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Pérez Montero A, Sanz-Rosa D, Carnés J. Retrospective, Real Life Study on the Effectiveness and Safety of a Depigmented-Polymerized Subcutaneous Vaccine Containing a Mixture of Grasses and Olea europaea. Int Arch Allergy Immunol 2024:1-8. [PMID: 39089230 DOI: 10.1159/000540280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 06/21/2024] [Indexed: 08/03/2024] Open
Abstract
INTRODUCTION Allergen immunotherapy is the only modifying treatment of the natural course of respiratory allergic diseases; however, the lack of evidence leads to little inconclusive results. Real life studies are on the rise and are becoming a valuable tool to confirm and complement findings from clinical trials. The objective of this study was to evaluate the effectiveness and safety of a depigmented-polymerized undiluted subcutaneous extract of grass and olive pollen, under routine clinical practice conditions. METHODS This was an observational, retrospective, longitudinal, single-center study on the use of a 2-pollen (grass mix and Olea europaea) undiluted subcutaneous extract over at least 3 consecutive years. Data were collected from 76 patients (n = 44 female; median age: 12.5 years old) diagnosed with allergic rhinoconjunctivitis with/without allergic asthma due to sensitization to both grasses and O. europaea. Primary and secondary effectiveness endpoints were symptom severity, concomitant medication, and immunological profile before and after completing the immunotherapy. A 2-year follow-up of patients' symptoms and medication history after completing the subcutaneous immunotherapy (SCIT) was performed. RESULTS There was a significant improvement of symptoms and medication consumption after 3 years of SCIT treatment, and a significant decrease in specific IgE levels for grasses and O. europaea was observed after finishing the treatment. CONCLUSION Three years treatment of allergic patients using an undiluted mixture of two allergen extracts was shown to be safe and effective for rhinitis and asthma, with efficacy maintained for at least 2 years after finishing SCIT. These results reinforce the importance of real life clinical data in addition to those from clinical trials, helping to individualize allergic treatments.
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Affiliation(s)
- Ana Pérez Montero
- Alergology Hospital Universitario Quirónsalud Madrid, Madrid, Spain
- Department of Medicine, Faculty of Biomedicine and Health, Universidad Europea Madrid, Madrid, Spain
| | - David Sanz-Rosa
- Department of Medicine, Faculty of Biomedicine and Health, Universidad Europea Madrid, Madrid, Spain
| | - Jerónimo Carnés
- R&D Allery and Immunology Unit, LETI Pharma S.L, Madrid, Spain
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Gazi U, Bahceciler NN. Immune mechanisms induced by sublingual immunotherapy in allergic respiratory diseases. Clin Exp Immunol 2022; 209:262-269. [PMID: 35975953 PMCID: PMC9521660 DOI: 10.1093/cei/uxac075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/22/2022] [Accepted: 08/15/2022] [Indexed: 01/25/2023] Open
Abstract
Allergic respiratory diseases (ARDs) are still a major burden on global public health. Sublingual immunotherapy (SLIT) is a mode of allergen immunotherapy (AIT) which involves administration of the allergen under the tongue, and benefits from tolerogenic properties of the oral mucosa. Studies revealed reduced levels of eosinophilia and eosinophil-dominated inflammation in airways of both animals and humans after SLIT. SLIT was also suggested to lower basophil responsiveness and innate lymphoid cell-2 function in blood samples collected from patients with ARD. Moreover, apart from shifting pathogenic type 2 (TH2) to a type 1 (TH1) and protective regulatory (Treg) polarization of helper T-cell immune response, antibody isotype switch from IgE to IgG1, IgG2, IgG4 and IgA was also reported in patients with ARD receiving SLIT. Today, the literature on SLIT-mediated activities is still scarce and more studies are required to further enlighten the mechanisms utilized by SLIT for the induction of tolerance. The aim of this review is to summarize the current knowledge about the immune-regulatory mechanisms induced by SLIT against ARDs.
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Affiliation(s)
- Umut Gazi
- Department of Medical Microbiology and Clinical Microbiology, Faculty of Medicine, Near East University, Nicosia, Cyprus
| | - Nerin Nadir Bahceciler
- Department of Pediatrics, Division of Allergy and Immunology, Faculty of Medicine, Near East University, Nicosia, Cyprus
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3
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Yadav S, Singh S, Mandal P, Tripathi A. Immunotherapies in the treatment of immunoglobulin E‑mediated allergy: Challenges and scope for innovation (Review). Int J Mol Med 2022; 50:95. [PMID: 35616144 DOI: 10.3892/ijmm.2022.5151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/28/2022] [Indexed: 11/05/2022] Open
Abstract
Immunoglobulin E (IgE)‑mediated allergy or hypersensitivity reactions are generally defined as an unwanted severe symptomatic immunological reaction that occurs due to shattered or untrained peripheral tolerance of the immune system. Allergen‑specific immunotherapy (AIT) is the only therapeutic strategy that can provide a longer‑lasting symptomatic and clinical break from medications in IgE‑mediated allergy. Immunotherapies against allergic diseases comprise a successive increasing dose of allergen, which helps in developing the immune tolerance against the allergen. AITs exerttheirspecial effectiveness directly or indirectly by modulating the regulator and effector components of the immune system. The number of success stories of AIT is still limited and it canoccasionallyhave a severe treatment‑associated adverse effect on patients. Therefore, the formulation used for AIT should be appropriate and effective. The present review describes the chronological evolution of AIT, and provides a comparative account of the merits and demerits of different AITs by keeping in focus the critical guiding factors, such as sustained allergen tolerance, duration of AIT, probability of mild to severe allergic reactions and dose of allergen required to effectuate an effective AIT. The mechanisms by which regulatory T cells suppress allergen‑specific effector T cells and how loss of natural tolerance against innocuous proteins induces allergy are reviewed. The present review highlights the major AIT bottlenecks and the importantregulatory requirements for standardized AIT formulations. Furthermore, the present reviewcalls attention to the problem of 'polyallergy', which is still a major challenge for AIT and the emerging concept of 'component‑resolved diagnosis' (CRD) to address the issue. Finally, a prospective strategy for upgrading CRD to the next dimension is provided, and a potential technology for delivering thoroughly standardized AIT with minimal risk is discussed.
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Affiliation(s)
- Sarika Yadav
- Systems Toxicology and Health Risk Assessment Group, CSIR‑Indian Institute of Toxicology Research, Lucknow, Uttar Pradesh 226001, India
| | - Saurabh Singh
- Systems Toxicology and Health Risk Assessment Group, CSIR‑Indian Institute of Toxicology Research, Lucknow, Uttar Pradesh 226001, India
| | - Payal Mandal
- Food, Drugs and Chemical Toxicology Group, CSIR‑Indian Institute of Toxicology Research, Lucknow, Uttar Pradesh 226001, India
| | - Anurag Tripathi
- Systems Toxicology and Health Risk Assessment Group, CSIR‑Indian Institute of Toxicology Research, Lucknow, Uttar Pradesh 226001, India
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Kim JY, Hwang D, Jang M, Rhee CS, Han DH. Clinical effectiveness of house dust mite immunotherapy in mono- versus poly-sensitised patients with allergic rhinitis: a systematic review and meta-analysis. Rhinology 2021; 59:352-359. [PMID: 34180463 DOI: 10.4193/rhin20.588] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Selecting an appropriate allergen-specific immunotherapy (AIT) regimen for polysensitised allergic rhinitis (AR) patients is challenging for clinicians. Although previous studies showed comparable effectiveness of single-allergen AIT with house dust mite (HDM) extract between monosensitised and polysensitised AR patients, there is no systematic review and meta-analysis demonstrating the comparable effectiveness of HDM AIT. In this meta-analysis, we analysed nine studies to compare the clinical effectiveness of HDM AIT. The primary outcome was nasal symptom score and secondary outcomes were medication and quality of life scores. The changes in nasal symptom score after HDM AIT did not significantly differ between monosensitised and polysensitised patients. The clinical effectiveness of HDM AIT regarding medication and quality of life score was not significantly different between monosensitised and polysensitised patients). In conclusion, single-allergen AIT with HDM extract showed comparable clinical effectiveness between polysensitised and monosensitised patients with AR.
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Affiliation(s)
- J Y Kim
- Department of Otorhinolaryngology "Head and Neck Surgery, Ilsan Hospital, Dongguk University, Goyang, Gyeonggi, Korea 2 Interdisciplinary Program of Medical Informatics, Seoul National University College of Medicine, Seoul, Korea
| | - D Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - M Jang
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea
| | - C S Rhee
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul, Korea; Graduate School of Immunology, Seoul National University College of Medicine, Seoul, Korea; Institute of Allergy and Clinical Immunology, and Sensory Organ Research Institute, Seoul National University Biomedical Research Center, Seoul, Korea
| | - D H Han
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul, Korea
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5
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Bahceciler NN, Yuruker O. Planning and approach to allergen-specific immunotherapy in polyallergic patients. Immunotherapy 2020; 12:577-585. [PMID: 32436419 DOI: 10.2217/imt-2019-0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Allergy immunotherapy (AIT) is currently the only disease-modifying treatment for allergic-respiratory diseases. Polysensitization may increase the severity of current disease resulting in subsequent asthma development in patients with allergic rhinitis. Due to the absence of general recommendations for the practical approach to polysensitized patients, clinical management is not standardized. The correlation between sensitizations and clinical symptoms, elimination of possible pollen cross-reactivities and principles of homologous allergen groups will guide the allergists to deduce the most relevant allergens for AIT. In the highlight of the previously proposed approach strategies to polyallergic patients, hereby we propose a revised practical stepwise approach based on the current European Medicine Agency (EMA) guidelines. However, more supporting data from well-designed, controlled, future studies are needed to improve clinical management recommendations for AIT in polyallergic patients.
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Affiliation(s)
- Nerin N Bahceciler
- Near East University, Faculty of Medicine, Division of Pediatric Allergy & Immunology, Nicosia, Cyprus
| | - Ozel Yuruker
- University of Kyrenia, Faculty of Medicine, Division of Immunology, Kyrenia, Cyprus
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6
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Alvaro-Lozano M, Akdis CA, Akdis M, Alviani C, Angier E, Arasi S, Arzt-Gradwohl L, Barber D, Bazire R, Cavkaytar O, Comberiati P, Dramburg S, Durham SR, Eifan AO, Forchert L, Halken S, Kirtland M, Kucuksezer UC, Layhadi JA, Matricardi PM, Muraro A, Ozdemir C, Pajno GB, Pfaar O, Potapova E, Riggioni C, Roberts G, Rodríguez Del Río P, Shamji MH, Sturm GJ, Vazquez-Ortiz M. EAACI Allergen Immunotherapy User's Guide. Pediatr Allergy Immunol 2020; 31 Suppl 25:1-101. [PMID: 32436290 PMCID: PMC7317851 DOI: 10.1111/pai.13189] [Citation(s) in RCA: 137] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Allergen immunotherapy is a cornerstone in the treatment of allergic children. The clinical efficiency relies on a well-defined immunologic mechanism promoting regulatory T cells and downplaying the immune response induced by allergens. Clinical indications have been well documented for respiratory allergy in the presence of rhinitis and/or allergic asthma, to pollens and dust mites. Patients who have had an anaphylactic reaction to hymenoptera venom are also good candidates for allergen immunotherapy. Administration of allergen is currently mostly either by subcutaneous injections or by sublingual administration. Both methods have been extensively studied and have pros and cons. Specifically in children, the choice of the method of administration according to the patient's profile is important. Although allergen immunotherapy is widely used, there is a need for improvement. More particularly, biomarkers for prediction of the success of the treatments are needed. The strength and efficiency of the immune response may also be boosted by the use of better adjuvants. Finally, novel formulations might be more efficient and might improve the patient's adherence to the treatment. This user's guide reviews current knowledge and aims to provide clinical guidance to healthcare professionals taking care of children undergoing allergen immunotherapy.
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Affiliation(s)
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland.,Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland
| | - Mubeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Cherry Alviani
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK.,Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Elisabeth Angier
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Stefania Arasi
- Pediatric Allergology Unit, Department of Pediatric Medicine, Bambino Gesù Children's research Hospital (IRCCS), Rome, Italy
| | - Lisa Arzt-Gradwohl
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Domingo Barber
- School of Medicine, Institute for Applied Molecular Medicine (IMMA), Universidad CEU San Pablo, Madrid, Spain.,RETIC ARADYAL RD16/0006/0015, Instituto de Salud Carlos III, Madrid, Spain
| | - Raphaëlle Bazire
- Allergy Department, Hospital Infantil Niño Jesús, ARADyAL RD16/0006/0026, Madrid, Spain
| | - Ozlem Cavkaytar
- Department of Paediatric Allergy and Immunology, Faculty of Medicine, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Pasquale Comberiati
- Department of Clinical Immunology and Allergology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Clinical and Experimental Medicine, Section of Paediatrics, University of Pisa, Pisa, Italy
| | - Stephanie Dramburg
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Medical University, Berlin, Germany
| | - Stephen R Durham
- Immunomodulation and Tolerance Group; Allergy and Clinical Immunology, Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, UK.,the MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - Aarif O Eifan
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospitals NHS Foundation Trust, London, UK
| | - Leandra Forchert
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Medical University, Berlin, Germany
| | - Susanne Halken
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Max Kirtland
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Inflammation, Repair and Development, National Heart and Lung Institute, Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, UK
| | - Umut C Kucuksezer
- Aziz Sancar Institute of Experimental Medicine, Department of Immunology, Istanbul University, Istanbul, Turkey
| | - Janice A Layhadi
- Immunomodulation and Tolerance Group; Allergy and Clinical Immunology, Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, UK.,the MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK.,Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Inflammation, Repair and Development, National Heart and Lung Institute, Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, UK
| | - Paolo Maria Matricardi
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Medical University, Berlin, Germany
| | - Antonella Muraro
- The Referral Centre for Food Allergy Diagnosis and Treatment Veneto Region, Department of Women and Child Health, University of Padua, Padua, Italy
| | - Cevdet Ozdemir
- Institute of Child Health, Department of Pediatric Basic Sciences, Istanbul University, Istanbul, Turkey.,Faculty of Medicine, Department of Pediatrics, Division of Pediatric Allergy and Immunology, Istanbul University, Istanbul, Turkey
| | | | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Ekaterina Potapova
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Medical University, Berlin, Germany
| | - Carmen Riggioni
- Pediatric Allergy and Clinical Immunology Service, Institut de Reserca Sant Joan de Deú, Barcelona, Spain
| | - Graham Roberts
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK.,NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Paediatric Allergy and Respiratory Medicine (MP803), Clinical & Experimental Sciences & Human Development in Health Academic Units University of Southampton Faculty of Medicine & University Hospital Southampton, Southampton, UK
| | | | - Mohamed H Shamji
- Immunomodulation and Tolerance Group; Allergy and Clinical Immunology, Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, UK.,the MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - Gunter J Sturm
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
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7
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Matricardi PM, Dramburg S, Potapova E, Skevaki C, Renz H. Molecular diagnosis for allergen immunotherapy. J Allergy Clin Immunol 2020; 143:831-843. [PMID: 30850070 DOI: 10.1016/j.jaci.2018.12.1021] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/05/2018] [Accepted: 12/14/2018] [Indexed: 12/16/2022]
Abstract
The extensive use of allergen molecules in birth cohort studies revealed that atopic sensitization is a sequential IgE response to distinct non-cross-reacting molecules from the same allergenic source (ie, molecular spreading), starting with an initiator molecule. This phenomenon reaches different degrees of progression (monomolecular, oligomolecular, and polymolecular) according to the individual atopic propensity and allergen exposure, thus producing an extreme heterogeneity of IgE sensitization profiles in patient populations. In patients with allergic rhinitis, the broader the IgE molecular sensitization profile, the greater is the risk of asthma and other allergic comorbidities, such as oral allergy syndrome. Hence it has been proposed to anticipate immunologic intervention at disease onset (early allergen immunotherapy) or even earlier during the preclinical sensitization stage (allergen immunoprophylaxis). Diagnostic algorithms based on singleplex or multiplex molecular IgE tests allow the discrimination of genuine from cross-reacting sensitization and the selection of the right extracts for allergen immunotherapy composition. Patients with extreme molecular poly-sensitization and greater risk of asthma or other IgE-mediated comorbidities, can be easily identified by means of allergen microarray or macroarray procedures and might benefit from anti-IgE treatment. IgE molecular tests have opened the era of precision allergology, and their routine use should aim at cost-effectiveness, according to the principles of the Choosing Wisely initiative.
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Affiliation(s)
- Paolo Maria Matricardi
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité-University Medicine Berlin, Berlin, Germany.
| | - Stephanie Dramburg
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité-University Medicine Berlin, Berlin, Germany
| | - Ekaterina Potapova
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité-University Medicine Berlin, Berlin, Germany
| | - Chrysanthi Skevaki
- Institute of Laboratory Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Philipps University Marburg, German Center for Lung Research (DZL) Marburg, Marburg, Germany
| | - Harald Renz
- Institute of Laboratory Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Philipps University Marburg, German Center for Lung Research (DZL) Marburg, Marburg, Germany
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Alba P, Moreno V, Arias-Irigoyen J, Antón M, Parra A, Gómez-Fernández MC, Madariaga B, Martínez A, Begoña L. Safety evaluation of a multiallergen immunotherapy treatment in polyallergic patients. APOLO observational study. Immunotherapy 2020; 12:75-87. [PMID: 31902260 DOI: 10.2217/imt-2019-0187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Aim: Assessment of safety, tolerability and changes in global clinical impression with an multiallergen immunotherapy treatment without dilutional effect in polyallergic patients. Patients & methods: This observational prospective study included patients with allergic rhinitis-rhinoconjunctivitis with or without asthma between 5 and 60 years old receiving immunotherapy treatment with a mixture of two allergenic sources. All adverse events were recorded. Global clinical impression, tolerability subjective assessment and satisfaction were also assessed. Results: 130 patients were analyzed. Nine clinically relevant local adverse reactions were reported in six patients (4.6%). Six systemic reactions (grades 0-I) occurred in four patients (3.1%). Patients improved significantly in their global clinical impression. Good tolerability subjective assessment and satisfaction values were also observed. Conclusion: This multiallergen immunotherapy treatment without dilutional effect can be considered as a potential therapeutic alternative for polyallergic patients suffering from allergic rhinitis.
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Affiliation(s)
- Pilar Alba
- Hospital de Manises. Allergy Department, Manises, Valencia, Spain
| | | | | | - Mónica Antón
- Department of Allergy, Hospital Universitario del Vinalopó. Elche, Alicante, Spain
| | - Antonio Parra
- Department of Allergy, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | | | - Begoña Madariaga
- R&D Department, ROXALL Medicina España S.A., Zamudio, Bizkaia, Spain
| | - Alberto Martínez
- R&D Department, ROXALL Medicina España S.A., Zamudio, Bizkaia, Spain
| | - Leire Begoña
- R&D Department, ROXALL Medicina España S.A., Zamudio, Bizkaia, Spain
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Wheatley LM, Wood R, Nadeau K, Liu A, Zoratti E, Bacharier L, Brittain E, Calderon M, Casale T, Chipps B, Cox L, Creticos PS, Desai M, Dreborg S, Durham S, Gergen PJ, Gruchalla R, Nelson H, O'Hehir RE, Plaut M, Schwaninger JM, Tilles S, Vickery B, Wittenberg KM, Togias A. Mind the gaps: Clinical trial concepts to address unanswered questions in aeroallergen immunotherapy-An NIAID/AHRQ Workshop. J Allergy Clin Immunol 2019; 143:1711-1726. [PMID: 30731123 DOI: 10.1016/j.jaci.2019.01.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/08/2019] [Accepted: 01/22/2019] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- Lisa M Wheatley
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Md.
| | | | | | - Andrew Liu
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
| | | | | | - Erica Brittain
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Md
| | | | | | - Bradley Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, Calif
| | - Linda Cox
- Nova Southeastern University, Fort Lauderdale, Fla
| | | | - Manisha Desai
- Quantitative Sciences Unit, Stanford University, Stanford, Calif
| | | | | | - Peter J Gergen
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Md
| | | | | | - Robyn E O'Hehir
- Alfred Hospital and Monash University Medical School, Melbourne, Australia
| | - Marshall Plaut
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Md
| | - Julie M Schwaninger
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Md
| | | | - Brian Vickery
- North Carolina Children's Hospital, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kim M Wittenberg
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Md
| | - Alkis Togias
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Md
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10
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Chaaban MR, Mansi A, Tripple JW, Wise SK. SCIT Versus SLIT: Which One Do You Recommend, Doc? Am J Med Sci 2019; 357:442-447. [PMID: 31010469 DOI: 10.1016/j.amjms.2019.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 01/21/2019] [Accepted: 02/06/2019] [Indexed: 12/27/2022]
Abstract
Allergic rhinitis is a prevalent condition that has a significant impact on the quality of life of many patients. When initial therapy fails to control the symptoms, allergen immunotherapy (AIT) has been suggested as an option by the Joint Task Force on Practice Parameters. The 2 main forms of AIT are via subcutaneous and sublingual routes, called subcutaneous immunotherapy and sublingual immunotherapy, respectively. There is debate about which is the better option for patients with each method offering its own pros and cons. We present 2 patients with allergic rhinitisAR that were deemed good candidates for AIT and explore current evidence for both subcutaneous immunotherapy and sublingual immunotherapy. The advantages and disadvantages of each method are discussed with the goal of providing a framework for the physician when deciding on AIT for their patients. In addition, we explore the use of AIT in patients with asthma and atopic dermatitis as potential patient populations that may benefit from the treatment. We use the discussion to provide recommendations regarding which method of AIT is best suited for both our patients.
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Affiliation(s)
| | | | - Julia W Tripple
- Department of Internal Medicince, University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Sarah K Wise
- Department of Otolaryngology, Emory University, Atlanta, Georgia
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11
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Long-term efficacy of standardised specific subcutaneous immunotherapy in children with persistent allergic rhinitis due to multiple allergens including house dust mites. The Journal of Laryngology & Otology 2018; 132:230-235. [DOI: 10.1017/s0022215117002547] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AbstractObjectives:To observe the five-year efficacy of standardised specific subcutaneous immunotherapy for house dust mite allergy in monosensitised and polysensitised children with persistent allergic rhinitis.Methods:From January 2007 to August 2009, 236 children with persistent allergic rhinitis were divided into 2 groups: 1 group received standardised specific subcutaneous immunotherapy using house dust mite extract; the other received pharmacotherapy with intranasal corticosteroids and oral antihistamines. A total of 193 patients (106 in the immunotherapy group and 87 in the pharmacotherapy group) completed treatment. Scores for symptoms, total medication and quality of life were evaluated.Results:The subcutaneous immunotherapy group demonstrated a significant reduction in visual analogue scale scores, Rhinoconjunctivitis Quality of Life Questionnaire scores and total medication scores (p < 0.05) compared with the pharmacotherapy group. No significant differences in the visual analogue scale and Rhinoconjunctivitis Quality of Life Questionnaire scores were found between the polysensitised and monosensitised subgroups (p > 0.05). No serious adverse events occurred.Conclusion:Standardised subcutaneous immunotherapy has long-term efficacy for children with persistent allergic rhinitis. Single-allergen subcutaneous immunotherapy was appropriate for allergic rhinitis caused by multiple allergens, including house dust mites, in the paediatric population.
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12
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Abstract
Polysensitization, sensitization to more than one allergen, is a common feature of patients with allergic rhinitis, and may be a risk factor for subsequent development of allergic diseases, especially allergic asthma. However, a polysensitized patient does not necessarily have polyallergy, a documented, causal relationship between exposure to 2 or more specific, sensitizing allergens and the subsequent occurrence of relevant clinical symptoms of allergy. Allergen immunotherapy treatment strategy for the polysensitized patient in Europe is to treat the single or 2 most clinically relevant allergen(s), whereas patients in the United States are usually treated for all potential clinically relevant allergens.
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Navarro AM, Delgado J, Muñoz-Cano RM, Dordal MT, Valero A, Quirce S. Allergic respiratory disease (ARD), setting forth the basics: proposals of an expert consensus report. Clin Transl Allergy 2017; 7:16. [PMID: 28533901 PMCID: PMC5437581 DOI: 10.1186/s13601-017-0150-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 05/03/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The variability of symptoms observed in patients with respiratory allergy often hampers classification based on the criteria proposed in guidelines on rhinitis and asthma. OBJECTIVES We assessed specific aspects of allergic respiratory disease (ARD) that are not explicitly addressed in the guidelines in order to issue specific recommendations and thus optimize clinical practice. METHODS Using the Delphi technique, 40 Spanish allergists were surveyed to reach consensus on 71 items related to ARD. RESULTS Consensus was achieved for 95.7% of the items. These included the following: the clinical manifestations of ARD are heterogeneous and individual airborne allergens can be related to specific clinical profiles; the optimal approach in patients with ARD is based on the global assessment of rhinoconjunctivitis and asthma; aeroallergens are largely responsible for the clinical features and severity of the disease; and clinical expression is associated with the period of environmental exposure to the allergen. Pharmacological treatment of ARD is often based on the intensity of symptoms recorded during previous allergen exposures and cannot always be administered following a step-up approach, as recommended in clinical practice guidelines. Allergen immunotherapy (AIT) is the only option for overall treatment of respiratory symptoms using an etiological approach. AIT can modify the prognosis of ARD and should therefore be considered a valuable first-line treatment. CONCLUSIONS The present study highlights gaps in current asthma and rhinitis guidelines and addresses specific aspects of ARD, such as global assessment of both asthma and rhinitis or the specific role of variable allergen exposure in the clinical expression of the disease.
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Affiliation(s)
- Ana M. Navarro
- UGC of Allergy, Hospital El Tomillar , Carretera Alcalá - Dos Hermanas km 6, 41700 Dos Hermanas, Seville Spain
| | - Julio Delgado
- UGC of Allergy, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Rosa M. Muñoz-Cano
- Allergy Unit, Pneumology Department, Hospital Clinic, Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain
| | - M. Teresa Dordal
- Allergy Service, Hospital Municipal, Badalona Serveis Assistencials, Badalona, Spain
- Allergy Service, Sant Pere Claver Fundació Sanitària, Barcelona, Spain
| | - Antonio Valero
- Allergy Unit, Pneumology Department, Hospital Clinic, Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain
| | - Santiago Quirce
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Behalf of the ARD Study Group
- UGC of Allergy, Hospital El Tomillar , Carretera Alcalá - Dos Hermanas km 6, 41700 Dos Hermanas, Seville Spain
- UGC of Allergy, Hospital Universitario Virgen Macarena, Seville, Spain
- Allergy Unit, Pneumology Department, Hospital Clinic, Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain
- Allergy Service, Hospital Municipal, Badalona Serveis Assistencials, Badalona, Spain
- Allergy Service, Sant Pere Claver Fundació Sanitària, Barcelona, Spain
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
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Kuperstock JE, Brook CD, Ryan MW, Platt MP. Correlation between the number of allergen sensitizations and immunoglobulin E: monosensitization vs polysensitization. Int Forum Allergy Rhinol 2016; 7:385-388. [PMID: 27888643 DOI: 10.1002/alr.21890] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/23/2016] [Accepted: 10/25/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND The purpose of this study was to determine if total serum immunoglobulin E (IgE) could predict monosensitization compared to polysensitization in patients with allergic rhinitis (AR). METHODS This was a retrospective study of a cohort of 1073 patients who underwent allergy testing. Differences in total IgE level between unsensitized, monosensitized, and polysensitized subjects were calculated. Pearson correlation coefficient was calculated to determine whether there was a relationship between total IgE level and the number of positive allergen sensitizations. In addition, allergen sensitization class was calculated for each allergen sensitization and totaled for each patient. Pearson correlation coefficient was calculated to determine the relationship between total IgE level and weighted allergen sensitization by class. RESULTS There were 159 patients who were monosensitized compared to 492 patients who were polysensitized. Of the monosensitized patients, almost 50% (74) were sensitized to one or both dust mites. Total IgE was higher in polysensitized patients compared to monosensitized compared to controls (p < 0.001). Pearson correlation coefficient between total IgE and number of positive allergen sensitizations was 0.465 (p ≤ 0.001). Pearson correlation coefficient between total IgE and allergen class-weighted sensitizations was 0.529 (p ≤ 0.001). CONCLUSION IgE level can be used to predict monosensitization vs polysensitization. There is a moderate correlation between total IgE sensitization and the number of positive allergen sensitizations, as well as allergen class-weighted sensitizations.
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Affiliation(s)
- Jacob E Kuperstock
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, Boston, MA
| | - Christopher D Brook
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, Boston, MA
| | - Matthew W Ryan
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael P Platt
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, Boston, MA
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Tortajada-Girbés M, Mesa Del Castillo M, Larramona H, Lucas JM, Álvaro M, Tabar AI, Jerez MJ, Martínez-Cañavate A. Evidence in immunotherapy for paediatric respiratory allergy: Advances and recommendations. Allergol Immunopathol (Madr) 2016; 44 Suppl 1:1-32. [PMID: 27776895 DOI: 10.1016/j.aller.2016.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 09/05/2016] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
- M Tortajada-Girbés
- Paediatric Allergology and Pulmonology Unit, Dr. Peset University Hospital, Valencia, Spain; Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, Valencia, Spain.
| | - M Mesa Del Castillo
- Paediatric Allergology and Neumology Unit, Hospital El Escorial, Madrid, Spain
| | - H Larramona
- Paediatric Allergology and Pulmonology Unit, Department of Paediatrics, University Autonoma of Barcelona, and Corporacio Sanitaria Parc Tauli, Hospital of Sabadell, Barcelona, Spain
| | - J M Lucas
- Pediatric Allergy and Immunology Unit, Virgen Arrixaca Clinic Universitary Hospital, Murcia, Spain
| | - M Álvaro
- Allergy and Clinical Immunology Section, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - A I Tabar
- Servicio de Alergología. Complejo Hospitalario de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), RETIC de Asma, Reacciones adversas y Alérgicas (ARADYAL), Pamplona, Spain
| | - M J Jerez
- Publications Office of the European Union, Luxembourg
| | - A Martínez-Cañavate
- Paediatric Allergology and Neumology Unit, Complejo Hospitalario Universitario de Granada, Spain
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Soyyigit S, Guloglu D, Ikinciogullari A, Secil D, Oztuna D, Mungan D, Misirligil Z, Sin BA. Immunologic alterations and efficacy of subcutaneous immunotherapy with Dermatophagoides pteronyssinus in monosensitized and polysensitized patients. Ann Allergy Asthma Immunol 2016; 116:244-251.e2. [PMID: 26945497 DOI: 10.1016/j.anai.2016.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/17/2015] [Accepted: 01/07/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND There is a continuing debate about whether monoallergen subcutaneous immunotherapy (SCIT) is able to modulate immune and clinical responses toward main causal allergen in polysensitized patients. OBJECTIVE To investigate short-term immunologic changes and clinical effectiveness of SCIT with Dermatophagoides pteronyssinus in monosensitized and polysensitized patients who have rhinitis with or without asthma. METHODS Nineteen monosensitized and 24 polysensitized patients participated in this prospective, self-placebo-controlled, interventional study. Cluster immunotherapy with D pteronyssinus was administered after 2 months of placebo in both groups. Immunologic parameters, including CD203c expression on basophils after allergen stimulation, total IgE, specific IgE, and specific IgG4, were evaluated at baseline, after placebo, and after immunotherapy. Clinical effectiveness was assessed using monthly symptom-medication scores, visual analog scale, quality-of-life questionnaire, and nasal allergen provocation test. RESULTS At baseline, polysensitized patients had higher CD203c expression on basophils than monosensitized patients (P = .007). Activated basophils expressing CD203c, total IgE, and specific IgG4 were significantly increased after immunotherapy compared with baseline and placebo in the polysensitized group (P < .025). After immunotherapy, specific IgE and D pteronyssinus-induced CD203c expression were significantly higher in polysensitized than monosensitized patients (P < .05). The total symptom scores and the Mini Rhinoconjunctivitis Quality of Life Questionnaire scores in polysensitized patients and the visual analog scale scores in both groups were lower after immunotherapy compared with baseline and placebo (P < .025). Titrated nasal allergen provocation test with D pteronyssinus increased after immunotherapy in the monosensitized group (P < .05). CONCLUSION This study indicates that monosensitized and polysensitized patients have distinct humoral response and basophil behavior to SCIT. However, a single-allergen immunotherapy corresponding to the most clinically troublesome allergy in polysensitized patients can lead to early clinical efficacy comparable to that seen in monosensitized patients. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01795846.
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Affiliation(s)
- Sadan Soyyigit
- Division of Immunology and Allergic Diseases, Department of Chest Diseases, Ankara University, School of Medicine, Ankara, Turkey
| | - Deniz Guloglu
- Department of Pediatric Immunology and Allergy, Ankara University, School of Medicine, Ankara, Turkey
| | - Aydan Ikinciogullari
- Department of Pediatric Immunology and Allergy, Ankara University, School of Medicine, Ankara, Turkey
| | - Derya Secil
- Division of Immunology and Allergic Diseases, Department of Chest Diseases, Ankara University, School of Medicine, Ankara, Turkey
| | - Derya Oztuna
- Department of Biostatistics, Ankara University, School of Medicine, Ankara, Turkey
| | - Dilsad Mungan
- Division of Immunology and Allergic Diseases, Department of Chest Diseases, Ankara University, School of Medicine, Ankara, Turkey
| | - Zeynep Misirligil
- Division of Immunology and Allergic Diseases, Department of Chest Diseases, Ankara University, School of Medicine, Ankara, Turkey
| | - Betul Ayse Sin
- Division of Immunology and Allergic Diseases, Department of Chest Diseases, Ankara University, School of Medicine, Ankara, Turkey.
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Demoly P, Passalacqua G, Pfaar O, Sastre J, Wahn U. Management of the polyallergic patient with allergy immunotherapy: a practice-based approach. Allergy Asthma Clin Immunol 2016; 12:2. [PMID: 26759555 PMCID: PMC4709898 DOI: 10.1186/s13223-015-0109-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 12/22/2015] [Indexed: 11/21/2022] Open
Abstract
Background The great majority (60–80 %) of patients consulting specialist physicians for allergic respiratory disease are polysensitized and thus may be potentially clinically polyallergic. However, management approaches to allergen immunotherapy (AIT) in polysensitized and polyallergic patients are not standardized. Methods An international group of clinicians with in-depth expertise in AIT product development, clinical trials and clinical practice met to generate up-to-date, unambiguous, pragmatic guidance on AIT in polysensitized and polyallergic patients. The guidance was developed after reviewing (1) the current stance of regulatory bodies and learned societies, (2) the literature data on single- and multi-AIT and (3) the members’ confirmed clinical experience with polysensitized patients. Results AIT is safe and effective in polysensitized
and polyallergic patients, and should always be based on the identification of one or more clinically relevant allergens (based on the type and severity of symptoms, the duration of induced symptoms, the impact on quality of life and how difficult an allergen is to avoid). Single-AIT is recommended in polyallergic patients in whom one of the relevant allergens is nevertheless clearly responsible for the most intense and/or bothersome symptoms. Parallel 2-allergen immunotherapy or mixed 2-allergen immunotherapy is indicated in polyallergic patients in whom two causal relevant allergens have a marked clinical and QoL impact. In parallel 2-allergen immunotherapy (whether subcutaneous or sublingual), high-quality, standardized, single-allergen formulations must be administered with an interval of 30 min. Mixing of allergen extracts may be considered, as long as (1) the mixture is technically feasible, (2) the mixture is allowed from a regulatory standpoint, (3) the allergen doses are reduced in proportion to the number of components but are still at concentrations with demonstrated efficacy. Conclusions Physicians can prescribe AIT (preferably with high-quality, standardized, single-allergen formulations) with confidence in polysensitized and polyallergic patients by focusing on clinical/QoL relevance and safety.
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Affiliation(s)
- Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France ; Sorbonne Universités, UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, Paris, France
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino-IST, University of Genoa, Genoa, Italy
| | - Oliver Pfaar
- Center for Rhinology and Allergology, Wiesbaden, Germany ; Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty Mannheim, Universitatsmedizin Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Ulrich Wahn
- Department of Paediatric Pulmonology and Immunology, Charité Virchow-Klinikum, Humboldt University, Berlin, Germany
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Shah-Hosseini K, Mioc K, Hadler M, Karagiannis E, Mösges R. Optimum treatment strategies for polyallergic patients - analysis of a large observational trial. Curr Med Res Opin 2015; 31:2249-59. [PMID: 26366617 DOI: 10.1185/03007995.2015.1094653] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To document the effectiveness and safety of sublingual allergen immunotherapy (SLIT) with a five-grass pollen tablet (Oralair ) and compare different treatment options in a broad, non-selected population of patients in a real-world clinical setting. RESEARCH DESIGN AND METHODS This was a 2 year, open, prospective, multicenter, single-arm, non-interventional study. Patients with a history of clinically relevant allergic symptoms caused by grass pollen, confirmed by skin prick testing, received treatment with the five-grass pollen tablet. Concomitant treatment with symptomatic medication and/or additional SLIT or subcutaneous immunotherapy (SCIT) was permitted. Twelve-month data are presented here. Effectiveness was assessed comparing a combined rhinoconjunctivitis (RC) score derived from the severity of rhinitis and conjunctivitis symptoms under treatment with retrospective data of the previous year. RESULTS A total of 1408 patients participated in the study, of whom 434 were children/adolescents and 962 polyallergic. Compared with the grass pollen season preceding five-grass pollen tablet treatment, a statistically significant reduction of 49.9% was achieved in RC score for the total population (p < 0.001), and an improvement in overall health was perceived by 90.9% of patients. The overall population of polyallergic patients derived similar benefits from treatment with the five-grass pollen tablet as monoallergic patients. The percentage reduction in RC score was larger in polyallergic patients taking no additional therapy (60.2%) than in those taking concomitant symptomatic medication (38.1%) or allergen immunotherapy (AIT) (50.8%). Within the last of these groups, RC score improved by 47.6% among patients receiving additional SCIT, versus 54.8% with additional SLIT. Adverse drug reactions, reported in 15.3% of study participants, were mostly local in nature and mild or moderate in intensity. CONCLUSIONS After 1 year of treatment, polyallergic patients responded similarly to the five-grass pollen tablet as monoallergic patients. For polyallergic patients in whom additional treatment was needed, a second SLIT may be more beneficial than a SCIT or symptomatic co-medication.
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Affiliation(s)
- Kija Shah-Hosseini
- a a Institute of Medical Statistics, Informatics and Epidemiology (IMSIE), Faculty of Medicine, University of Cologne , Cologne , Germany
| | - Katharina Mioc
- a a Institute of Medical Statistics, Informatics and Epidemiology (IMSIE), Faculty of Medicine, University of Cologne , Cologne , Germany
| | | | | | - Ralph Mösges
- a a Institute of Medical Statistics, Informatics and Epidemiology (IMSIE), Faculty of Medicine, University of Cologne , Cologne , Germany
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Incorvaia C, Mauro M, Ridolo E. Sublingual immunotherapy for allergic rhinitis: where are we now? Immunotherapy 2015; 7:1105-10. [DOI: 10.2217/imt.15.72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Sublingual immunotherapy (SLIT) was introduced in the 1980s as a safer option to subcutaneous immunotherapy and in the latest decade achieved significant advances. Its efficacy in allergic rhinitis is supported by a number of meta-analyses. The development of SLIT preparations in tablets to fulfill the requirements of regulatory agencies for quality of allergen extracts made available optimal products for grass-pollen-induced allergic rhinitis. Preparations of other allergens based on the same production methods are currently in progress. A notable outcome of SLIT, that is shared with subcutaneous immunotherapy, is the evident cost–effectiveness, showing significant cost savings as early as 3 months from starting the treatment, that become as high as 80% compared with drug treatment in the ensuing years.
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Affiliation(s)
- Cristoforo Incorvaia
- Allergy/Pulmonary Rehabilitation, ICP Hospital, via Bignami 1, 20100 Milan, Italy
| | | | - Erminia Ridolo
- Department of Clinical & Experimental Medicine, University of Parma, Parma, Italy
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House Dust Mite Respiratory Allergy: An Overview of Current Therapeutic Strategies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:843-55. [PMID: 26342746 DOI: 10.1016/j.jaip.2015.06.019] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 05/15/2015] [Accepted: 06/01/2015] [Indexed: 01/24/2023]
Abstract
Although house dust mite (HDM) allergy is a major cause of respiratory allergic disease, specific diagnosis and effective treatment both present unresolved challenges. Guidelines for the treatment of allergic rhinitis and asthma are well supported in the literature, but specific evidence on the efficacy of pharmacotherapy treatment for known HDM-allergic patients is weaker. The standard diagnostic techniques--skin prick test and specific IgE testing--can be confounded by cross-reactivity. However, component-resolved diagnosis using purified and recombinant allergens can improve the accuracy of specific IgE testing, but availability is limited. Treatment options for HDM allergy are limited and include HDM avoidance, which is widely recommended as a strategy, although evidence for its efficacy is variable. Clinical efficacy of pharmacotherapy is well documented; however, symptom relief does not extend beyond the end of treatment. Finally, allergen immunotherapy has a poor but improving evidence base (notably on sublingual tablets) and its benefits last after treatment ends. This review identifies needs for deeper physician knowledge on the extent and impact of HDM allergy in respiratory disease, as well as further development and improved access to molecular allergy diagnosis. Furthermore, there is a need for the development of better-designed clinical trials to explore the utility of allergen-specific approaches, and uptake of data into guidance for physicians on more effective diagnosis and therapy of HDM respiratory allergy in practice.
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Ridolo E, Montagni M, Bonzano L, Senna G, Incorvaia C. Arguing the misconceptions in allergen-specific immunotherapy. Immunotherapy 2015; 6:587-95. [PMID: 24896627 DOI: 10.2217/imt.14.23] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Allergen immunotherapy (AIT) has a clear evidence of efficacy and safety, as shown by a number of meta-analyses. However, a number of issues limit the use of AIT, many of them being not actually supported by solid data from the literature. In particular, several contraindications to AIT deserve to be argued, being needed to accurately balance in single cases the benefits versus the disadvantages. This concerns comorbidities, such as autoimmune diseases and malignancies, concomitant drug treatments, particularly β-blockers and angiotensin-converting enzyme inhibitors, pregnancy, patient's age, the severity of asthma, allergen polysensitization and the period of starting the treatment. Another important aspect producing misconceptions on AIT is the quality of the allergen extracts, because currently a patient with respiratory allergy to a given source may be prescribed to treat his allergyby products with very different quality. Improving characterization and standardization of allergen extracts will pave the way to the general acknowledgment of AIT as an effective treatment.
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Affiliation(s)
- Erminia Ridolo
- Department of Clinical and Experimental Medicine, University of Parma, via Gramsci 14, 43100 Parma, Italy
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Sublingual immunotherapy in allergic rhinitis: efficacy, safety, adherence and guidelines. Clin Exp Otorhinolaryngol 2014; 7:241-9. [PMID: 25436040 PMCID: PMC4240478 DOI: 10.3342/ceo.2014.7.4.241] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 05/20/2013] [Accepted: 07/02/2013] [Indexed: 11/08/2022] Open
Abstract
Allergic rhinitis (AR) is a globally increasing health problem affecting the quality of life. Specific immunotherapy is an available causal treatment changing the basic allergic mechanisms of the disease. Over one hundred years, subcutaneous immunotherapy (SCIT) was developed and proved its efficacy but many adverse effects were recorded including anaphylaxis. In 1986, sublingual immunotherapy (SLIT) was introduced as an alternative solution to solve this problem. Our study aims to discuss SLIT from the points of efficacy, safety, adherence and guidelines developed. A literature search was conducted in Medline/PubMed and the Cochrane Library in January 2013 using the keywords "allergic rhinitis, sublingual immunotherapy, efficacy, safety, compliance, adherence, guidelines." All types of publications were included. We augmented our study by searching the reference lists of identified reviews. SLIT has been established in many guidelines as an evidence-based effective treatment in AR with safer profile than SCIT. The meta-analyses confirmed its efficacy and showed a significant reduction in both symptoms and medication scores. The most common recorded adverse effects were minor local effects in the mouth, gastrointestinal reactions with few cases of anaphylaxis and no fatality. Adherence is more favorable for SLIT mainly because it is safe, noninvasive and easily taken at home. We support the call to conduct large multi-centric studies to gain more statistical power and overcome the problem of heterogeneity observed in the meta-analyses.
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Vidal C, Enrique E, Gonzalo A, Moreno C, Tabar AI. Diagnosis and allergen immunotherapy treatment of polysensitised patients with respiratory allergy in Spain: an Allergists' Consensus. Clin Transl Allergy 2014; 4:36. [PMID: 25699172 PMCID: PMC4334589 DOI: 10.1186/2045-7022-4-36] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 09/29/2014] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Polysensitisation is common in patients with respiratory allergy in Spain. Selection of the best allergen immunotherapy (AIT) is difficult in polysensitised patients. The present study was designed to help allergists better identify relevant allergens in these patients and to improve the selection of AIT in Spain. METHODS Sixty-two Spanish allergists answered a survey containing 88 items divided into four groups: 1) general approach to polysensitised subjects; 2) sensitisation profile involving mite, animal dander and moulds; 3) grass and olive pollen co-sensitisation, and 4) other pollen polysensitisation profile (weed and tree pollen). The Delphi method was used. RESULTS A consensus was achieved for 83% of items (92%, 81%, 83% and 73% of the four groups analysed, respectively). Only polysensitised patients with clinical relevance should be considered polyallergic. A detailed medical history (clinical symptoms and medication) together with a profound knowledge of allergens present in the patient's environment are essential for diagnosis. Skin prick tests (SPTs) are not adequate to decide the clinical relevance of each allergen. Serum specific IgE against allergen sources adds value to SPT but molecular diagnosis, when possible, is strongly recommended, especially in pollen-allergic patients. Specific allergen challenge tests are difficult to perform and not recommended for daily practice. Regarding AIT composition, up to three allergens can be used in the same vaccine, but only related allergens may be mixed. In some cases more than one vaccine may be needed. CONCLUSION Some criteria have been established to improve diagnosis and AIT prescription in polysensitised patients.
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Affiliation(s)
- Carmen Vidal
- Allergy Departments of Complejo Hospitalario Universitario de Santiago, Rúa Ramón Baltar s/n, Santiago de Compostela, 15706 Spain
| | | | - Angeles Gonzalo
- Allergy Departments of Hospital Universitario Infanta Cristina, Badajoz, Spain
| | - Carmen Moreno
- Allergy Departments of Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Ana I Tabar
- Allergy Departments of Complejo Hospitalario de Navarra, Pamplona, Spain
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Calderon MA, Cox LS. Monoallergen sublingual immunotherapy versus multiallergen subcutaneous immunotherapy for allergic respiratory diseases: a debate during the AAAAI 2013 Annual Meeting in San Antonio, Texas. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:136-43. [PMID: 24607039 DOI: 10.1016/j.jaip.2013.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 12/18/2013] [Accepted: 12/30/2013] [Indexed: 02/03/2023]
Affiliation(s)
- Moises A Calderon
- Section of Allergy and Clinical Immunology, Imperial College London, National Heart and Lung Institute, Royal Brompton Hospital, London, United Kingdom.
| | - Linda S Cox
- College of Osteopathic Medicine, Nova Southeastern University, Davie, Fla
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Kim SH, Shin SY, Lee KH, Kim SW, Cho JS. Long-term Effects of Specific Allergen Immunotherapy Against House Dust Mites in Polysensitized Patients With Allergic Rhinitis. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2014; 6:535-40. [PMID: 25374753 PMCID: PMC4214974 DOI: 10.4168/aair.2014.6.6.535] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 05/03/2014] [Accepted: 05/04/2014] [Indexed: 01/07/2023]
Abstract
Purpose Allergen-specific immunotherapy is the only currently available treatment to modify the natural history of allergic rhinitis (AR). If patients are polysensitized, it is difficult to identify the allergen causing the allergic symptoms. We evaluated the effectiveness of immunotherapy against house dust mites (HDMs) in AR patients polysensitized to both HDMs and seasonal allergens. Methods Thirty AR patients polysensitized to both HDMs and seasonal allergens (group A) and 30 patients sensitized to HDMs only (group B) were enrolled in this study. All subjects who received immunotherapy against HDMs for more than 2 years were evaluated by the multiple allergen simultaneous test (MAST) to determine the specific IgE level in luminescence units, total eosinophil counts in peripheral blood, serum total IgE, total nasal symptom scores, and the rhinoconjunctivitis quality of life questionnaire (RQLQ) before and after immunotherapy. Results There were no statistical differences in levels of total and specific IgE, or total eosinophil count between the two groups. The total nasal symptom scores, RQLQ and medication scores significantly decreased after immunotherapy in both groups, however no significant differences were noted between the two groups. Conclusions We determined that the primary causative allergen of AR in Seoul, Korea is perennial allergens, such as HDMs, rather than seasonal allergens. This study provides a reference for the selection of allergens to use in immunotherapy for polysensitized AR patients living in an urban environment.
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Affiliation(s)
- Sang Hoon Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Seung Youp Shin
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Kun Hee Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sung Wan Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Joong Saeng Cho
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
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Migueres M, Dávila I, Frati F, Azpeitia A, Jeanpetit Y, Lhéritier-Barrand M, Incorvaia C, Ciprandi G. Types of sensitization to aeroallergens: definitions, prevalences and impact on the diagnosis and treatment of allergic respiratory disease. Clin Transl Allergy 2014; 4:16. [PMID: 24817997 PMCID: PMC4016618 DOI: 10.1186/2045-7022-4-16] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 03/25/2014] [Indexed: 12/27/2022] Open
Abstract
The type of allergic sensitization is of central importance in the diagnosis and treatment of respiratory allergic diseases. At least 10% of the general population (and more than 50% of patients consulting for respiratory allergies) are polysensitized. Here, we review the recent literature on (i) the concepts of polysensitization, paucisensitization, co-sensitization, co-recognition, cross-reactivity, cross-sensitization, and polyallergy, (ii) the prevalence of polysensitization and (iii) the relationships between sensitization status, disease severity and treatment strategies. In molecular terms, clinical polysensitization can be divided into cross-sensitization (also known as cross-reactivity, in which the same IgE molecule binds to several allergens with common structural features) and co-sensitization (the simultaneous presence of different IgEs binding to allergens that may not necessarily have common structural features). There is a strong overall association between sensitization in skin prick tests and total IgE values but there is debate as to whether IgE thresholds are useful guides to the presence or absence of clinical symptoms in individual cases. Molecular information from component-resolved techniques appears to be of value for diagnosis and treatment decisions. Polysensitization develops over time and is a risk factor for respiratory allergy (being associated with disease severity) and therefore has clinical relevance for treatment decisions. The subterm polysensitization has been defined as polysensitization to between two and four allergens. Polyallergy is defined as clinically confirmed allergy to two or more allergens. Single-allergen grass pollen allergen immunotherapy (AIT) is safe and effective in polysensitized patients, whereas multi-allergen AIT requires more supporting evidence. Given that AIT may be more efficacious in moderate-to-severe disease than in mild disease, polysensitization could be an indication for this type of treatment. There is a need for flowcharts or decision trees for choosing the allergens for AIT in polysensitized patients and polyallergic patients.
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Affiliation(s)
- Michel Migueres
- Service de Pneumologie et Allergologie, Clinique de L'Union, Saint-Jean, France
| | - Ignacio Dávila
- Allergy Department, IBSAL, University Hospital of Salamanca, Salamanca, Spain
| | | | | | | | | | | | - Giorgio Ciprandi
- Department of Medicine, IRCCS-Azienda Ospedaliera Universitaria San Martino, Genoa, Italy
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Molecular profile clustering of IgE responses and potential implications for specific immunotherapy. Curr Opin Allergy Clin Immunol 2013; 13:438-45. [DOI: 10.1097/aci.0b013e3283630ca5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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