A meta-analysis of sublingual allergen immunotherapy and pharmacotherapy in pollen-induced seasonal allergic rhinoconjunctivitis

Allergen Testing: A Review of the Indications, Procedures, and Limitations in Ocular Allergy

Allergen-based diagnostics are essential in the management algorithm of allergic diseases. Unlike systemic allergy, where the indications and interpretation of these diagnostic modalities are well established, their utility in ocular allergy is not well-defined. With the rising prevalence of ocular allergies and the need for personalized treatment strategies, there is a growing demand for precision allergen diagnostics. This review describes the commonly used tests with their indications, procedures, and limitations. A review of the literature was carried out on articles on allergen diagnostics in ocular allergy, and after excluding articles that were not relevant, 82 papers were included in the current review. IgE-mediated pathways contribute significantly to seasonal and perennial ocular allergy and partly to vernal keratoconjunctivitis. Most diagnostic techniques aim to detect IgE sensitization. In vivo tests include skin prick (SPT), intradermal, and patch tests. SPT is considered the gold standard and directly evaluates the presence of allergen-specific IgE in the skin. In vitro tests measure total and specific IgE from either tears or sera. Tear IgE measurement is relatively specific for allergic conjunctivitis and can provide insight into the potential allergens responsible for local sensitization. The conjunctival provocation test can help establish true allergy, especially in patients with polysensitization. This review also provides an overview of evidence in literature segregated based on the test employed. This includes 17 studies on only SPT; 42 studies on IgE measured in serum, tears, or both; and 20 studies which have evaluated both SPT and IgE. The pattern of allergen sensitization can guide recommendations for avoidance measures and immunotherapy. Thus, this could create a corticosteroid-sparing therapy avenue in these patients, reducing disease severity and resulting visual morbidity.

Current Management of Allergic Rhinitis

Allergic rhinitis (AR) is the most common allergic disease worldwide and one of the most common chronic diseases in general. Allergic rhinitis is caused by inhalant allergens from outdoor and indoor environments with varying significance of different allergens in global regions. We provide options for the current management for AR including pharmacological treatments and nonpharmacological options and allergen immunotherapy (AIT). A literature review has been conducted in Medline, Pubmed, as well as the national and international study (ClinicalTrials.gov) and guideline registers and the Cochrane Library. Human studies published on the topic in the period up to and including November 2023 were taken into account. Allergen avoidance measures, pharmacotherapy, and AIT are the cornerstones of AR treatment. Nonpharmacological measures and behavioral recommendations should be adequately added. Tools of precision medicine are already playing a significant role and will be part of the diagnostic and therapeutic standard in the future. Patients benefit most in a network of different pharmacological and nonpharmacological treatment measures including AIT. Application of precision medicine tools for diagnosis and treatment will improve standards of care.

Factors associated with allergic rhinitis and combined allergic rhinitis and asthma syndrome (CARAS) in adults undergoing immunotherapy in a tropical country: Is ISAAC-III questionnaire useful in adult populations?

BACKGROUND

Allergic diseases affect about 10-30% of the population in low- or middle-income tropical countries. Few studies describe the factors associated with allergic diseases in adult patients undergoing immunotherapy in Latin American countries.

OBJECTIVE

This study aimed to determine the factors associated with allergic rhinitis (AR) and AR in comorbidity with asthma (CARAS) in adults treated with immunotherapy in two allergy referral centers in Bogotá (Colombia).

MATERIAL AND METHODS

Observational, cross-sectional study conducted between January 2018 and January 2019. ISAAC-III and sociodemographic questionnaires were applied to determine the factors associated with AR and CARAS in adults treated with immunotherapy who attended the allergy consult at the Fundación Santa Fe de Bogotá and Unimeq-Orl.

RESULTS

Among 416 adults aged 18-68 years, 71.4% (n = 297) were women. Regarding the sensitization results obtained by skin prick test, the most frequent allergens were house dust mites (64.18%): 49.03% were positive for both Dermatophagoides pteronyssinus and Dermatophagoides farinae, while 28.61% were positive for Blomia tropicalis. Excluding house dust mites, the most frequent allergens were dog hair (31.01%), cat hair (15.1%), grasses (15.9%), and food (15.9%). The main factor associated with exclusive AR was regular acetaminophen use more than four times a year: Prevalence ratio (PR) = 1.77 (95% CI: 1.12-2.25). The main factor associated with CARAS was cesarean delivery PR: 1.44 (95% CI: 1.09-1.78).

CONCLUSION

The main factor associated with AR was regular acetaminophen use, while that associated with CARAS was cesarean delivery. The ISAAC-III questionnaire can be a useful low-cost tool to assess the factors associated with allergic diseases in adults in tropical countries.

Updates in the diagnosis and practical management of allergic rhinitis

INTRODUCTION

Allergic rhinitis (AR) is a widespread disease that can be associated with other conditions, including conjunctivitis, rhinosinusitis, asthma, food allergy, and atopic dermatitis. Diagnosis is based on the history and documentation of sensitization, such as the production of allergen-specific IgE, preferably using molecular diagnostics. Treatments are based on patient education, non-pharmacological and pharmacological remedies, allergen-specific immunotherapy (AIT), and surgery. Symptomatic treatments mainly concern intranasal/oral antihistamines and/or nasal corticosteroids.

AREAS COVERED

This review discusses current and emerging management strategies for AR, covering pharmacological and non-pharmacological remedies, AIT, and biologics in selected cases with associated severe asthma. However, AIT presently remains the unique causal treatment for AR.

EXPERT OPINION

The management of allergic rhinitis could include new strategies. In this regard, particular interest should be considered in the fixed association between intranasal antihistamines and corticosteroids, probiotics and other natural substances, and new formulations (tablets) of AIT.

Subcutaneous birch pollen allergen immunotherapy with a depigmented polymerized extract shows only sustained and long-term efficacy in a subgroup of monosensitized adults and adolescents with allergic rhinitis

Background

Allergen immunotherapy (AIT) is an approved treatment for seasonal respiratory allergic diseases. A depigmented polymerized birch pollen extract for subcutaneous allergen immunotherapy (SCIT) has been demonstrated to be efficacious and safe in patients allergic to birch pollen and its homologous group.

Objective

To determine whether SCIT with a birch pollen formulation (5000 depigmented polymerized (DPP) units/mL) shows sustained and long-term efficacy in adults and adolescents with birch-pollen induced allergic rhinitis with or without intermittent asthma.

Methods

A multicentre (n = 66), double-blind, placebo-controlled Phase III clinical trial was performed in the Czech Republic, Finland, Germany, Latvia, Lithuania, Poland and Russia. Participants were randomized 2:1 to active treatment (birch 5000 DPP/ml) or placebo for three years of SCIT and followed up for two treatment-free years. The primary efficacy endpoint was the EAACI's combined symptom and medication score for rhinoconjunctivitis (CSMSEAACI).

Results

A total of 973 participants were screened and 649 were randomized (active treatment: n = 434; placebo: n = 215). The intention-to-treat analysis of the CSMSEAACI in the overall study population did not demonstrate statistically significant differences in years 1, 2 and 3. In a post-hoc analysis, among the subgroup of patients monosensitized to birch pollen allergen only (n = 200), we observed a statistically significant difference (active treatment vs. placebo) in the CSMSEAACI in year 2, 3 and 5. The AIT's safety profile was good.

Conclusions

SCIT with a depigmented polymerized birch pollen extract was safe. Sustained and long-term efficacy in years 2, 3 and 5 in monosensitized patients, but not in polysensitized patients was demonstrated.(EudraCT 2012-000414-11).

Current treatment strategies for seasonal allergic rhinitis: where are we heading?

INTRODUCTION

Allergic rhinitis (AR) is very commonly caused by pollens. The symptoms of AR consist of sneezing, nasal congestion, rhinorrhea, nasal itching and airflow obstruction. The diagnosis has long been based on clinical history, skin prick tests and in vitro measurement of specific IgE, but the innovative approach of precision medicine has made diagnostic tools of much greater accuracy available.

AREAS COVERED

This review covers the advances in the treatment of seasonal AR concerning the drugs to be used according to the grade of disease and the characteristics of the patients, and the role of allergen immunotherapy (AIT), which is the only treatment capable of acting, in addition to the symptoms, on the cause of AR and therefore to modify its natural history.

EXPERT OPINION

Drug treatment of AR include a large number of agents, the choice of which depends on the severity of the disease. AIT has high evidence of efficacy demonstrated by meta-analyses, and further improvement is currently apparent, as for diagnosis, applying the means of precision medicine. However, when AIT is performed in current practice, without the strict rules of controlled trials, long-term low adherence is a major problem to be solved.

Comparing available treatments for pollen-induced allergic rhinitis in children

INTRODUCTION

Pollen-induced allergic rhinitis (PIAR) is a widespread disease in children, and its prevalence is rapidly evolving. In addition, it may be associated with other atopic diseases, in particular asthma. In most cases, PIAR can be treated effectively by avoiding exposure to responsible allergens and using symptomatic treatments, including intranasal/oral antihistamines or/and nasal corticosteroids, according to ARIA guidelines. In recent decades, new medicines have been studied and developed: allergen-specific immunotherapy (AIT), anti-IgE antibodies, and probiotics. In addition, nutraceuticals have also been used as add-on treatments. This review aims to discuss and compare the old and new therapeutic strategies for PIAR in children.

AREAS COVERED

Allergic rhinitis is a type 2 inflammatory disease. The management of patients with PIAR entails medications, AIT, and ancillary therapies. In addition, children with PIAR and associated severe asthma may be inclusively treated with biologics. Namely, subjects with allergic comorbidities could benefit from biological agents. However, AIT presently remains the unique causal treatment for PIAR.

EXPERT OPINION

New strategies may include combined treatments, mainly concerning fixed associations with antihistamines and corticosteroids, nutraceutical products, and new AIT formulations.

Environmental exposure unit simulates natural seasonal birch pollen exposures while maximizing change in allergic symptoms

BACKGROUND

Birch pollen is a prevalent aeroallergen during the springtime allergy season. In field studies, variable allergen exposure and environmental factors can affect data quality while environmental exposure units (EEUs) deliver controlled, standardized, and reproducible allergen exposures.

OBJECTIVE

To inform study design for EEU trials evaluating antiallergic therapies.

METHODS

In this prospective study, 76 participants with birch allergy experienced 3 exposures to birch pollen: (1) an out-of-season EEU challenge (two 3-hour sessions on consecutive days); (2) a natural seasonal exposure; and (3) an in-season EEU challenge (3-hour exposure for 2 weeks after birch pollen season initiation).

RESULTS

The total nasal symptom score, total ocular symptom score, and total symptom score (TSS = total nasal symptom score plus total ocular symptom score) were assessed every 30 minutes and daily during EEU and natural exposures. A high association between TSSs and day 2 of the out-of-season and in-season EEU challenges was noted, with a good association between the maximum TSS during the natural and in-season EEU challenges, and natural season and day 2 of the out-of-season EEU challenge (P < .001 for all). Participants had higher maximum change from the baseline TSS during day 2 of the out-of-season EEU challenge (12.4) vs the following: (1) first day (9.8); (2) in-season EEU challenge (8.4); and (3) natural seasonal exposure (7.6) (P < .001 for all).

CONCLUSION

A strong association was seen between the presence of allergy symptoms and exposure to birch pollen in the EEU (maximum change in symptom scores during day 2) and in the field. A hybrid trial design may be useful to demonstrate the clinical efficacy of novel antiallergic therapies requiring fewer participants and shorter timelines and expediting treatment availability.

Turkish Guideline for Diagnosis and Treatment of Allergic Rhinitis (ART)

OBJECT

To prepare a national guideline for Otorhinolaryngologist who treat allergic rhinitis patients.

METHODS

The study was conducted by three authors, namely the writing support team. The support team made the study plan, determined the writing instructions, chose the subgroups including the advisory committee, the advisors for authors and the authors. A workshop was organized at the very beginning to explain the details of the study to the team. Advisors took the chance to meet their coworkers in their subgroups and determined the main headings and subheadings of the guideline, together with the authors. After key words were determined by the authors, literature search was done in various databases. The authors keep in touch with the advisors and the advisors with the advisory committee and the support group at every stage of the study. National and International published articles as well as the abstracts of unpublished studies, imperatively presented in National Congresses, were included in this guideline. Only Guideline and meta-analyses published in last seven years (2013-2017) and randomized controlled studies published in last two years (2015-2017) were included. After all work was completed by the subgroups, support team brought all work together and edited the article.

RESULTS

A detailed guideline about all aspects of allergic rhinitis was created.

CONCLUSION

The authors believe that this guideline will enable a compact and up-to-date information on allergic rhinitis to healthcare professionals. This guideline is the first in the field of Otolaryngology in Turkey. It should be updated at regular intervals.

Personalized medicine for allergy treatment: Allergen immunotherapy still a unique and unmatched model

The introduction of personalized medicine (PM) has been a milestone in the history of medical therapy, because it has revolutionized the previous approach of treating the disease with that of treating the patient. It is known today that diseases can occur in different genetic variants, making specific treatments of proven efficacy necessary for a given endotype. Allergic diseases are particularly suitable for PM, because they meet the therapeutic success requirements, including a known molecular mechanism of the disease, a diagnostic tool for such disease, and a treatment blocking the mechanism. The stakes of PM in allergic patients are molecular diagnostics, to detect specific IgE to single-allergen molecules and to distinguish the causative molecules from those merely cross-reactive, pursuit of patient's treatable traits addressing genetic, phenotypic, and psychosocial features, and omics, such as proteomics, epi-genomics, metabolomics, and breathomics, to forecast patient's responsiveness to therapies, to detect biomarker and mediators, and to verify the disease control. This new approach has already improved the precision of allergy diagnosis and is likely to significantly increase, through the higher performance achieved with the personalized treatment, the effectiveness of allergen immunotherapy by enhancing its already known and unique characteristics of treatment that acts on the causes.

A 300 IR sublingual tablet is an effective, safe treatment for house dust mite-induced allergic rhinitis: An international, double-blind, placebo-controlled, randomized phase III clinical trial

BACKGROUND

Allergic rhinitis induced by house dust mites (HDMs) is a highly prevalent but often underdiagnosed and undertreated/untreated chronic disease. It often has a negative impact on sleep, work, leisure activities, and health-related quality of life. Allergen immunotherapy is a proven, safe treatment for respiratory allergies.

OBJECTIVE

We sought to assess the efficacy and safety of a 300 index of reactivity (IR) sublingual tablet formulation of Dermatophagoides pteronyssinus:Dermatophagoides farinae 1:1 extract in adolescents (aged ≥12) and adults with moderate to severe HDM-induced allergic rhinitis.

METHODS

In a phase III, international, double-blind, placebo-controlled, randomized clinical trial, participants received approximately 12 months of treatment with placebo or the 300 IR tablet. The primary end point was the average total combined score during 4 weeks at the end of the treatment period.

RESULTS

A total of 1607 participants were randomized, and 1476 (including 555 [37.6%] with concomitant mild controlled asthma at inclusion) comprised the full analysis set. Over the primary evaluation period, the least squares mean average total combined score in the 300 IR group (3.62) was significantly lower (P < .0001) than in the placebo group (4.35), with a relative least squares mean difference of -16.9% (95% CI, -24.0% to -9.2%). All prespecified secondary end points were consistently improved in the 300 IR group, relative to placebo. The 300 IR tablet was generally well tolerated. Treatment-related adverse events (mainly mild or moderate local reactions) were reported for 51.0% of the patients in the 300 IR group and 14.9% in the placebo group.

CONCLUSIONS

The 300 IR sublingual HDM tablet is an effective, safe treatment for HDM-induced allergic rhinitis.

Intranasal antihistamine is superior to oral H1 antihistamine as an add-on therapy to intranasal corticosteroid for treating allergic rhinitis

BACKGROUND

Currently, a combination of intranasal corticosteroid (INCS) plus oral H₁ antihistamine (OAH) or intranasal H₁ antihistamine (INAH) therapy is frequently used in the treatment of allergic rhinitis (AR). The superiority of the 2 combined treatments needs to be further examined.

OBJECTIVE

To identify the better of the 2 therapeutic strategies for treating AR.

METHODS

A literature review was performed on MEDLINE, Cochrane Library, and EMBASE databases. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses, meta-analyses of the total nasal symptom scores and individual nasal symptom scores were pooled based on studies that compared concomitant H₁ antihistamines plus INCS with INCS alone in the treatment of AR. The pooled results were expressed as weighted mean differences between the treatments. For each selected study, we calculated the relative clinical impact based on the total nasal symptom scores as follows: 100 × (Score_Monotherapy - Score_{Combined therapy}) / Score_Monotherapy.

RESULTS

A total of 13 publications met our selection criteria, with 5066 patients. The pooled results revealed no significant weighted mean difference on the total nasal symptom scores between concomitant OAH plus INCS and INCS alone. As for the individual symptoms, the most common symptom that revealed remission was rhinorrhea, which was after OAH in combination with INCS. The combination therapy of INAH and INCS was superior to INCS alone. In an indirect comparison, the weighted mean relative clinical impact of INAH plus INCS was significantly higher than that of OAH plus INCS.

CONCLUSION

Intranasal H₁ antihistamines have an add-on effect on intranasal corticosteroids, and the combination of intranasal H₁ antihistamines plus intranasal corticosteroid is superior to that of oral H₁ antihistamines plus intranasal corticosteroid in improving nasal symptoms for patients with AR.

Clinical Practice of Allergen Immunotherapy for Allergic Rhinoconjunctivitis and Asthma: An Expert Panel Report

Allergen immunotherapy (AIT) reduces symptoms and medication use associated with allergic rhinitis with or without conjunctivitis and allergic asthma. Although several AIT guidelines exist, there remain unanswered questions about AIT that are relevant to everyday practice. Our objective was to prepare an evidence-based overview addressing the practical aspects of AIT in clinical practice based on published evidence and the experience of international experts in the field. Topics covered include interpretation and translation of clinical trial data into everyday clinical practice (eg, allergen doses and treatment duration), assessment of risk and treatment of local and systemic allergic reactions, recommendations for improvement of AIT guidelines, and identification of appropriate data for seeking regulatory approval, to name a few. Many informational gaps in AIT practice need further evaluation as products and practices evolve.

A Review of the Anti-Inflammatory Effects of Rosmarinic Acid on Inflammatory Diseases

Inflammatory diseases are caused by abnormal immune responses and are characterized by an imbalance of inflammatory mediators and cells. In recent years, the anti-inflammatory activity of natural products has attracted wide attention. Rosmarinic acid (RosA) is a water-soluble phenolic compound that is an ester of caffeic acid and 3, 4-dihydroxyphenyl lactic acid. It is discovered in many plants, like those of the Boraginaceae and Lamiaceae families. RosA has a wide range of pharmacological effects, including anti-oxidative, anti-apoptotic, anti-tumorigenic, and anti-inflammatory effects. The anti-inflammatory effects of RosA have been revealed through in vitro and in vivo studies of various inflammatory diseases like arthritis, colitis, and atopic dermatitis. This article mainly describes the preclinical research of RosA on inflammatory diseases and depicts a small amount of clinical research data. The purpose of this review is to discuss the anti-inflammatory effects of RosA in inflammatory diseases and its underlying mechanism.

Reliability of the Evidence Addressing Treatment of Corneal Diseases: A Summary of Systematic Reviews

Importance

Patient care should be informed by clinical practice guidelines, which in turn should be informed by evidence from reliable systematic reviews. The American Academy of Ophthalmology is updating its Preferred Practice Patterns (PPPs) for the management of the following 6 corneal diseases: bacterial keratitis, blepharitis, conjunctivitis, corneal ectasia, corneal edema and opacification, and dry eye syndrome.

Objective

To summarize the reliability of the existing systematic reviews addressing interventions for corneal diseases.

Data Source

The Cochrane Eyes and Vision US Satellite database.

Study Selection

In this study of published systematic reviews from 1997 to 2017 (median, 2014), the Cochrane Eyes and Vision US Satellite database was searched for systematic reviews evaluating interventions for the management of any corneal disease, combining eyes and vision keywords and controlled vocabulary terms with a validated search filter.

Data Extraction and Synthesis

The study classified systematic reviews as reliable when each of the following 5 criteria were met: the systematic review specified eligibility criteria for inclusion of studies, conducted a comprehensive literature search for studies, assessed risk of bias of the individual included studies, used appropriate methods for quantitative syntheses (meta-analysis) (only assessed if meta-analysis was performed), and had conclusions that were supported by the results of the systematic review. They were classified as unreliable if at least 1 criterion was not met.

Main Outcomes and Measures

The proportion of systematic reviews that were reliable and the reasons for unreliability.

Results

This study identified 98 systematic reviews that addressed interventions for 15 corneal diseases. Thirty-three of 98 systematic reviews (34%) were classified as unreliable. The most frequent reasons for unreliability were that the systematic review did not conduct a comprehensive literature search for studies (22 of 33 [67%]), did not assess risk of bias of the individual included studies (13 of 33 [39%]), and did not use appropriate methods for quantitative syntheses (meta-analysis) (12 of 17 systematic reviews that conducted a quantitative synthesis [71%]). Sixty-five of 98 systematic reviews (66%) were classified as reliable. Forty-two of the 65 reliable systematic reviews (65%) addressed corneal diseases relevant to the 2018 American Academy of Ophthalmology PPPs; 33 of these 42 systematic reviews (79%) are cited in the 2018 PPPs.

Conclusions and Relevance

One in 3 systematic reviews addressing interventions for corneal diseases are unreliable and thus were not used to inform PPP recommendations. Careful adherence by systematic reviewers and journal editors to well-established best practices regarding systematic review conduct and reporting might help make future systematic reviews in eyes and vision more reliable.

Clinical aspects of sublingual immunotherapy tablets and drops

BACKGROUND

Sublingual immunotherapy (SLIT) is administered via tablets (SLIT-T) or liquid drops (SLIT-D). In North America, currently 4 SLIT-T formulations are approved by the US Food and Drug Administration for allergy immunotherapy, and SLIT-D is an off-label use of subcutaneous immunotherapy (SCIT) extracts.

OBJECTIVE

To compare and contrast aspects of SLIT-T and SLIT-D, including physical characteristics, mechanism of action, dosing, efficacy, safety, adherence, and cost.

DATA SOURCES

PubMed literature review (no limits), product prescribing information, and manufacturer websites.

STUDY SELECTIONS

Publications related to physical characteristics, mechanism of action, dosing, efficacy, safety, and adherence.

RESULTS

Published evidence indicates that tablet and drop formulations differ in regard to physical characteristics, dosing, and strength of evidence for efficacy. Whether there are any differences in absorption and mechanism of action between the 2 formulations is currently unknown. Optimal dosing, efficacy, and safety have been established for SLIT-T. In contrast, in North America there is little support for efficacy of SLIT-D from randomized double-blind, placebo-controlled trials, and dose ranges have not been appropriately evaluated. SLIT-T treats a single allergen, whereas in the United States SLIT-D often contains multiple allergens to treat polysensitization. The safety profiles of SLIT-T and SLIT-D appear similar, and both formulations are considered safer than SCIT.

CONCLUSION

Professional guidelines should make a clear distinction between SLIT-T and SLIT-D in their recommendations to minimize confusion with the umbrella term SLIT.

Highlights of Novel Vaccination Strategies in Allergen Immunotherapy

Increasing safety while maintaining or even augmenting efficiency are the main goals of research for novel vaccine development and improvement of treatment schemes in allergen immunotherapy (AIT). To increase the efficacy of AIT, allergens have been coupled to innate immunostimulatory substances and new adjuvants have been introduced. Allergens have been modified to increase their uptake and presentation. Hypoallergenic molecules have been developed to improve the safety profile of the vaccines. Administration of recombinant IgG4 antibodies is a new, quick, passive immunization strategy with remarkable efficiency. Results of some current investigations aiming at further improvement of AIT vaccines have been summarized.

Management of ocular allergy

The treatment and management of ocular allergy (OA) remain a major concern for different specialties, including allergists, ophthalmologists, primary care physicians, rhinologists, pediatricians, dermatologists, clinical immunologists, and pharmacists. We performed a systematic review of all relevant publications in MEDLINE, Scopus, and Web Science including systematic reviews and meta-analysis. Publications were considered relevant if they addressed treatments, or management strategies of OA. A further wider systematic literature search was performed if no evidence or good quality evidence was found. There are effective drugs for the treatment of OA; however, there is a lack an optimal treatment for the perennial and severe forms. Topical antihistamines, mast cell stabilizers, or double-action drugs are the first choice of treatment. All of them are effective in reducing signs and symptoms of OA. The safety and optimal dosing regimen of the most effective topical anti-inflammatory drugs, corticosteroids, are still a major concern. Topical calcineurin inhibitors may be used in steroid-dependent/resistant cases of severe allergic keratoconjunctivitis. Allergen-specific immunotherapy may be considered in cases of failure of first-line treatments or to modify the natural course of OA disease. Based on the current wealth of publications and on the collective experience, recommendations on management of OA have been proposed.

Clinical efficacy of sublingual immunotherapy tablets for allergic rhinitis is unlikely to be derived from in vitro allergen-release data

Introduction: Allergen bioavailability underpins the efficacy and safety of SLIT tablets. Three product-related factors are likely to influence this: tablet potency, formulation and sublingual holding time. Areas covered: Tablet formulation determines the rate and extent of solubilized allergen release. Using validated in vitro dissolution assays, the two licensed grass pollen SLIT tablets are shown to release ≥85% of their total allergenic activity within several minutes. Sublingual holding time affects the contact duration between solubilized allergens and sublingual tissue. Maximal uptake of allergens by sublingual tissue requires ~5 minutes, with little uptake occurring within the first minute. A higher potency tablet with longer sublingual holding time would provide higher bioavailability, while faster rates of allergen release in vitro are unlikely to translate to a greater increase in bioavailability. Differences in dissolution times cannot serve as a surrogate of in vivo bioavailability, and are not related to differences in efficacy at the marketed tablet dosages. Rapid in vitro dissolution is likely not a key requirement for inducing a potent immune response. Expert opinion: In vitro dissolution cannot predict the clinical efficacy of SLIT tablets but could be important in immune tolerance and safety. In addition, a discontinuous administration regimen may have benefits for adherence and cost without compromising efficacy.

Immunotherapy with grass pollen tablets reduces medication dispensing for allergic rhinitis and asthma: A retrospective database study in France

BACKGROUND

Moderate-to-severe allergic rhinitis (AR) may increase the risk of developing or worsening asthma, whereas treatment of AR with subcutaneously or sublingual allergen immunotherapy (SLIT) may slow this progression.

METHODS

In a retrospective real-world analysis, prescription fulfilment data were gathered from French retail pharmacies between 1 March 2012 and 31 December 2016. Using linear regression analyses, patients having received at least two prescriptions of grass pollen SLIT tablets over at least 2 successive years were compared with control patients having received symptomatic medications only.

RESULTS

A total of 1099 SLIT patients and 27 475 control patients were included in the main analysis. With regard to symptomatic AR medication dispensing, we observed a 50% decrease in the pre-index/follow-up ratio in the SLIT group, a 30% increase in the control group without age matching (P < 0.0001 vs SLIT) and a 20% increase in the control group with age matching (P < 0.0001 vs SLIT). During the follow-up, 11 (1.8%) and 782 (5.3%) patients initiated asthma treatment in the SLIT and control groups, respectively. The relative risk of medication dispensing for new asthma was lower in the SLIT group (by 62.5% [29.1%-80.1%] without age matching (P = 0.0025) and by 63.7% [31.5%-80.7%] with age matching; P = 0.0018). SLIT was also associated with slower progression of asthma medication dispensing during the follow-up period, relative to the control group (regression coefficient: -0.58 [-0.74 to 0.42] without age matching (P < 0.0001) and -0.61 [-0.76 to -0.46] with age matching; P < 0.0001).

CONCLUSION

Prescription of grass pollen SLIT tablets reduced the dispensing of AR and asthma medications in real life.

Mind the gaps: Clinical trial concepts to address unanswered questions in aeroallergen immunotherapy-An NIAID/AHRQ Workshop

The Agency for Healthcare Research and Quality and the National Institute of Allergy and Infectious Diseases organized a workshop to develop trial concepts that could improve the use and effectiveness of aeroallergen immunotherapy (AAIT). Expert groups were formed to accomplish the following tasks: (1) propose a study design to compare the effectiveness and safety of subcutaneous versus sublingual AAIT; (2) propose a study design to compare the effectiveness and safety of AAIT by using 1 or a few allergens versus all or most allergens to which a patient is sensitized; (3) propose a study design to determine whether AAIT can alter the progression of childhood allergic airways disease; and (4) propose a study design to determine the optimal dose and duration of AAIT to achieve maximal effectiveness with acceptable safety. Study designs were presented by the workgroups, extensively discussed at the workshop, and revised for this report. The proposed trials would be of long duration and require large highly characterized patient populations. Scientific caveats and feasibility matters are discussed. These concepts are intended to help the development of clinical trials that can address some of the major questions related to the practice of AAIT for the management and prevention of allergic airways disease.

Adherence During Early Allergen Immunotherapy and Strategies to Motivate and Support Patients

Allergic rhinitis is one of the most common chronic inflammatory conditions, affecting up to 30% of people in Europe. Allergen immunotherapy (AIT) is the only treatment for allergic rhinitis and asthma that has a disease-modifying effect, and it is recommended in European guidelines for use in conjunction with patient education, specific allergen avoidance, and symptomatic pharmacotherapy. Reported AIT adherence rates vary widely but are often low in real-world settings. Factors known to affect adherence are patient, treatment, or physician-related, and vary between healthcare settings. Misconceptions or a lack of AIT knowledge among patients with regard to efficacy and side effects may contribute to high rates of discontinuation observed during the first year of AIT treatment. Interventions to improve patient adherence are multifaceted and should focus on patient education, particularly the provision of accurate information regarding adverse effects of AIT and when to expect an improvement in symptoms, patient-support programmes, and the use of regular eHealth reminders via a telephone call, text message, or social media. Serum-based biomarkers also have the potential to play a role in evaluating early response to AIT and in monitoring treatment adherence in clinical practice. In this review, the authors explore barriers to continuation with AIT and discuss initiatives to motivate and support patients through the challenging early months of treatment, prior to the onset of clinical effect and when side effects are most common, to encourage long-term adherence to therapy and achieve optimal patient outcomes.

Efficacy and safety of allergen immunotherapy in patients with allergy to molds: A systematic review

BACKGROUND

Allergen immunotherapy (AIT) with mould extracts has been performed for many years but the final demonstration of its clinical efficacy is still missing, due to the small number of studies and their inconsistent results.

OBJECTIVE

To systematically review efficacy and safety of AIT for the treatment of respiratory allergies to moulds.

DESIGN

The primary outcomes were safety and reduction of symptoms (Symptom Score, SS) and medication use (Medication Score, MS) in patients treated with AIT compared to controls. The strength of the evidence was graded based on the risk of bias, consistency and magnitude of effect, according to the GRADE Working Group's guide.

DATA SOURCES

Medline, Web of Science and the Cochrane Library (through September 2017) supplemented with manual searches of reference lists.

ELIGIBILITY CRITERIA

Randomized studies of intervention comparing AIT to placebo/pharmacotherapy. Studies not reporting on our outcome of interest or without a control population were excluded.

RESULTS

Nine studies (168 children, 99 adults; median sample size, 27) met the inclusion criteria. The risk of bias was moderate-to-high in all but one study. Low strength evidence supports the assumption that AIT is effective in reducing symptoms and medication use, with only four of nine studies reporting higher benefit of AIT vs. comparators. The highest benefit of AIT compared to pharmacotherapy/placebo was reported in studies with a longer follow-up (SMD for MS from -3.96 to -3.97 in favour of AIT) and low risk of bias (VAS for SS: 66.3 ± 13 in AIT group; 186.6 ± 39 in comparators; P < 0.05). No difference was reported with respect to study sample size, route of administration, age of participants. Generalised adverse reactions were reported in 12.5% of participants treated with sublingual immunotherapy, and 37.2% of participants treated with subcutaneous immunotherapy.

CONCLUSIONS

Low strength evidence suggests that mould AIT is efficacious for the treatment of respiratory allergies. High-quality studies with an adequate sample size are needed.

Clinical Applications of Sublingual Immunotherapy

Sublingual immunotherapy (SLIT) is effective for the treatment of allergic rhinitis and allergic asthma in adults and children. In a limited number of studies, SLIT efficacy has been demonstrated for the treatment of food allergy. SLIT has a higher safety profile versus subcutaneous immunotherapy, although some systemic reactions have been reported. Appropriate patient selection, meticulous patient education, and routine follow-up are key for the safe and effective administration of SLIT. With organization and attention to detail, adding SLIT to one's practice can provide a highly valued patient service.

The global development and clinical efficacy of sublingual tablet immunotherapy for allergic diseases

Allergy immunotherapy (AIT) is a treatment option for respiratory allergy that is complementary to pharmacotherapy, with a distinct mechanism of action. Alternative methods to subcutaneous administration of AIT that enable patients to safely self-administer AIT is considered an unmet clinical need. The sublingual immunotherapy tablet (SLIT-tablet) is an orally disintegrating pharmaceutical formulation (oral lyophilisate) containing standardized allergens. SLIT-tablets have been developed for sublingual immunotherapy (SLIT) of cedar-pollen, grass-pollen, ragweed-pollen, tree-pollen, and house dust mite allergies. It is a once-daily tablet treatment to be self-administered after the first dose has been provided under the supervision of a physician with experience in the diagnosis and treatment of allergic diseases. Once the first dose is adequately tolerated, subsequent doses may be self-administered. SLIT-tablets have proven efficacy for allergic rhinitis (AR) with and without conjunctivitis (C) and allergic asthma (AA) in adults, children, and poly-sensitized allergic patients. Meta-analyses indicate that SLIT-tablets have superior or similar efficacy compared with anti-allergic pharmacotherapies for seasonal AR and superior efficacy for perennial AR. SLIT-tablets have also demonstrated clinically relevant improvements of asthma, with significant reductions in the following: daily inhaled corticosteroid use, risk of asthma exacerbations, and asthma symptoms. SLIT-tablets are generally well tolerated, with a low risk of systemic allergic reactions. The most common treatment-related adverse events are mild-moderate oral reactions. Current evidence supports SLIT-tablets to be considered as an alternative or add-on treatment to pharmacotherapy for AR/C and asthma. Future SLIT developments may include early intervention to prevent the development or progression of allergic disease in children.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Specific immunotherapy in allergic rhinitis

Allergic rhinitis is a common condition, with significant impact on quality of life depending on severity and quality of control. Allergen-specific immunotherapy (allergen-SIT) is the only known treatment able to alter the natural course of allergic rhinitis. Although well known to allergologists, it has yet to be fully adopted by the ENT community. This review, based on the most recent meta-analyses and clinical studies, shows that SIT significantly reduces symptoms and medication requirements (nasal corticosteroids, H1-antihistamines) in allergic rhinitis. It can reduce the risk of progression to asthma and, if initiated early enough, of developing new sensitizations. Immunobiological analysis shows an altered inflammatory profile following SIT, with immune tolerance involving T-regulatory lymphocyte induction and IgG production. Sublingual SIT with drops is as effective as subcutaneous SIT and is simpler to use, with less anaphylactic risk. Standardization of trial protocols in terms of treatment response assessment and side effect grading is recommended to improve comparative studies. Sublingual SIT with tablets has recently been introduced, providing a good opportunity for ENT practitioners to adopt the SIT approach in rhinitis triggered by allergy to pollens and, in the near future, to house dust mites.

Allergen immunotherapy for the treatment of allergic rhinitis and/or asthma: an umbrella review

BACKGROUND

Allergic rhinitis and asthma are important public health concerns, yet there is no consensus about the benefits and harms of allergen-specific immunotherapy to treat these conditions. We performed an umbrella review of systematic reviews summarizing the current evidence for the benefits and harms of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT).

METHODS

We searched MEDLINE, Embase, the Cochrane Library and the grey literature from Jan. 1, 2010 to Nov. 20, 2016 for systematic reviews of randomized controlled trials or prospectively controlled studies involving children or adults with allergic rhinitis or asthma. Outcomes were summarized narratively (benefits: total combined symptom-medication score, symptom score, medication score, disease-specific quality of life, adherence; harms: anaphylaxis, death, local and systemic reactions).

RESULTS

Twenty-three systematic reviews were included. SCIT and SLIT were more effective than placebo for most outcomes. SCIT was better than SLIT at improving medication and symptom scores, with no differences in quality of life; however, data were limited for this comparison. Anaphylaxis and death were infrequently reported. Few reviews assessed benefits or harms among children.

INTERPRETATION

Allergen immunotherapy appears to be effective among patients with allergic rhinitis and asthma. The safety of allergen immunotherapy is not conclusively established, although death and anaphylaxis appear to be rare. PROSPERO no.: CRD42015024590.

Efficacy of allergen immunotherapy in reducing the likelihood of developing new allergen sensitizations: a systematic review

BACKGROUND

Guidelines and position papers indicate that allergen immunotherapy (AIT) is the only disease-modifying treatment, including prevention of the onset of new allergen sensitizations. However, this preventive effect was shown by only a few observational studies. Our aim was to systematically review the efficacy of AIT in preventing the onset of new allergen sensitizations.

METHODS

Computerized bibliographic searches of Medline, EMBASE, and the Cochrane Library (through June 2015) were supplemented with manual searches of reference lists. Observational studies or randomized controlled trials with a long-term observation period were included. Paired reviewers extracted data about study characteristics and assessed biases. The end point was the risk difference in the onset of new allergen sensitizations between patients treated with AIT and pharmacotherapy. The strength of the evidence was graded based on the risk of bias, consistency, and magnitude of effect, according to the GRADE Working Group's guide.

RESULTS

Eighteen studies (1049 children, 10 057 adults) met the inclusion criteria. The risk of bias was high in all but one study. Low evidence supports the position that AIT prevents the onset of new allergen sensitizations, with 10 of 18 studies reporting a reduction in the onset of new sensitizations in patients treated with AIT vs placebo. Small studies and studies with a shorter follow-up showed the highest benefit of AIT.

CONCLUSIONS

The overall evidence provides a low-grade level of the evidence supporting the efficacy of AIT in preventing the onset of new allergen sensitizations, but high-quality studies could change this estimate.

[Therapeutic adherence in asthma in France: A general review]

INTRODUCTION

Adherence in asthma is a paramount issue of disease management. A general review of the French publications on this topic has been conducted.

METHODS

Research equations used for bibliographic databases (MEDLINE, Science Direct, Banque de données en santé publique, Cochrane and Cairn.info) comprised the following keywords: "asthma", "therapeutic adherence" and "France". These publications unrelated to asthma, focused on asthma management without exploring adherence, or those conducted in populations without French patients were excluded.

RESULTS

A total of 82 articles have been selected (36 surveys, 4 randomized trials and 42 reviews/syntheses). Whatever the methodology used and publication year, the inadequate therapeutic adherence in asthma was steadily reported, notably for controllers and the quality of use of inhaled devices.

CONCLUSION

The present review highlights the sustainability of adherence-related issues in asthma and the need to improve patients' knowledge on asthma and the finality of therapy. It also highlights the need of an improved communication between patients and physicians is also advocated. Further studies with more recent data are desirable to assess changes in disease management of asthma and the impact of potential future corrective interventions.

Sublingual immunotherapy tablets as a disease-modifying add-on treatment option to pharmacotherapy for allergic rhinitis and asthma

Allergic rhinitis (AR) with or without conjunctivitis (AR/C) is associated with a significant health and economic burden, and is often accompanied by asthma. Pharmacotherapies are the mainstay treatment options for AR and asthma, but guidelines also recommend allergy immunotherapy (AIT). Unlike pharmacotherapies, AIT has the ability to modify the underlying immunologic mechanisms of AR and asthma with the potential for long-term benefits after treatment is discontinued. Immunotherapy may also prevent progression of AR/C to asthma. Sublingual immunotherapy (SLIT)-tablets are a self-administered alternative to subcutaneous immunotherapy that provide the benefits of AIT without the cost and inconvenience of frequent office visits or the discomfort of injections. SLIT-tablets are also an option that can be utilized by primary care clinicians. Pharmacotherapies are generally effective in mild disease although a number of patients remain uncontrolled. SLIT-tablets have proven efficacy for AR in adults, children, and poly-sensitized allergic patients. Indirect comparisons indicate that SLIT-tablets have superior or comparable efficacy compared with traditional pharmacotherapies for seasonal AR, and superior efficacy for perennial AR. House dust mite (HDM) SLIT-tablets have also demonstrated clinically relevant benefits for asthma, with significant observed reductions in daily inhaled corticosteroid use, risk of asthma exacerbations, and asthma symptoms. SLIT-tablets are well tolerated, with minimal risk of systemic allergic reactions. The most common treatment-related adverse events are oral site reactions such as oral pruritus and throat irritation. Based on the favorable efficacy and safety profile, as well as the convenience of at-home oral administration and disease-modifying effects, SLIT-tablets should be considered as an alternative or add-on treatment to pharmacotherapy for AR/C, and as an add-on treatment for HDM allergic asthma.

Evaluation of a sublingual immunotherapy solution in olive-induced respiratory allergy in Jordan: a retrospective observational study

Background

Olive pollen is an important cause of respiratory allergy in the Middle East. In this study, the clinical characteristics of adults and children with confirmed allergic rhinitis (AR; with or without asthma) in Jordan were described, and the use of sublingual immunotherapy (SLIT) in a real-life clinical setting was assessed.

Methods

This retrospective observational study evaluated the clinical features of olive-induced allergy and the use of an SLIT solution of standardized extracts toward Ole e 1 given in a pre- and coseasonal scheme with a daily dose of 300 index of reactivity for two consecutive seasons. Inclusion criteria were as follows: ≥5 years of age, AR, proven olive sensitization, and at least 2 years follow-up after SLIT initiation. The following data were recorded at SLIT initiation: clinical characteristics, rhinitis and asthma symptom scores, and concomitant symptomatic medications. During follow-up and at the end of each season, the following data were recorded: symptom progression/scores, any changes to symptomatic medications, and treatment compliance. The secondary objective was to determine any effect on quality of life, use of concomitant AR medications, and treatment compliance.

Results

Eighty-six patients with seasonal AR were included in this analysis (52.3% with coexisting asthma). Between the initiation of treatment and the end of second pollen season, symptoms of AR and asthma were decreased by 79.5% and 41.7%, respectively, with an improvement in quality of life score in 71.5% of the patients (P<0.0001 for all). Physicians reported that after 2 years of SLIT, there was an improvement in the symptoms of both AR (95.2%) and asthma (93.3%), with 98.8% of the patients showing good treatment compliance. A reduction in symptomatic medications was also found. SLIT was well tolerated with no systemic reactions being reported.

Conclusion

In children and adults with olive-associated respiratory allergy in Jordan, the use of a pre- and coseasonal SLIT with a 300 index of reactivity daily dose is effective in reducing the clinical burden of AR and asthma with no tolerability issues.

Allergic Rhinitis Control Test questionnaire-driven stepwise strategy to improve allergic rhinitis control: a prospective study

BACKGROUND

Allergic Rhinitis Control Test (ARCT) has been validated for assessing allergic rhinitis (AR) control and identifying severe AR. The aim of the study was to assess the ARCT questionnaire as a tool for stepwise pharmacotherapy.

METHODS

A standard pharmacotherapy regimen from Step 1 (oral second-generation H1 antihistamine as needed) to Step 5 (oral corticosteroid) was carried out prospectively in a Chinese AR population. The AR patients were initiated with Allergic Rhinitis and its Impact on Asthma (ARIA) appropriate step treatment and assessed with ARCT every 15 days. If ARCT score was equal or above 20 (controlled AR) and maintained for 15 days, the patient would finish the study; if ARCT score was strictly <20 (uncontrolled AR), the patient would receive higher step treatment according to a predefined open design up to Step 5. The different AR control subgroups were compared.

RESULTS

A total of 255 patients were enrolled in the study; 5 patients dropped out and 2 (0.8%) were controlled at day 0, 85 (34.0%) at day 15, 177 (70.8%) at day 30, 222 (88.8%) at day 45, 241 (96.4%) at day 60 and 242 (96.8%) at day 75. Only 8 (3.2%) patients remained uncontrolled at the endpoint of the study. Patients with ARIA moderate/severe or persistent symptoms, moderate/severe impaired quality of life, asthma history, rhinorrhea and cough symptoms always needed up to Step 4 (nasal corticosteroid plus antihistamine) and prolonged treatments to achieve disease control.

CONCLUSIONS

The majority of AR can be controlled with standard stepwise treatment. ARCT offers an objective criterion for the stepwise pharmacotherapy of AR.

Efficacy of house dust mite sublingual immunotherapy tablet in North American adolescents and adults in a randomized, placebo-controlled trial

BACKGROUND

The house dust mite (HDM) sublingual immunotherapy (SLIT) tablet (MK-8237; Merck & Co, Kenilworth, NJ/ALK-Abelló, Hørsholm, Denmark) has demonstrated beneficial effects on allergic rhinoconjunctivitis and asthma outcomes in European trials.

OBJECTIVE

This is the first trial to assess the efficacy/safety of HDM SLIT-tablets in North American subjects with HDM-induced allergic rhinitis with or without conjunctivitis (AR/C).

METHODS

In this double-blind, multicenter trial (NCT01700192) 1482 subjects (aged ≥12 years) with HDM-induced AR/C with or without asthma were randomized to a daily SQ HDM SLIT-tablet (12 SQ-HDM dose) or placebo for up to approximately 52 weeks. A rhinitis daily symptom score (DSS; 4 nasal symptoms, maximum score = 12) of 6 or greater, or 5 or greater with 1 symptom being severe, on 5 of 7 consecutive days before randomization was required. The primary end point was the average total combined rhinitis score, which was defined as the rhinitis DSS plus rhinitis daily medication score (DMS), during the last 8 treatment weeks.

RESULTS

Treatment with 12 SQ-HDM improved the total combined rhinitis score by 17% (95% CI, 10% to 25%) versus placebo. Improvements versus placebo in the secondary end points of average rhinitis DSS, rhinitis DMS, total combined rhinoconjunctivitis score, and visual analog scale-assessed AR/C symptoms were 16%, 18%, 17%, and 16%, respectively. All nominal P values were less than .001 versus placebo, except rhinitis DMS (P = 0.15). No treatment-related adverse events meeting the International Council on Harmonization definition of a serious adverse event were reported; 1 nonserious treatment-related systemic allergic reaction occurred (assessed as moderate intensity) at first administration under medical supervision and was treated with epinephrine.

CONCLUSIONS

In the first North American trial of use of a SLIT-tablet for HDM allergy, 12 SQ-HDM was well tolerated and improved HDM-induced rhinitis symptoms in adults and adolescents.

Treatment effect of sublingual immunotherapy tablets and pharmacotherapies for seasonal and perennial allergic rhinitis: Pooled analyses

BACKGROUND

Data comparing the treatment effect of allergy immunotherapy and pharmacotherapy are lacking.

OBJECTIVE

We sought to indirectly compare the treatment effect of sublingual immunotherapy (SLIT)-tablets with pharmacotherapy for seasonal allergic rhinitis (SAR) and perennial allergic rhinitis (PAR).

METHODS

Pooled data from randomized, double-blind, placebo-controlled trials for the clinical development programs of selected allergic rhinitis treatments were evaluated. Total nasal symptom scores (TNSSs) relative to placebo were compared. Subjects scored symptoms daily during entire pollen seasons in 6 timothy grass SLIT-tablet trials (n = 3094) and 2 ragweed SLIT-tablet trials (n = 658) and during the last 8 weeks of treatment in 2 house dust mite (HDM) SLIT-tablet trials (n = 1768). Subjects scored symptoms daily in 7 montelukast (10 mg, n = 6799), 9 desloratadine (5 mg, n = 4455), and 8 mometasone furoate nasal spray (MFNS; 200 μg daily, n = 2140) SAR or PAR trials. SLIT-tablet trials allowed rescue medication use, whereas most pharmacotherapy trials did not. A fixed-effect meta-analysis method estimated differences in on-treatment average TNSSs.

RESULTS

In grass and ragweed SLIT-tablet trials, overall improvement in TNSSs relative to placebo was 16.3% and 17.1%, respectively. In HDM SLIT-tablet trials, TNSS overall improvement relative to placebo was 16.1%. In the montelukast, desloratadine, and MFNS trials, TNSS overall improvement relative to placebo was 5.4%, 8.5%, and 22.2%, respectively, for SAR trials, and 3.7%, 4.8%, and 11.2%, respectively, for PAR trials.

CONCLUSIONS

Although comparisons were limited by study design heterogeneity and use of rescue medications in SLIT-tablet trials, effects on nasal symptoms with timothy grass and ragweed SLIT-tablets were nearly as great as with MFNS and numerically greater than with montelukast and desloratadine for SAR. HDM SLIT-tablet effects were numerically greater than all pharmacotherapies for PAR. SLIT-tablets offer the additional benefit of long-term efficacy.

Grass pollen sublingual immunotherapy and paediatric allergic rhinitis: A patient-oriented decision

Guidelines and systematic review report that allergen immunotherapy (AIT) is, in general, effective in the treatment of allergic rhinitis. However, experts suggest not generalising the results of different clinical studies: for example, it would not be advisable to translate the results found in an adult population to a paediatric population or the results on the efficacy of AIT against a specific allergen to the AIT against a different allergen. Moreover, according to Evidence Based Medicine (EBM), clinical decisions are individualised and should derive from the "integration of best research evidence with clinical expertise and patient values". Taking into account the high specificity of the AIT and EBM principles, we tried to answer the question on how advisable it is to prescribe the AIT for the management of grass allergic rhinitis in children. To do this, we revised the scientific literature in order to solve a specific case scenario.

Mometasone furoate nasal spray: a systematic review

The inflammatory diseases of the nose, rhino-pharynx and paranasal sinuses (allergic and non allergic rhinitis, NARES; rhinosinusitis with/without nasal polyposis, adenoidal hypertrophy with/without middle ear involvement) clinically manifest themselves with symptoms and complications severely affecting quality of life and health care expenditure.

Intranasal administration of corticosteroids, being fast, simple, and not requiring cooperation, is the preferred way to treat the patients, to optimize their quality of life, at the same time minimizing the risk of exacerbations and complications.

Among the different topical steroids available on the market, we performed a comparative analysis in terms of effectiveness and safety between mometasone furoate (MF) and its main competitors.

Searching through Pub Med and Google Scholar and using as entries “mometasone furoate”, “rhinitis”, “sinusitis”, “asthma”, “polyposis”, “otitis media with effusion”, and “adenoid hypertrophy” we found 344 articles, 300 of which met the eligibility criteria.

Taking into account relevance and date of publication, a sample of 40 articles was considered for the review.

MF effectiveness for treatment and/or prophylaxis of nasal symptoms in seasonal and perennial allergic rhinitis has been fully established with a level of evidence Ia.

Even though it has not been assessed for MF in particular, topical steroids are the most appropriate treatment in mixed rhinitis and NARES.

In acute rhinosinusitis (ARS) evidences support their use as mono-therapy or as adjuvant to antibiotics for reducing the recurrence rate, and decrease the usage of related prescriptions and medical consultations.

In chronic rhinosinusitis (CRS) with Nasal polyposis, MF reduces polyps size, nasal congestion, improves quality of life and sense of smell and it is also effective in the treatment of daytime cough.

The topical use of MF has great efficacy in the management of adenoidal hypertrophy and otitis media of atopic children.

As regards the safety, MF has demonstrated an excellent safety profile: pregnant women can safely use it; no systemic effects on growth velocity and adrenal suppression have been shown; no changes in epithelial thickness or atrophy have been observed after long term administration of the drug.

Conclusions: MF has been demonstrated to be effective in the treatment of the inflammatory diseases of the nose and paranasal sinuses; when compared to its competitors it shows a greater symptom control; it is a reliable treatment in the long term thanks not only to its proven efficacy, but also to its safety being on the market since more than 17 years.

MACVIA clinical decision algorithm in adolescents and adults with allergic rhinitis

The selection of pharmacotherapy for patients with allergic rhinitis (AR) depends on several factors, including age, prominent symptoms, symptom severity, control of AR, patient preferences, and cost. Allergen exposure and the resulting symptoms vary, and treatment adjustment is required. Clinical decision support systems (CDSSs) might be beneficial for the assessment of disease control. CDSSs should be based on the best evidence and algorithms to aid patients and health care professionals to jointly determine treatment and its step-up or step-down strategy depending on AR control. Contre les MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon (MACVIA-LR [fighting chronic diseases for active and healthy ageing]), one of the reference sites of the European Innovation Partnership on Active and Healthy Ageing, has initiated an allergy sentinel network (the MACVIA-ARIA Sentinel Network). A CDSS is currently being developed to optimize AR control. An algorithm developed by consensus is presented in this article. This algorithm should be confirmed by appropriate trials.

Minimal Clinically Important Difference (MCID) in Allergic Rhinitis: Agency for Healthcare Research and Quality or Anchor-Based Thresholds?

BACKGROUND

In 2013, the Agency for Healthcare Research and Quality (AHRQ) recommended that allergic rhinitis (AR) studies calculate a minimal clinically important difference (MCID) based on an estimated threshold equal to 30% of the maximum total nasal symptom score. Applying this threshold, their data showed no differences between well-established treatments, and a subsequent analysis using prescribing information found no differences between active treatments and placebo controls.

OBJECTIVE

The objective of this study was to demonstrate the application of an evidence-based model to determine MCIDs for AR studies, with an absolute value for an anchor-based threshold and validated methods for calculating distribution-based thresholds.

METHODS

Using the same studies as the AHRQ report, anchor- and distribution-based MCID thresholds were determined for 3 clinical comparisons identified by the AHRQ: (1) oral antihistamine+intranasal corticosteroid (INCS) versus INCS, (2) montelukast versus INCS, and (3) intranasal antihistamine+INCS in a single device versus the monotherapies. The outcomes were compared with those reported using the AHRQ threshold.

RESULTS

No treatment comparison met the AHRQ-defined MCID threshold; all treatments were determined to be equivalent for all 3 queries. In contrast, the evidence-based model revealed some differences between treatments: INCS > montelukast; intranasal antihistamine+INCS > either monotherapy. No clinically relevant benefit was observed for adding an oral antihistamine to INCS, but some studies were not optimal choices for quantitative determination of MCIDs. Updating the literature search revealed no additional studies that met the AHRQ inclusion criteria.

CONCLUSIONS

The evidence-based threshold for MCID determination for AR studies should supersede the threshold recommended in the AHRQ report.

Clinically relevant outcome measures for new pharmacotherapy, allergen avoidance and immunotherapy trials in allergic rhinoconjunctivitis

PURPOSE OF REVIEW

The purpose of this review is to provide a current overview on both primary and secondary measures of efficacy of therapeutic interventions for clinical trials in allergic rhinoconjunctivitis (ARC) patients. In particular, this review highlights similarities and differences regarding endpoints in trials involving allergen immunotherapy (AIT), pharmacotherapy and allergen avoidance and addresses unmet needs regarding these measures in the future.

RECENT FINDINGS

In 2014, the European Academy of Allergy and Clinical Immunology (EAACI) proposed a standard for the definition of the primary endpoint for AIT trials in ARC and, moreover, emphasized the advantages and disadvantages as well as unmet needs considering outcome measures for this treatment. Recently, as an (indirect) comparison of clinical efficacy of different interventions, the relative clinical impact (RCI) has been used to determine the percentage reduction of symptom scores in active versus placebo treatment.

SUMMARY

Several primary and secondary clinical endpoints of therapeutic interventions for clinical trials in ARC patients such as AIT or pharmacotherapy have been proposed by the U.S. Food and Drug Administration (FDA) as well as by the European Medicines Agency (EMA). Moreover, recommendations for the implication of these endpoints in clinical trials have been promoted by academia such as the World Allergy Organization (WAO) or the European Academy of Allergy and Clinical Immunology (EAACI).However, an urgent need for the future will be a thorough international harmonization regarding the definition of clinical endpoints, timing of assessments of clinical efficacy and determination of the clinically meaningful and relevant magnitude of efficacy of therapeutic interventions for clinical trials in ARC patients.

[Seasonality in asthma: Impact and treatments]

The role of seasons should be taken into account in the management of asthma. The environment varies between seasons and it is well documented that asthma is modulated by environment. Viruses cause asthma exacerbations peak, in winter, in adults while the peak is present in September in children. Allergens are probably a less powerful source of asthma exacerbation than viruses but pollen involvement in spring and summer and dust mites in autumn are indisputable. Air pollutants, present in summer during the hottest periods, are also highly involved in asthma exacerbations. Indoor air pollution, in winter, is also implicated in asthma disease. All these environmental factors are synergistic and increase the risk of asthma exacerbation. Therapies should be adapted to each season depending on environmental factors potentially involved in the asthma disease.