The allergic march in pollinosis: natural history and therapeutic implications

Dose-finding study of carbamylated monomeric allergoid tablets in grass-allergic rhinoconjunctivitis patients

AIM

To determine the optimal effective and safe dose of sublingual immunotherapy tablets containing carbamylated monomeric allergoids in patients with grass pollen-induced allergic rhinoconjunctivitis.

METHODS

In this prospective, randomized, double-blind, active-controlled, multicenter, Phase II study, four different daily doses were applied preseasonally for 12 weeks.

RESULTS

Of 158 randomized adults, 155 subjects (safety population) received 300 units of allergy (UA)/day (n = 36), 600 UA/day (n = 43), 1000 UA/day (n = 39), or 2000 UA/day (n = 37). After treatment, 54.3, 47.6, 59.0 and 51.4% of patients, respectively, ceased to react to the highest allergen concentration in a conjunctival provocation test. Furthermore, the response threshold improved in 70.4, 62.9, 76.7 and 66.7% of patients, respectively. No serious adverse events occurred.

CONCLUSION

This study found 1000 UA/day to be the optimal effective and safe dose.

Allergy immunotherapy: what is the evidence for cost saving?

PURPOSE OF REVIEW

Given the widespread prevalence of allergic disease, its substantially associated clinical and economic burden, the unique disease-modifying benefits of allergy immunotherapy (AIT), and increased availability of sublingual immunotherapy (SLIT), a critical update of the evidence for AIT-related cost savings [for both subcutaneous immunotherapy (SCIT) and SLIT] is particularly relevant and timely. The present article reviews the evidence for SCIT-related and SLIT-related cost savings derived from a systematic review of the published literature.

RECENT FINDINGS

Examined were 24 publications pertaining to the health economics of AIT. Except for one early study comparing the costs of AIT to symptomatic drug treatment (SDT), the remainder provide compelling evidence for AIT cost savings (whether SCIT or SLIT) over SDT. Furthermore, of the six studies comparing cost outcomes of SLIT to SCIT, four reported cost savings favoring SLIT.

SUMMARY

This review, spanning research from Southern Europe, Scandinavia, Northern Europe, North America, and the Czech Republic, encompasses a range of perennial and seasonal allergic conditions, including allergic asthma, allergic rhinitis with or without asthma, and rhinoconjunctivitis with or without allergic rhinitis due to house dust mite, grass or ragweed pollen, or a mixture of various allergens. All but one study compellingly demonstrate cost savings conferred by AIT over SDT.

A survey of the burden of allergic rhinitis in Hungary from a specialist's perspective

BACKGROUND

The casual and severity distribution of allergic rhinitis (AR) in Hungary is unknown.The aim of this survey was to evaluate symptom perception, disease severity, concomitant asthma frequency and the impact of AR on everyday life activities in a cross-sectional, multicenter study in Hungary under the supervision of Hungarian Respiratory Society.

METHODS

Data were recorded by 933 AR patients (65.93% women) and their treating specialists. The perceptions of patients regarding the symptoms (nasal, ocular and others) of AR and its severity, together with its impact on everyday life were assessed. Physicians recorded data regarding the diagnosis and severity of AR, and comorbidities.

RESULTS

52.5% of patients suffered from seasonal AR, 35.1% from perennial AR. A large proportion of patients had moderate to severe disease (MS-AR) (57.34%), persistent disease (98.0%) and concomitant asthma (53.32% in the mild, 57.52% in the MS-AR group). MS-AR was more frequent among women. Despite the treatment used, in MS-AR the proportions of patients reporting moderate to severe rhinorrhoea, nasal obstruction, ocular itching/redness, watering, itchy throat and sneezing were as high as 52.0%, 54.0%, 33.8%, 26.5%, 44.0% and 31.2%, respectively. Overall, there was a poor agreement between disease severity reported by patients and specialists. The adherence to oral antihistamines and intranasal corticosteroids was found to be between 50 and 65%; mostly depending on the dosage form.

CONCLUSIONS

AR remains a significant health problem in Hungary because of the burden of symptoms, high rate of concomitant asthma and the significant proportion of MS-AR affecting general well being.

Allergy immunotherapy among Medicaid-enrolled children with allergic rhinitis: patterns of care, resource use, and costs

BACKGROUND

Although research demonstrates that allergy immunotherapy (IT) improves allergic rhinitis (AR) outcomes, little is known about IT patterns of care and associated resource use and costs among US children with diagnoses of AR.

OBJECTIVE

We sought to examine characteristics associated with receiving IT, patterns of IT care, and health care use and costs incurred in the 6 months before versus after IT.

METHODS

We performed retrospective Florida Medicaid claims data (1997-2004) analysis of children (<18 years of age) given new diagnoses of AR.

RESULTS

Of 102,390 patients with new diagnoses of AR, 3048 (3.0%) received IT. Male patients, Hispanic patients, and those with concomitant asthma were significantly more likely to receive IT. Approximately 53% completed less than 1 year and 84% completed less than 3 years of IT. Patients who received IT used significantly less pharmacy (12.1 vs 8.9 claims, P < .0001), outpatient (30.7 vs 22.9 visits, P < .0001), and inpatient (1.2 vs 0.4 admissions, P = .02) resources in the 6 months after versus before IT. Pharmacy ($330 vs $60, P < .0001), outpatient ($735 vs $270, P < .0001), and inpatient ($2441 vs $1, P < .0001) costs (including costs for IT care) were significantly reduced after IT.

CONCLUSION

Despite suboptimal treatment persistence (only 16% of patients completed 3 years of IT), resource use and costs after treatment were significantly reduced from pre-IT levels.

A prospective study on the association between hay fever among children and incidence of asthma in East Germany

BACKGROUND

Aim of this study was to examine the effect of hay fever in childhood for asthma onset from childhood to adulthood in a prospective cohort of 3,199 asthma-free children, initially aged 5-13 years, which were followed for up to 12 years in East-Germany.

METHODS

Crude and adjusted incidence rate ratios (IRR) of asthma onset due to hay fever at baseline were calculated by a generalized estimation equation approach accounting for person years at risk, age at study entry, parental asthma, and gender.

RESULTS

Overall 142 incident cases of asthma were observed. Prevalence of hay fever at baseline was 4%. Crude and adjusted IRR were essentially the same and showed overall and in each age group a substantial higher risk of asthma onset due to hay fever. The adjusted IRR was 4 overall and ranged between 3 and 5 within the three age groups. Restricting the analysis to those participants, who were 17-25 years of age at the end of follow-up resulted in similar IRR.

CONCLUSION

Hay fever in childhood is a strong predictor of asthma onset later in life up to adulthood. The preventive potential of early and efficient treatment of allergic rhinitis to avoid asthma development needs to be investigated.

Stability of standardized grass, dust mite, cat, and short ragweed allergens after mixing with mold or cockroach extracts

BACKGROUND

Limited data are available on the immunochemical compatibilities of standardized and nonstandardized allergen extracts in immunotherapy vaccines. Extract combinations recommended in immunotherapy practice parameters are based primarily on theoretical considerations rather than on actual product compatibilities.

OBJECTIVES

To determine the stabilities of standardized grass, short ragweed, dust mite, and cat extracts after mixing with fungal and cockroach extracts at final product concentrations similar to those recommended for maintenance immunotherapy injections.

METHODS

Mixtures were prepared using individual products from multiple sources at variable glycerin concentrations and were analyzed after storage for up to 1 year at 2 degrees C to 8 degrees C. Quantitative analyses included radial immunodiffusion assays for cat Fel d 1 and short ragweed Amb a 1 and human IgE enzyme-linked immunosorbent assay inhibitions for meadow fescue grass and dust mite allergens. Immunoblot analyses provided qualitative patterns of IgE binding.

RESULTS

Meadow fescue grass allergens were unstable after mixing with fungal or cockroach extracts but were highly compatible with dust mite extracts from numerous commercial sources. Fescue and dust mite allergen recoveries varied considerably when mixed with different mold extracts. The presence of cockroach extracts reduced dust mite allergen potencies but retained moderate levels of cat and short ragweed allergen activities. In all cases examined, glycerin provided concentration-dependent improvements in allergen recoveries.

CONCLUSIONS

Several allergen extract combinations generally regarded as unstable by current practice parameters seem to possess considerable biochemical compatibilities. Use of these mixtures in immunotherapy vaccines is supported for practitioners seeking to optimize formulations, doses, and treatment regimens for their patients.

The type of sensitizing allergen can affect the evolution of respiratory allergy

BACKGROUND

Numerous factors affect the evolution of respiratory allergy, in children, but little is known in adults. We assessed in a prospective study the influence of the type of allergen on the progression of disease.

METHODS

Outpatients, with respiratory allergy underwent skin tests and pulmonary function/methacholine challenge at baseline and after 3 years. Patients were subdivided in pure rhinitis or rhinitis + bronchial hyperreactivity (BHR). In polysensitized subjects a single relevant allergen (mites, grasses, birch, Parietaria) was identified based on symptom distribution and when needed on nasal challenge.

RESULTS

6750 patients (age range 12-46) were studied. Of them, 17.8% were monosensitized but this percentage decreased to 10.4% after 3 years (P < 0.05). Subjects with pure rhinitis were 81% at the beginning and 48% at the end. After 3 years, the patients with bronchial responsiveness increased from 18% to 58% for mites, 22% to 49% for birch, 18% to 44% for grasses, 17% to 32% for Parietaria, with a significant difference among allergens (P < 0.05). Almost the same was seen in monosensitized subjects, being mites most likely to cause a worsening. All patients with BHR at baseline received immunotherapy. In these patients the onset of new sensitizations was significantly lower than in the group (pure rhinitis) receiving drugs only and lower airways symptoms disappeared more frequently.

CONCLUSION

The different type of allergen influences the course of the disease, as well as the use of immunotherapy.

Three-year follow-up of clinical and inflammation parameters in children monosensitized to mites undergoing sub-lingual immunotherapy

Parallel follow-up of clinical and inflammatory markers during sub-lingual immunotherapy (SLIT) is highly beneficial. Twenty-four children (age 4-16) monosensitized to house dust mite were randomized to receive either active or placebo SLIT for 1 yr in a double-blind placebo controlled design (Marcucci et al., Allergy 2003: 58: 657-62). Thereafter, for 2 yr they all received active treatment. Symptom scores for rhinitis, asthma, and drug usage were daily recorded. Eosinophil cationic protein (ECP) and tryptase in sputum and nasal secretions, serum and nasal mite-specific immunoglobulin E (IgE) were recorded before treatment and at 10-12 months intervals. Nasal ECP and nasal tryptase after specific nasal provocation tests were significantly reduced as compared to baseline values (p = 0.0043 and 0.0195, respectively) in the third year of active treatment. None of the other inflammatory parameters was increased. In placebo treated patients all these parameters tended to decrease only after switching to active treatment. Clinical scores did not improve in treated vs. placebo patients in the double-blind placebo-controlled phase of the study. In both cohorts a clinical benefit was observed as intra-group score reduction as compared to baseline. A significant difference was reached in patients treated for 2 yr for rhinitis and asthma (p = 0.0009 and 0.0019, respectively) but not for drug usage and in patients treated for 3 yr for rhinitis, asthma, and drug usage (p = 0.0105, 0.0048, and 0.02, respectively). SLIT in children monosensitized to mites reverted the spontaneous increase in nasal IgE and in local parameters of allergic inflammation. These outcomes were followed by a consolidated clinical improvement in the second and third year of treatment.