Premedication with Montelukast Reduces Local Reactions of Allergen Immunotherapy

Clinical manifestations of wasp stings: a case report and a review of literature

Background

Wasp stinging, a neglected tropical entity can have a myriad of local and systemic effects. We present a case of multi-organ injury following multiple wasp stings and a review of literature on the systemic manifestations of wasp stings.

Case presentation

A 48-year-old Sri Lankan male who suffered multiple wasp stings, developed an anaphylactic shock with respiratory failure, which was treated with adrenaline and mechanical ventilation. Within the next 2 days the patient developed acute fulminant hepatitis, stage III acute kidney injury, rhabdomyolysis, haemolysis and thrombocytopenia. The patient was treated in the intensive care unit with ionopressors and continuous renal replacement therapy (CRRT). Haemoadsorbant therapy was used in adjunct with CRRT. There was a gradual recovery of the organ functions over the 1st week. However, the patient succumbed to fungal sepsis on the 16th day despite treatment. We conducted a literature review to identify the various clinical manifestations of wasp stinging. Wasp venom contains enzymes, amines, peptides and other compounds. These proteins can cause type 1 hypersensitive reactions ranging from local skin irritation to anaphylactic shock. Furthermore, the toxins can cause direct organ injury or delayed hypersensitivity reactions. The commonly affected organs are the kidneys, liver, and muscles. The effect on the haematological system manifests as coagulopathy and/or cytopenia. The heart, nervous system, lungs, intestines and skin can be affected rarely. Treatment is mainly supportive.

Conclusion

In conclusion, wasp envenomation can result in multi-organ injury and attention should be paid in doing further research and establishing evidence-based treatment practices.

Oral Immunotherapy in Patients with IgE Mediated Reactions to Egg White: A Clinical Trial Study

BACKGROUND

Oral immunotherapy (OIT) is under consideration as a promising treatment for desensitization of egg-allergic patients. The objective of this study was to assess the effectiveness of egg-white OIT in patients with IgE-mediated allergy to egg white and to compare the clinical and laboratory findings before and after OIT.

METHODS

This clinical trial was performed from February to August 2018 in Rasool e Akram Hospital, Tehran, Iran. Patients' selection criteria included a history of allergic symptoms, skin prick test (SPT) reactivity to egg white, and the inability to pass the Oral Food Challenge (OFC). Egg-white OIT was done for eight patients in the OIT group for 6 months while egg-white-free products were administrated for controls. The SPT reactivity, specific IgE, and IgG4 for egg white and ovomucoid were evaluated before and after OIT.

RESULTS

Hundred percent of the subjects in OIT group were desensitized and tolerated 40 cc raw egg white following 6-month maintenance whereas none of the controls was able to pass the OFC. The findings obtained from the evaluations indicated a significant decrease in the wheal size and specific IgE to egg white after OIT (P = .001). Furthermore, a significant decrease of IgE/IgG4 ratio to egg white was found in OIT group (P = .01).

CONCLUSION

This OIT protocol was successful as all OIT patients were able to continue 6-month OIT process and the reaction threshold to egg white increased in the OIT group. Therefore, it could be regarded as an effective and safe protocol to treat egg-allergic patients.

Antihistamine premedication improves safety and efficacy of allergen immunotherapy

BACKGROUND

Allergen immunotherapy (AIT)-associated adverse events are a major concern for safety and efficacy of AIT. Presently, there is no consensus to whether antihistamine premedication could improve such conditions.

OBJECTIVE

To identify the superiority of antihistamine pretreatment in AIT.

METHODS

A comprehensive literature search for randomized controlled trials reporting the effects of antihistamine premedication on safety and efficacy of AIT was performed in MEDLINE, Embase, and Cochrane Library databases. Safety was evaluated according to the number of patients reporting systemic adverse reactions (SARs, the primary outcome) and efficacy according to the number of patients achieving target maintenance dose (TMD) and sustained unresponsiveness to allergen.

RESULTS

A total of 11 randomized controlled trials (including 609 patients) satisfied the inclusion criteria for the meta-analysis. All premedication protocols were temporary. Pooled analysis revealed that compared with control patients, significantly fewer antihistamine-pretreated patients reported total and moderate-to-severe SARs (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.23-0.56; P < .05 and OR, 0.20; 95% CI, 0.06-0.74; P < .05, respectively) and total and moderate-to-severe SAR episodes (OR, 0.42; 95% CI, 0.34-0.53; P < .05 and OR, 0.09; 95% CI, 0.01-0.50; P < .05, respectively). Similarly, antihistamine pretreatment significantly increased the number of patients achieving TMD (OR, 2.94; 95% CI, 1.72-5.03; P < .05), but not sustained unresponsiveness (OR, 1.65; 95% CI, 0.77-3.54; P = 0.2), compared with the control group. Subgroup analysis according to different allergens and dose-escalating approaches also displayed superiority of antihistamine pretreatment than control.

CONCLUSION

Antihistamine premedication can markedly improve safety and efficacy of AIT by reducing frequency and severity of SAR and increasing TMD.

Adverse reactions to subcutaneous immunotherapy in patients with allergic rhinitis, a real-world study

PURPOSE

The efficacy of subcutaneous immunotherapy (SCIT) for allergic rhinitis (AR) have been proven but application is still limited by concerns about the safety. The aims of this study were to investigate the incidence of adverse reactions and to ascertain possible risk factors in patients treated with SCIT in central China.

METHODS

This study retrospectively analyzed the application of SCIT from 2016 to 2018, in 236 patients with AR. After each injection, allergen dosage and details about local reactions (LRs)/systemic reactions (SRs) were recorded.

RESULTS

Totaling 236 patients received 5844 injections. The rates of LR were 3.0% per injection and 34.7% per patient, while the rates of SR were 0.48% per injection and 10.6% per patient. 86.9 percent LRs were small. Most SRs were grade 1 (16/57.1%), followed by grade 2 (8/28.6%), grade 3 (4/14.3%). No fatal SRs was recorded. Children, high sensitization and absence of premedication were identified as risk factors for LRs. Recurrent LRs increased the risk of SRs. Premedication could reduce the number and severity of LRs, but not SRs. Dual therapy with antihistamine and montelukast did not provide additional benefit when compared with antihistamine alone.

CONCLUSION

The incidence of SRs was low while LRs were common in SCIT. Children may be prone to develop LRs, while pretreatments could reduce the number and severity of LRs. Recurrent LRs was a risk factor for SRs.

Venom Immunotherapy: Questions and Controversies

Questions and controversies regarding venom immunotherapy (VIT) remain. It is important to recognize risk factors for severe sting anaphylaxis that guide the recommendation for testing, epinephrine injectors, and VIT. Premedication, rush VIT, and omalizumab are successful in overcoming recurrent systemic reactions to VIT. A maintenance dose is adequate in children, but higher doses are needed in high-risk patients. The consensus on risk of β-blockers and angiotensin-converting enzyme inhibitors in patients on VIT has shifted to the belief that risk is small. The decision to stop VIT after 5 years rests on known risk factors rather than any diagnostic tests.

Comparison of adverse events between cluster and conventional immunotherapy for allergic rhinitis patients with or without asthma: A systematic review and meta-analysis

BACKGROUND

Cluster schedule of allergen-specific immunotherapy (AIT) is a cost-effective choice for allergic rhinitis (AR) patients, but its safety has been questioned due to the greater dosages required at each treatment compared with conventional immunotherapy. It remains a question that whether cluster schedule leads to a higher risk of side effects.

OBJECTIVE

This study was designed to update the evidence and investigate whether cluster schedule leads to a higher risk of local adverse reactions (LARs) and systemic adverse reactions (SARs) than cluster schedule does.

METHODS

We searched the Cochrane Central Register of Controlled Trials, EMBASE and Medline thoroughly and included studies comparing cluster and conventional schedules. A meta-analysis of 5 outcomes related to adverse events was performed after bias and heterogeneity assessments. And as a result of language limitations, we considered only articles in Chinese and English.

RESULTS

5 observational studies and 6 interventional studies were included in the meta-analysis. There were no differences between cluster and conventional schedules when analyzing SARs by the number of patients, delayed SARs, grade 2 SARs and LARs. Analyses of SARs by injection, grade 1 SARs and LARs by injection in observational studies showed that cluster schedule had a lower risk of adverse events than did conventional schedule.

CONCLUSION

Our data suggest that cluster schedule is as safe as or even safer than conventional schedule for AR patients with or without asthma (AS).

Chinese Society of Allergy Guidelines for Diagnosis and Treatment of Allergic Rhinitis

Allergic rhinitis (AR) is a global health problem that causes major illnesses and disabilities worldwide. Epidemiologic studies have demonstrated that the prevalence of AR has increased progressively over the last few decades in more developed countries and currently affects up to 40% of the population worldwide. Likewise, a rising trend of AR has also been observed over the last 2-3 decades in developing countries including China, with the prevalence of AR varying widely in these countries. A survey of self-reported AR over a 6-year period in the general Chinese adult population reported that the standardized prevalence of adult AR increased from 11.1% in 2005 to 17.6% in 2011. An increasing number of Journal Articles and imporclinical trials on the epidemiology, pathophysiologic mechanisms, diagnosis, management and comorbidities of AR in Chinese subjects have been published in international peer-reviewed journals over the past 2 decades, and substantially added to our understanding of this disease as a global problem. Although guidelines for the diagnosis and treatment of AR in Chinese subjects have also been published, they have not been translated into English and therefore not generally accessible for reference to non-Chinese speaking international medical communities. Moreover, methods for the diagnosis and treatment of AR in China have not been standardized entirely and some patients are still treated according to regional preferences. Thus, the present guidelines have been developed by the Chinese Society of Allergy to be accessible to both national and international medical communities involved in the management of AR patients. These guidelines have been prepared in line with existing international guidelines to provide evidence-based recommendations for the diagnosis and management of AR in China.

A Novel Pretreatment Regimen for Breakthrough Radiocontrast Media Anaphylaxis in Cardiac Patients

BACKGROUND

Radiocontrast media allergy is a severe and potentially life-threatening condition. This creates a clinical dilemma for cardiac patients who require urgent interventions with radiocontrast media. Several pretreatment regimens have been suggested for patients with prior immediate hypersensitivity reactions to radiocontrast media. Despite using pretreatment regimens, breakthrough reactions have been reported in 2.1%-18% of patients with radiocontrast media allergy. Little is known about management of patients with a history of breakthrough radiocontrast media anaphylaxis who require urgent lifesaving procedures.

METHODS

We report a retrospective analysis of 2 cardiac cases with a history of breakthrough radiocontrast media anaphylaxis despite standard pretreatment. These patients required urgent cardiac intervention with the use of radiocontrast media.

RESULTS

We present a novel pretreatment regimen for high-risk cardiac patients with breakthrough radiocontrast media anaphylaxis despite prior pretreatment who need urgent coronary interventions.

CONCLUSION

This protocol is both safe and effective in mitigating anaphylaxis in cardiac patients.

Allergen-specific immunotherapy of Hymenoptera venom allergy - also a matter of diagnosis

Stings of hymenoptera can induce IgE-mediated hypersensitivity reactions in venom-allergic patients, ranging from local up to severe systemic reactions and even fatal anaphylaxis. Allergic patients' quality of life can be mainly improved by altering their immune response to tolerate the venoms by injecting increasing venom doses over years. This venom-specific immunotherapy is highly effective and well tolerated. However, component-resolved information about the venoms has increased in the last years. This knowledge is not only able to improve diagnostics as basis for an accurate therapy, but was additionally used to create tools which enable the analysis of therapeutic venom extracts on a molecular level. Therefore, during the last decade the detailed knowledge of the allergen composition of hymenoptera venoms has substantially improved diagnosis and therapy of venom allergy. This review focuses on state of the art diagnostic and therapeutic options as well as on novel directions trying to improve therapy.

Evidence in immunotherapy for paediatric respiratory allergy: Advances and recommendations

Allergic respiratory diseases are major health problems in paediatric population due their high level of prevalence and chronicity, and to their relevance in the costs and quality of life. One of the most important risk factors for the development of airway diseases in children and adolescents is atopy. The mainstays for the treatment of these diseases are avoiding allergens, controlling symptoms, and preventing them through sustained desensitization by allergen immunotherapy (AIT). AIT is a treatment option that consists in the administration of increasing amounts of allergens to modify the biological response to them, inducing long-term tolerance even after treatment has ended. This treatment approach has shown to decrease symptoms and improve quality of life, becoming cost effective for a large number of patients. In addition, it is considered the only treatment that can influence the natural course of the disease by targeting the cause of the allergic inflammatory response. The aim of this publication is to reflect the advances of AIT in the diagnosis and treatment of allergic respiratory diseases in children and adolescents reviewing articles published since 2000, establishing evidence categories to support the strength of the recommendations based on evidence. The first part of the article covers the prerequisite issues to understand how AIT is effective, such as the correct etiologic and clinical diagnosis of allergic respiratory diseases. Following this, the article outlines the advancements in understanding the mechanisms by which AIT achieve immune tolerance to allergens. Administration routes, treatment regimens, dose and duration, efficacy, safety, and factors associated with adherence are also reviewed. Finally, the article reviews future advances in the research of AIT.

Immunotherapy: a new horizon for egg allergy?

Egg allergy is the second most frequent food allergy in children of the Western Countries, with an overall prevalence of 1-3%. Today strict avoidance diet is the only treatment, but its feasibility is difficult to obtain in childhood because of the large amount of egg proteins present in different foods. From 1998, a growing number of protocols on immunotherapy for egg allergy have been published, but all of them differ for patients' age, inclusion of high-risk patients, amount of allergen administered, duration of the protocols and presence of a control group. We reviewed the protocols performed in the last 15 years, to underline the most important issues in this kind of food immunotherapy, and the rates of tolerance or desensitization induction.

Accelerated immunotherapy schedules

Rush and cluster immunotherapy schedules are accelerated immunotherapy build-up schedules. A cluster immunotherapy schedule involves the patient receiving several allergen injections (generally 2-4) sequentially in a single day of treatment on nonconsecutive days. The maintenance dose is generally reached in 4-8 weeks. In rush immunotherapy protocols, higher doses are administered at 15- to 60-min intervals over a 1- to 3-day period until the maintenance dose is achieved. This review will serve as an update for accelerated immunotherapy schedules. The review will include recent investigations demonstrating the safety of cluster schedules in atopic dermatitis, pediatric patients, and inhalant allergen mixtures and an accelerated protocol utilizing an infusion pump for allergen delivery. There has also been further elucidation on the immunological changes which occur during accelerated immunotherapy. Finally, new studies analyzing systemic reaction risk factors are discussed.

A 1-day imported fire ant rush immunotherapy schedule with and without premedication

BACKGROUND

Rush immunotherapy (RIT) schedules can expedite protection in individuals sensitive to imported fire ant (IFA) stings.

OBJECTIVE

To evaluate the safety and efficacy of 1-day RIT with IFA whole body extract (WBE) and determine the benefit of premedication with antihistamines and prednisone.

METHODS

Patients with systemic reactions to IFAs and evidence of specific IgE by skin test or serologic test started a 1-day RIT protocol without premedication. The 1-day RIT protocol consisted of a total of 10 injections every 30 to 60 minutes to achieve a 0.3-mL 1:100 (wt/vol) dose. A higher systemic reaction rate (SRR) prompted protocol revision to include a 3-day course of oral 20 mg of prednisone twice daily, 150 mg of ranitidine, and 10 mg of loratadine started 2 days before the 1-day RIT. Patients returned on days 8 and 15 to receive a 0.5 mL 1:100 (wt/vol) maintenance injection. The effectiveness of the RIT was evaluated with a sting challenge on approximately day 22.

RESULTS

Eighty of the 96 patients enrolled initiated the 1-day RIT. The first nonpremedicated group exhibited a SRR of 24.3% (9 of 37 patients), whereas the revised premedicated group had a SRR of 9.5% (4 of 42 patients; P = .07). The most severe reaction during RIT included dizziness, angioedema, and urticaria. Sting challenges on 53 patients resulted in 1 mild rhinitis reaction (efficacy, 98.1%).

CONCLUSION

One-day RIT with IFA WBE for IFA hypersensitivity is efficacious. Although there was a trend with premedications to reduce SRRs during the RIT, safety data with premedication require confirmation in a larger trial.

Venom immunotherapy for preventing allergic reactions to insect stings

BACKGROUND

Venom immunotherapy (VIT) is commonly used for preventing further allergic reactions to insect stings in people who have had a sting reaction. The efficacy and safety of this treatment has not previously been assessed by a high-quality systematic review.

OBJECTIVES

To assess the effects of immunotherapy using extracted insect venom for preventing further allergic reactions to insect stings in people who have had an allergic reaction to a sting.

SEARCH METHODS

We searched the following databases up to February 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE (from 1946), EMBASE (from 1974), PsycINFO (from 1806), AMED (from 1985), LILACS (from 1982), the Armed Forces Pest Management Board Literature Retrieval System, and OpenGrey. There were no language or publication status restrictions to our searches. We searched trials databases, abstracts from recent European and North American allergy meetings, and the references of identified review articles in order to identify further relevant trials.

SELECTION CRITERIA

Randomised controlled trials of venom immunotherapy using standardised venom extract in insect sting allergy.

DATA COLLECTION AND ANALYSIS

Two authors independently undertook study selection, data extraction, and assessment of risk of bias. We identified adverse events from included controlled trials and from a separate analysis of observational studies identified as part of a National Institute for Health and Clinical Excellence Health Technology Assessment.

MAIN RESULTS

We identified 6 randomised controlled trials and 1 quasi-randomised controlled trial for inclusion in the review; the total number of participants was 392. The trials had some risk of bias because five of the trials did not blind outcome assessors to treatment allocation. The interventions included ant, bee, and wasp immunotherapy in children or adults with previous systemic or large local reactions to a sting, using sublingual (one trial) or subcutaneous (six trials) VIT. We found that VIT is effective for preventing systemic allergic reaction to an insect sting, which was our primary outcome measure. This applies whether the sting occurs accidentally or is given intentionally as part of a trial procedure.In the trials, 3/113 (2.7%) participants treated with VIT had a subsequent systemic allergic reaction to a sting, compared with 37/93 (39.8%) untreated participants (risk ratio [RR] 0.10, 95% confidence interval [CI] 0.03 to 0.28). The efficacy of VIT was similar across studies; we were unable to identify a patient group or mode of treatment with different efficacy, although these analyses were limited by small numbers. We were unable to confirm whether VIT prevents fatal reactions to insect stings, because of the rarity of this outcome.Venom immunotherapy was also effective for preventing large local reactions to a sting (5 studies; 112 follow-up stings; RR 0.41, 95% CI 0.24 to 0.69) and for improving quality of life (mean difference [MD] in favour of VIT 1.21 points on a 7-point scale, 95% CI 0.75 to 1.67).We found a significant risk of systemic adverse reaction to VIT treatment: 6 trials reported this outcome, in which 14 of 150 (9.3%) participants treated with VIT and 1 of 135 (0.7%) participants treated with placebo or no treatment suffered a systemic reaction to treatment (RR 8.16, 95% CI 1.53 to 43.46; 2 studies contributed to the effect estimate). Our analysis of 11 observational studies found systemic adverse reactions occurred in 131/921 (14.2%) participants treated with bee venom VIT and 8/289 (2.8%) treated with wasp venom VIT.

AUTHORS' CONCLUSIONS

We found venom immunotherapy using extracted insect venom to be an effective therapy for preventing further allergic reactions to insect stings, which can improve quality of life. The treatment carries a small but significant risk of systemic adverse reaction.

Efficacy of venom immunotherapy given every 3 or 4 months: a prospective comparison with the conventional regimen

BACKGROUND

Standard venom immunotherapy involves the administration of the maintenance dose every 4 to 6 weeks. This regimen may have adherence problems, especially in the long term; thus, extended intervals have been proposed.

OBJECTIVE

We prospectively compared the efficacy of 3- or 4-month extended maintenance dose vs the conventional regimen.

METHODS

Patients receiving immunotherapy with a single venom were offered the extended maintenance dose (EMD) and were then followed up for field re-stings. Only the re-stings by the insect for which the patients received immunotherapy were considered. A comparable group of patients receiving the conventional maintenance dose (CMD) was used for comparison by logistic regression analysis.

RESULTS

Seventy-six patients (60 male; mean age, 48 years) receiving the EMD were re-stung on 247 occasions by the insect for which they were receiving immunotherapy. The group receiving CMD included 110 patients (82 male; mean age, 44 years) certainly re-stung on 167 occasions by the specific insect. The percentage of re-sting without reaction was 93.5% in the EMD group and 81.5% in the CMD group, with a significant difference in favor of the former (P=.001). At logistic regression analysis, only age, but not maintenance dose protocol, was predictive of subsequent systemic reactions.

CONCLUSION

The EMD is as effective and safe as the CMD. An increased maintenance seems to be the best option in term of convenience and economic savings.

Anaphylaxis on reperfusion during liver transplantation with coagulopathy

We present a case in which anaphylaxis on hepatic reperfusion during liver transplantation presented only with hypotension and coagulopathy. There were no cutaneous manifestations or clinical features distinguishing anaphylaxis from postreperfusion syndrome. The recipient regularly consumed seafood, and the organ donor died of anaphylaxis to shellfish. The trigger for anaphylaxis was postulated to be passive transfer of immunoglobulin to the recipient. Anesthesiologists should be notified of donor factors to anticipate anaphylaxis. In this report, we discuss coagulopathy of anaphylaxis and contrast it with disseminated intravascular coagulation.

Safety of allergen immunotherapy: a review of premedication and dose adjustment

From the first allergen immunotherapy proposed in the early 1900s to the present day, numerous studies have proven the efficacy of allergen immunotherapy for the treatment of allergic rhinitis, allergic conjunctivitis, allergic asthma and stinging insect hypersensitivity. The major risk, however small, with allergen immunotherapy is anaphylaxis. There has been considerable interest and debate regarding risk factors for immunotherapy reactions (local and systemic) and interventions to reduce the occurrence of these reactions. One of these interventions that is especially debated regards dose adjustment for various reasons, but in particular for local reactions. In this review, we discuss the safety of immunotherapy and provide a comprehensive review of the literature regarding immunotherapy schedules and doses.

[Pharmacoprophylaxis and co-medications in allergen-specific immunotherapy]

Drugs that are used in relation to allergen-specific immunotherapy (SIT) can be separated into pharmacoprophylaxis to avoid or decrease local and systemic adverse effects of SIT and in co-medications to treat other diseases. Regarding pharmacoprophylaxis, H1-antihistamines are able to reduce local and mild systemic, but not severe systemic side effects of SIT. H1-antihistamines do not attenuate the efficacy of SIT. Severe systemic side effects have been blocked in some cases with omalizumab; currently this agent can be used off-label during venom SIT. With regard to co-medication, the concomitant use of immunomodulating drugs during SIT must be individualized, if the effective profile and side effects of the immunomodulating drug are well-known and a negative effect on SIT is not likely. Recently approved immunosuppressive drugs and biologics are perceived critically due to their unpredictable immunologic effects. For forensic reasons cardioselective beta blockers should be discontinued although no data are available demonstrating adverse effects. If discontinuation is not justified and venom SIT is indicated, SIT can be performed while taking beta blockers. In contrast, ACE-inhibitors should always be stopped in patients with insect venom allergy.

Venom immunotherapy in patients with mastocytosis and hymenoptera venom anaphylaxis

Systemic mastocytosis (SM) is typically suspected in patients with cutaneous mastocytosis (CM). In recent years, the presence of clonal mast cells (MCs) in a subset of patients with systemic symptoms associated with MC activation in the absence of CM has been reported and termed monoclonal MC activation syndromes or clonal systemic MC activation syndromes. In these cases, bone marrow (BM) MC numbers are usually lower than in SM with CM, there are no detectable BM MC aggregates, and serum baseline tryptase is often <20 µg/l; thus, diagnosis of SM in these patients should be based on careful evaluation of other minor WHO criteria for SM in reference centers, where highly sensitive techniques for immunophenotypic analysis and investigation of KIT mutations on fluorescence-activated cell sorter-purified BM MCs are routinely performed. The prevalence of hymenoptera venom anaphylaxis (HVA) among SM patients is higher than among the normal population and it has been reported to be approximately 5%. In SM patients with IgE-mediated HVA, venom immunotherapy is safe and effective and it should be prescribed lifelong. Severe adverse reactions to hymenoptera stings or venom immunotherapy have been associated with increased serum baseline tryptase; however, presence of clonal MC has not been ruled out in most reports and thus both SM and clonal MC activation syndrome might be underdiagnosed in such patients. In fact, clonal BM MC appears to be a relevant risk factor for both HVA and severe reactions to venom immunotherapy, while the increase in serum baseline tryptase by itself should be considered as a powerful surrogate marker for anaphylaxis. The Spanish Network on Mastocytosis has developed a scoring system based on patient gender, the clinical symptoms observed during anaphylaxis and serum baseline tryptase to predict for the presence of both MC clonality and SM among individuals who suffer from anaphylaxis.

Malignancy and specific allergen immunotherapy: the results of a case series

BACKGROUND

Specific immunotherapy with allergen is the only causative treatment for IgE-mediated allergies such as stinging insect allergy or hay fever and works by the induction of blocking antibodies and regulatory T lymphocytes.

OBJECTIVE

Does a hypothetical obstruction of tumor surveillance presupposing the induction of regulatory T cells really justify detaining immunotherapy to oncologic patients as suggested by recent guidelines?

METHODS

We report 6 patients (4 female, 2 male) suffering or having suffered from stage 1 cancer (4 melanomas, 1 lung cancer, 1 breast cancer) and concomitant IgE-mediated allergy. Four of them had a history of severe anaphylactic reactions to the insect yellow jacket, the 5th suffered from allergic rhinoconjunctivitis to dust mites, and the 6th to grass/rye pollen.

RESULTS

Between 2004 and 2010, subcutaneous immunotherapy was safely performed in 5 patients without signs of tumor reactivation. The cancer in 2 of them was diagnosed immediately after specific immunotherapy had been initiated and in another 2 the active cancer phase had already finished years before; the 5th suffered from a relapse around the time of the initiation of immunotherapy. At the time of the writing of the manuscript, 4 of them had already concluded 3 years of treatment, another one almost 1 year. The melanoma in the 6th patient was diagnosed 5 months after reaching the maintenance dose. Immunotherapy with grass/rye pollen was aborted in this patient based on current guidelines.

CONCLUSIONS

Specific immunotherapy was safely administered in patients suffering concomitantly from IgE-mediated allergy and lower stage cancer.

How should allergists deal with local reactions to allergen immunotherapy?

Despite the well-known benefits of subcutaneous immunotherapy (SCIT), adverse reactions include both local reactions (LRs) and systemic reactions. An LR is a well-known adverse event associated with SCIT injections and is defined as any swelling located at or near the injection site following allergen injection. Concerns that LRs might predict systemic reactions have historically motivated allergists to dose adjust for LRs. More recent data have dispelled this notion, although many allergists continue to dose adjust for other reasons. This article discusses the historical response to LRs and dose adjustments and reviews the most recent literature addressing LRs to SCIT. Treatment options, although they are either unproven or not studied, are offered as an alternative to routine dose adjustments for LRs. Education remains the foundation of physician-patient communication concerning LRs.

Hymenoptera venom immunotherapy

Subcutaneous venom immunotherapy is the only effective treatment for patients who experience severe hymenoptera sting-induced allergic reactions, and the treatment also improves health-related quality of life. This article examines advances in various areas of this treatment, which include the immunological mechanisms of early and long-term efficacy, indications and contraindications, selection of venom, treatment protocols, duration, risk factors for systemic reactions in untreated and treated patients as well as for relapse following cessation of treatment. Current and future strategies for improving safety and efficacy are also examined. However, although progress in the past few years has been fruitful, much remains to be accomplished.

Stinging insect hypersensitivity: a practice parameter update 2011

These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Stinging insect hypersensitivity: a practice parameter update II." Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or the ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. These parameters are not designed for use by pharmaceutical companies in drug promotion. The Joint Task Force understands that the cost of diagnostic tests and therapeutic agents is an important concern that may appropriately influence the work-up and treatment chosen for a given patient. The Joint Task Force recognizes that the emphasis of our primary recommendations regarding a medication may vary, for example, depending on third party payer issues and product patent expiration dates. However, since a given test or agent's cost is so widely variable, and there is a paucity of pharmacoeconomic data, the Joint Task Force generally does not consider cost when formulating Practice Parameter recommendations. In extraordinary circumstances, when the cost benefit of an intervention is prohibitive as supported by pharmacoeconomic data, commentary may be provided.

The REPEAT study: recognizing and evaluating periodic local reactions in allergen immunotherapy and associated systemic reactions

BACKGROUND

prior studies have demonstrated that large local reactions (LLRs) to subcutaneous immunotherapy do not predict systemic reactions (SRs). However, a recent study demonstrated an increase in LLRs among systemic reactors in practices using routine local reaction dose adjustments.

OBJECTIVE

to investigate the association between LLRs and SRs within a practice that does not dose adjust for LLRs.

METHODS

we performed a retrospective analysis of an electronic immunotherapy database during a 12-month period at a single site that does not dose adjust for LLRs. An LLR was defined as larger than the size of the patient's palm measured at 30 minutes. Logistic regression was performed to investigate the association between SRs and LLRs after controlling for variable numbers of injections and visits among patients.

RESULTS

three hundred sixty patients received a total of 9,679 injections (6,609 visits). Twenty-four patients (6.7% of patients) experienced 38 LLRs (0.4% of injections, 0.6% of visits), whereas 46 patients (12.7% of patients) experienced 51 SRs (0.5% of injections, 0.77% of visits). Only 10 patients (2.8%) experienced both LLRs and SRs, and 36 of 46 SR patients (78.3%) never had an LLR. Among the 24 LLR patients, the SR rate was 1.3% (12/932) of injections and 2.0% (12/611) of visits compared with the 336 non-LLR patients for whom the SR rate was 0.4% (39/8,747) of injections and 0.7% (39/5998) of visits. Of these 24 LLR patients, 10 (41.7%) experienced at least 1 SR vs 36 of 336 non-LLR patients (10.7%). After controlling for number of injections and 1 vs 2 injections per visit, a subgroup of LLR patients were more likely to have an SR during their subcutaneous immunotherapy course (odds ratio, 4.7; 95% confidence interval, 1.9-11.7). Recurrent LLR patients (n = 10) were not more likely to experience an SR (0.4% per injection).

CONCLUSIONS

although LLRs do not predict SRs, a subgroup (41.7%) of LLR patients experience a higher frequency of SRs during their immunotherapy course. In light of a similar previous study, this association occurs irrespective of whether a dose adjustment protocol is used for LLRs.

Montelukast treatment may alter the early efficacy of immunotherapy in children with asthma

BACKGROUND

Allergen-specific immunotherapy (SIT) is the only available potentially curative approach in the management of allergic diseases. Therapies that boost regulatory T cell induction during SIT might further enhance its effectiveness.

OBJECTIVE

The purpose of this study was to assess the effect of montelukast treatment on early clinical and immunologic effects of allergen-specific immunotherapy in children with asthma.

METHODS

It was a randomized, double-blind, placebo-controlled trial conducted in 36 children with asthma and allergy to house dust mites who required from 400 to 800 microg of inhaled budesonide per day during the 7-month run-in period. Patients were randomly allocated to receive 5 mg montelukast daily (n = 18) or placebo (n = 18) as an addition to inhaled corticosteroid (ICS) treatment during the 3-month build-up phase of SIT, when modification of ICS doses was not allowed. During the 7 months of the maintenance phase of SIT, ICS doses were adjusted to control the asthma symptoms.

RESULTS

After 12 months of SIT, a reduction of the median daily ICS dose, necessary to control asthma symptoms, was 16.7% grater in patients from the placebo group than in patients from the montelukast group. Intervention with montelukast significantly impaired the induction of regulatory T lymphocytes. During the build-up phase of SIT, patients in the placebo group frequently experienced an increase in asthma symptoms leading to exclusions from the per protocol population.

CONCLUSION

Our study failed to show a beneficial effect of montelukast on SIT. In fact, quite the opposite occurred: compared with placebo, montelukast intervention led to less effectiveness of SIT.

Issues in stinging insect allergy immunotherapy: a review

PURPOSE OF REVIEW

The treatment of insect allergy by desensitization still continues to present with some unanswered questions. This review will focus mainly on articles that have dealt with these issues in the past 2 years.

RECENT FINDINGS

With the publication in 2007 of Allergen Immunotherapy: a practice parameter second update, many of the key issues were reviewed and summarized. Other recent studies deal with omalizumab pretreatment of patients with systemic mastocytosis and very severe allergic reactions to immunotherapy. It would appear that venom immunotherapy is somewhat unique compared to inhalant allergen immunotherapy in that premedication prior to rush protocols may not be necessary and that intervals of therapy may be longer than with allergen immunotherapy. The use of concomitant medications such as beta-blockers may be indicated in special situations. Angiotensin-converting enzyme inhibitors can be stopped temporarily before venom injections to prevent reactions. The issue of when to discontinue immunotherapy remains unsettled and should be individualized to patient requirements.

SUMMARY

The newest revision of the Immunotherapy Parameters provides much needed information concerning successful treatment with immunotherapy of Hymenoptera-sensitive patients.

A review of allergen-specific immunotherapy in human and veterinary medicine

This article reviews allergen-specific immunotherapy in human and veterinary medicine. Current hypotheses of possible mechanisms of actions are outlined. Indications, success rates, adverse effects and factors influencing outcome of therapy are discussed in humans, dogs, cats and horses.