immunotherapy (SIT) to treat asthma has been, and still is, a matter of debate, and there are no clear or unequivocal indications in the official documents. This is partly due to the fact that there are few studies specifically designed to assess asthma, that none of such studies had a formal sample size calculation, and that objective parameters of pulmonary function have been assessed only sporadically. Nonetheless, there are good quality studies for both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) where asthma symptoms were evaluated, and showing positive results. Moreover, several favourable meta-analyses are available, although their validity is limited by the great heterogeneity of the trials included. The disease modifying effect of SIT, that is the capacity of preventing asthma onset should be also taken into account. Concerning the safety, fatalities seem to be an exceptional event and in Europe no fatality has been reported over the last two decades. Uncontrolled asthma is universally recognized as the most important risk factor for severe adverse events. In conclusion both SLIT and SCIT can be used in asthma associated with rhinitis (which is the most common condition), provided that asthma is adequately controlled by pharmacotherapy. In such case, a measurable clinical benefit on asthma symptoms can be expected. On the other hand, SIT cannot be presently recommended as single therapy when asthma is the unique manifestation of respiratory allergy.
Collapse
Affiliation(s)
- G Passalacqua
- Allergy and Respiratory Diseases, University Of Genoa, Genoa, Italy.
| | | |
Collapse
|
43
|
Cox L, Calderon MA. Subcutaneous specific immunotherapy for seasonal allergic rhinitis: a review of treatment practices in the US and Europe. Curr Med Res Opin 2010; 26:2723-33. [PMID: 20979432 DOI: 10.1185/03007995.2010.528647] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Subcutaneous specific immunotherapy (SCIT) is claimed to be successful both in the US and Europe, yet treatment methodology differs. METHODS The authors review current literature surrounding guidelines and clinical trials in Europe and the US and contrast the treatment approach to SCIT for allergic rhinitis. Search methodology employs MEDLINE and PubMed, selecting articles on SCIT and allergic rhinitis, limited between 1990-2009. They focus on the safety and efficacy of vaccines, and the differences in formulations. Also mentioned are: standardization, new approaches in SCIT and sublingual immunotherapy (SLIT). RESULTS SCIT treatment differs in many respects regarding availability of SCIT products, regulatory controls, guidelines (e.g. multiple allergen vaccines in US, single allergen vaccines in Europe) and in location of formulation (US, clinician's office; Europe, manufacturers). CONCLUSIONS SCIT is an effective and safe therapy, but major evidence for efficacy is provided from European studies of single allergen extract vaccines; these vaccines may gain more acceptance because of increasing regulatory approval and lower numbers of injections. The potential impact upon public health (e.g. arrest of the 'allergic march') should not be overlooked.
Collapse
MESH Headings
- Administration, Sublingual
- Allergens/administration & dosage
- Clinical Trials as Topic
- Desensitization, Immunologic/methods
- Desensitization, Immunologic/statistics & numerical data
- Europe/epidemiology
- Humans
- Immunotherapy/methods
- Injections, Subcutaneous
- Professional Practice/statistics & numerical data
- Rhinitis, Allergic, Seasonal/epidemiology
- Rhinitis, Allergic, Seasonal/immunology
- Rhinitis, Allergic, Seasonal/therapy
- United States/epidemiology
- Vaccines/administration & dosage
Collapse
Affiliation(s)
- Linda Cox
- Nova Southeastern University Osteopathic College of Medicine, Florida, USA.
| | | |
Collapse
|
44
|
Pfaar O, Robinson DS, Sager A, Emuzyte R. Immunotherapy with depigmented-polymerized mixed tree pollen extract: a clinical trial and responder analysis. Allergy 2010; 65:1614-21. [PMID: 20645937 DOI: 10.1111/j.1398-9995.2010.02413.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Rhinoconjunctivitis because of tree pollen sensitization is common in Northern Europe. Specific subcutaneous immunotherapy (SCIT) is the only disease-modifying treatment, but unmodified allergen extracts carry a risk of allergic side-effects. Our objective was to examine efficacy and safety of a depigmented-polymerized mixed tree pollen extract. METHODS A double-blind, placebo-controlled trial of 184 tree pollen allergic adults was performed. SCIT consisted of four increasing doses at 7-day intervals, then maintenance injections every 6 weeks for 18 months. Primary outcome was combined symptom and medication score during the 2008 season. Secondary outcomes included analysis at different levels of pollen exposure and a responder analysis. Adverse events were classified using the EAACI scale. Birch pollen-specific IgE and IgG(4) were measured before and after treatment. RESULTS The combined symptom and medication score of actively treated patients was significantly lower than those on placebo (P < 0.04). Increased efficacy was seen at high pollen exposure (median score 2.1 for active [IQR 0.7-3.4] vs 4.2 [IQR 2.4-5.3] for placebo for days with 500 or more pollen grains per m(3) , a 50% reduction, P < 0.01). A modified responder analysis revealed 64% responders in the active and 32% in the placebo group (P < 0.01). There were 17 systemic reactions. All were mild (grade 1 or 2) and required no treatment. Serum birch-specific IgG(4) increased in the SCIT group (P < .01). CONCLUSIONS SCIT with depigmented- polymerized tree pollen extract was clinically effective and well tolerated. Responder analysis suggested that one-third of patients treated with immunotherapy may not respond.
Collapse
Affiliation(s)
- O Pfaar
- Center for Rhinology and Allergology Wiesbaden, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Germany.
| | | | | | | |
Collapse
|
45
|
Höiby AS, Strand V, Robinson DS, Sager A, Rak S. Efficacy, safety, and immunological effects of a 2-year immunotherapy with Depigoid birch pollen extract: a randomized, double-blind, placebo-controlled study. Clin Exp Allergy 2010; 40:1062-70. [PMID: 20642579 DOI: 10.1111/j.1365-2222.2010.03521.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Rhinoconjunctivitis due to birch pollen sensitization is common in Northern Europe. A depigmented polymerized birch pollen extract - Depigoid has been developed for immunotherapy. OBJECTIVE To evaluate its clinical efficacy, safety, and effects on immunological parameters. METHODS Sixty-one patients aged 7-69 years were included in a randomized, double-blind, placebo-controlled trial of subcutaneous immunotherapy (SCIT) using depigmented polymerized birch pollen extract. SCIT consisted of four increasing doses at 7-day intervals, followed by maintenance injections of 500 DPP (corresponding to 30 microg Bet v1 before depigmentation) at 6-week intervals for 18 months. The primary outcome was the combined symptom and medication score during the 2006 birch pollen season. The frequency of peripheral blood mononuclear cells (PBMC)producing IL-4, IL-10, IL-12, and IL-13 was assessed in a subgroup of patients by ELISPOT assay. RESULTS After 18 months of treatment, the median combined symptom and medication score (upper/lower quartile) of treated patients was significantly lower than those on placebo: 8.0 (5.8-10.3) and 12.6 (8.6-16.2), respectively (P=0.004). Systemic reactions occurred in 29 patients (12 active, 17 placebo), were grades 1 or 2, and none required specific treatment. After 18 months of treatment, mean serum concentrations of specific IgE increased significantly in both groups (P<0.0001) whereas serum concentrations of both specific IgG1 and IgG4 only increased significantly in the SCIT group (P=0.002) and not in the placebo group. The seasonal increase in numbers of IL-4- and IL-13-producing PBMC was blunted by immunotherapy. CONCLUSIONS SCIT with depigmented polymerized birch pollen extract significantly reduced symptom and medication scores when compared with the placebo, was well tolerated, and resulted in immunological changes comparable with those of native pollen extracts.
Collapse
Affiliation(s)
- A-S Höiby
- Asthma and Allergy Research Group, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Göteborg, Sweden
| | | | | | | | | |
Collapse
|
46
|
Rogala B, Glück J. Risks and benefits of allergen immunotherapy. Expert Opin Drug Saf 2010; 8:253-6. [PMID: 19432555 DOI: 10.1517/14740330802457208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
47
|
Pfaar O, Klimek L, Sager A, Bräutigam M. Safety of a depigmented, polymerized vaccine for the treatment of allergic rhinoconjunctivitis and allergic asthma. Am J Rhinol Allergy 2010; 24:220-5. [PMID: 20167138 DOI: 10.2500/ajra.2010.24.3437] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Clinical efficacy of specific immunotherapy (SIT) with depigmented, polymerized allergen extracts is well documented in placebo-controlled trials, and safety data are encouraging although further data are required. METHODS We enrolled 768 patients (51% men; mean age, 31 years) in this prospective multicenter study on safety and clinical effects of Depigoid (Laboratorios LETI, S.L., Madrid, Spain). Immunotherapy consisted of four injections of increasing doses of Depigoid at weekly intervals followed by monthly maintenance injections. All adverse events were documented. Moreover, nose, eye, and lung symptoms were assessed at baseline after 3 and 6 months. Results were compared with the scores of the preceding season. RESULTS Rates for local and systemic reactions that might possibly be related to the study medication were 2.36 and 4.56/1000 injections, respectively. With 5923 injections given, 14 local reactions were reported (5 patients), and 27 systemic reactions were reported, including 20 of grade 1 (6 patients) and 7 of grade 2 (4 patients). The best safety profile was seen for patients vaccinated against house-dust mites. Reductions in nose, eye, and lung symptoms as well as in concomitant medication compared with either the preceding season (pollen-sensitized patients) or the baseline (house-dust mite-sensitized patients) were observed at the end of study. CONCLUSION In this large multicenter study on 768 patients with allergic rhinoconjunctivitis and allergic asthma under daily practice conditions SIT with Depigoid was well tolerated with low rates of local and systemic reactions. Furthermore, SIT resulted in considerable reductions in symptoms and concomitant medication.
Collapse
Affiliation(s)
- Oliver Pfaar
- Center for Rhinology and Allergology, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, An den Quellen 10, Wiesbaden, Germany.
| | | | | | | |
Collapse
|
48
|
Affiliation(s)
- Kimihiro Okubo
- Department of Head & Neck and Sensory Organ Science, Graduate School of Medicine, Nippon Medical School
| | - Minoru Gotoh
- Department of Head & Neck and Sensory Organ Science, Graduate School of Medicine, Nippon Medical School
| |
Collapse
|
49
|
Klimek L, Thorn C, Pfaar O. Depigmentierte Allergoide für die allergenspezifische Immuntherapie. HNO 2009; 58:51-6. [DOI: 10.1007/s00106-009-2006-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
50
|
Ceuppens JL, Bullens D, Kleinjans H, van der Werf J. Immunotherapy with a modified birch pollen extract in allergic rhinoconjunctivitis: clinical and immunological effects. Clin Exp Allergy 2009; 39:1903-9. [DOI: 10.1111/j.1365-2222.2009.03379.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|