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Rodríguez-Otero N, Ramírez-Mateo E, Plana MN, Heffler E, Antolín-Amérigo D. Cost-effectiveness of allergen immunotherapy. Curr Opin Allergy Clin Immunol 2024:00130832-990000000-00154. [PMID: 39364915 DOI: 10.1097/aci.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
PURPOSE OF REVIEW Allergic rhinitis is a relevant and global health problem affecting up to 5-50% of the general population and its prevalence is increasing due to climate change and pollution among other factors and counts among the 10 most frequent reasons for medical consultation, generating an important economic impact. Allergen immunotherapy (AIT) is the only allergy-disease-modifying treatment and there is plenty of evidence of its effectiveness with regards subcutaneous and oral routes of AIT.This narrative review article examines published literature in the last 24 months regarding the pharmacoeconomics of AIT versus standard of care treatment (SOC) for the treatment of allergic rhinitis and asthma. RECENT FINDINGS Farraia et al. assessed in 2022 subcutaneous immunotherapy (SCIT, _438/$500.28) and sublingual immunotherapy (SLIT) (_1021/$1116.19) plus symptomatic treatment versus SOC treatment in children with HDM-driven allergic asthma, measuring QALYs, decrease of medication, decrease of exacerbations and symptoms. They used the cost-effective threshold: _18 482.80 ($21 110.14), finding that AIT is cost-effective.Also, SCIT and SLIT plus symptomatic treatment was assessed versus SOC treatment in children with grass pollen allergic rhinitis. The authors concluded that SCIT (_933/$1065.67) and SLIT (_1408/ $1608.22) seem cost-effective, particularly SCIT. SUMMARY Allergen immunotherapy is cost-effective in the management of allergic rhinitis and asthma as compared with SOC alone. As most studies consider only during-treatment costs and no long-term benefits or preventive effects are being assessed, the real cost-effectiveness of allergen immunotherapy could be even higher.
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Affiliation(s)
- Natalia Rodríguez-Otero
- Servicio de Alergia, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) Madrid, Spain. University of Alcalá (UAH)
| | - Elena Ramírez-Mateo
- Servicio de Alergia, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) Madrid, Spain. University of Alcalá (UAH)
| | - Maria Nieves Plana
- Health Technology Assessment Unit. Ramón y Cajal University Hospital, IRYCIS
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Enrico Heffler
- Department of Biomedical Sciences - Humanitas University, Pieve Emanuele (MI)
- Personalized Medicine Asthma and Allergy - IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Darío Antolín-Amérigo
- Servicio de Alergia, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) Madrid, Spain. University of Alcalá (UAH)
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2
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Zemelka-Wiacek M, Agache I, Akdis CA, Akdis M, Casale TB, Dramburg S, Jahnz-Różyk K, Kosowska A, Matricardi PM, Pfaar O, Shamji MH, Jutel M. Hot topics in allergen immunotherapy, 2023: Current status and future perspective. Allergy 2024; 79:823-842. [PMID: 37984449 DOI: 10.1111/all.15945] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/10/2023] [Accepted: 11/04/2023] [Indexed: 11/22/2023]
Abstract
The importance of allergen immunotherapy (AIT) is multifaceted, encompassing both clinical and quality-of-life improvements and cost-effectiveness in the long term. Key mechanisms of allergen tolerance induced by AIT include changes in memory type allergen-specific T- and B-cell responses towards a regulatory phenotype with decreased Type 2 responses, suppression of allergen-specific IgE and increased IgG1 and IgG4, decreased mast cell and eosinophil numbers in allergic tissues and increased activation thresholds. The potential of novel patient enrolment strategies for AIT is taking into account recent advances in biomarkers discoveries, molecular allergy diagnostics and mobile health applications contributing to a personalized approach enhancement that can increase AIT efficacy and compliance. Artificial intelligence can help manage and interpret complex and heterogeneous data, including big data from omics and non-omics research, potentially predict disease subtypes, identify biomarkers and monitor patient responses to AIT. Novel AIT preparations, such as synthetic compounds, innovative carrier systems and adjuvants, are also of great promise. Advances in clinical trial models, including adaptive, complex and hybrid designs as well as real-world evidence, allow more flexibility and cost reduction. The analyses of AIT cost-effectiveness show a clear long-term advantage compared to pharmacotherapy. Important research questions, such as defining clinical endpoints, biomarkers of patient selection and efficacy, mechanisms and the modulation of the placebo effect and alternatives to conventional field trials, including allergen exposure chamber studies are still to be elucidated. This review demonstrates that AIT is still in its growth phase and shows immense development prospects.
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Affiliation(s)
| | - Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University Zurich, Davos, Switzerland
| | - Mübeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University Zurich, Davos, Switzerland
| | - Thomas B Casale
- Departments of Medicine and Pediatrics and Division of Allergy and Immunology, Joy McCann Culverhouse Clinical Research Center, University of South Florida, Tampa, Florida, USA
| | - Stephanie Dramburg
- Department of Pediatric Respiratory Care, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Karina Jahnz-Różyk
- Department of Internal Diseases, Pneumonology, Allergology and Clinical Immunology, Military Institute of Medicine-National Research Institute, Warsaw, Poland
| | - Anna Kosowska
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
- ALL-MED Medical Research Institute, Wroclaw, Poland
| | - Paolo M Matricardi
- Department of Pediatric Respiratory Care, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Pfaar
- Section of Rhinology and Allergy, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Mohamed H Shamji
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
- ALL-MED Medical Research Institute, Wroclaw, Poland
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3
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Vogelberg C, Klimek L, Brüggenjürgen B, Jutel M. Real-world evidence for the long-term effect of allergen immunotherapy: Current status on database-derived European studies. Allergy 2022; 77:3584-3592. [PMID: 36074052 PMCID: PMC10087412 DOI: 10.1111/all.15506] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/21/2022] [Accepted: 09/02/2022] [Indexed: 01/28/2023]
Abstract
Randomized controlled trials (RCTs) are the gold-standard for benefit-risk assessments during drug approval processes. Real-word data (RWD) and the resulting real-world evidence (RWE) are becoming increasingly important for assessing the effectiveness of drug products after marketing authorization showing how RCT results are transferred into real life care. The effectiveness of allergen immunotherapy (AIT) has been assessed in several RWE studies based on large prescription databases. We performed a literature search for retrospective cohort assessments of prescription databases in Europe to provide an overview on the methodology, long-term effectiveness outcomes, and adherence to AIT. Thirteen respective publications were selected. AIT was more effective in reducing the progression of allergic rhinitis (AR) compared to a non-AIT control group receiving only symptomatic treatment for AR for up to 6 years. The development and progression of asthma were hampered for most endpoints in patients treated with most preparations compared to the non-AIT group, receiving only anti-asthmatic medication. The results for "time to onset" of asthma were inconsistent. Adherence to AIT decreased during the recommended 3-year treatment period, however, in most studies higher adherence to subcutaneous than to sublingual AIT was shown. The analysis of long-term effectiveness outcomes of the RWE studies based on prescription databases confirms the long-term efficacy of AIT demonstrated in RCTs. Progression of rhinitis and asthma symptoms as well as delayed onset of asthma triggered by different allergens, real life adherence to the treatment shows differences in particular application routes.
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Affiliation(s)
- Christian Vogelberg
- Department of Pediatric Pneumology and Allergology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Bernd Brüggenjürgen
- Institute for Healthcare Research and Technical Orthopedics, Medical University, Hannover, Germany
| | - Marek Jutel
- All-MED Medical Research Institute, Wrocław, Poland.,Department of Clinical Immunology, Wroclaw Medical University, Wrocław, Poland
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4
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Vogelberg C, Klimek L, Brüggenjürgen B, Jutel M. Real-world evidence for the long-term effect of allergen immunotherapy: Current status on database-derived European studies. Allergy 2022; 77:3584-3592. [PMID: 36074052 PMCID: PMC10087412 DOI: 10.1111/all.15506 10.1111/all.15506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/21/2022] [Accepted: 09/02/2022] [Indexed: 07/07/2023]
Abstract
Randomized controlled trials (RCTs) are the gold-standard for benefit-risk assessments during drug approval processes. Real-word data (RWD) and the resulting real-world evidence (RWE) are becoming increasingly important for assessing the effectiveness of drug products after marketing authorization showing how RCT results are transferred into real life care. The effectiveness of allergen immunotherapy (AIT) has been assessed in several RWE studies based on large prescription databases. We performed a literature search for retrospective cohort assessments of prescription databases in Europe to provide an overview on the methodology, long-term effectiveness outcomes, and adherence to AIT. Thirteen respective publications were selected. AIT was more effective in reducing the progression of allergic rhinitis (AR) compared to a non-AIT control group receiving only symptomatic treatment for AR for up to 6 years. The development and progression of asthma were hampered for most endpoints in patients treated with most preparations compared to the non-AIT group, receiving only anti-asthmatic medication. The results for "time to onset" of asthma were inconsistent. Adherence to AIT decreased during the recommended 3-year treatment period, however, in most studies higher adherence to subcutaneous than to sublingual AIT was shown. The analysis of long-term effectiveness outcomes of the RWE studies based on prescription databases confirms the long-term efficacy of AIT demonstrated in RCTs. Progression of rhinitis and asthma symptoms as well as delayed onset of asthma triggered by different allergens, real life adherence to the treatment shows differences in particular application routes.
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Affiliation(s)
- Christian Vogelberg
- Department of Pediatric Pneumology and AllergologyUniversity Hospital Carl Gustav Carus, Technical University DresdenDresdenGermany
| | - Ludger Klimek
- Center for Rhinology and AllergologyWiesbadenGermany
| | - Bernd Brüggenjürgen
- Institute for Healthcare Research and Technical Orthopedics, Medical UniversityHannoverGermany
| | - Marek Jutel
- All‐MED Medical Research InstituteWrocławPoland
- Department of Clinical ImmunologyWroclaw Medical UniversityWrocławPoland
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5
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Klimek L, Brehler R, Mösges R, Demoly P, Mullol J, Wang DY, O'Hehir RE, Didier A, Kopp M, Bos C, Karagiannis E. Update about Oralair® as a treatment for grass pollen allergic rhinitis. Hum Vaccin Immunother 2022; 18:2066424. [PMID: 35704772 PMCID: PMC9302518 DOI: 10.1080/21645515.2022.2066424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Sublingual immunotherapy (SLIT) is a well-tolerated, safe, and effective approach to treating allergic rhinitis (AR). Oralair® is a five-grass pollen SLIT tablet containing natural pollen allergens from five of the major grass species responsible for seasonal AR due to grass pollen allergy. Recommended use is in a pre-coseasonal regimen, starting daily treatment approximately 4 months before the start of the pollen season, with treatment then continued daily throughout the season; treatment should continue for 3–5 y. Clinical efficacy and safety of Oralair® in patients with grass pollen-induced AR has been demonstrated in a comprehensive clinical development program of randomized controlled trials. Effectiveness has been substantiated in subsequent observational studies with sustained efficacy following treatment cessation and a favorable level of adherence, quality of life, benefit, and satisfaction for the patients. Supportive evidence for a benefit in reducing the risk or delaying the development of allergic asthma is emerging.
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Affiliation(s)
- L Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | - R Brehler
- Department of Skin Diseases, Outpatient Clinic for Allergology, Occupational Dermatology and Environmental Medicine, Münster University Hospital, Münster, Germany
| | - R Mösges
- Institute of Medical Statistics and Computational Biology (IMSB), Medical Faculty of the University of Cologne, Cologne, Germany.,CRI - Clinical Research International Ltd, Hamburg, Germany.,ClinCompetence Cologne GmbH, Cologne, Germany
| | - P Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France.,Université, Equipe EPAR - IPLESPUMR-S 1136 INSERM-Sorbonne, Paris, France
| | - J Mullol
- Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic; Clinical & Experimental Respiratory Immunoallergy, IDIBAPS, CIBERES, University of Barcelona, Barcelona, Spain
| | - D Y Wang
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - R E O'Hehir
- Department of Allergy, Immunology and Respiratory Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - A Didier
- Pôle des Voies Respiratoires, Hôpital Larrey, CHU de Toulouse and Centre de Physiopathologie Toulouse Purpan, INSERM U1043, CNRS UMR 5282, Université Toulouse III, Toulouse, France
| | - M Kopp
- Clinic of Pediatric and Adolescent Medicine, Airway Research Center North (ARCN), Member of the German Lung Center (DZL), Lübeck University, Lübeck, Germany
| | - C Bos
- Global Medical Affairs Department, Stallergenes Greer, Antony, France
| | - E Karagiannis
- Global Medical Affairs Department, Stallergenes Greer, Antony, France
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6
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Augustin M. Sozioökonomische Bedeutung allergischer Erkrankungen. ALLERGO JOURNAL 2021. [DOI: 10.1007/s15007-021-4777-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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7
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Cox L. Pharmacoeconomics of allergy immunotherapy versus pharmacotherapy. Expert Rev Clin Immunol 2021; 17:255-268. [PMID: 33645387 DOI: 10.1080/1744666x.2021.1886079] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Introduction: The purpose of this review is to evaluate the cost-effectiveness of allergy immunotherapy (AIT) in the treatment of allergic rhinitis, asthma, and other allergic conditions.Area covered: An extensive search of the PubMed and Medline database (January 1996 up to June of 2020) was conducted using the search terms allergy immunotherapy, pharmacoeconomics, cost-effectiveness, allergic rhinitis, and asthma. Studies were included if they included information on the economics of AIT in comparison to pharmacotherapy in the treatment of allergic rhinitis or asthma either as actual costs or based on theoretical models. Systematic reviews were included if they included information about the cost-effectiveness of AIT.Most clinical trials found significant cost-savings with AIT. The cost-effective time-point ranged from a few months to several years after treatment initiation.. Cost savings were demonstrated as early as 3 months after treatment initiation and were as great as 80% less than SDT in some studies.Expert opinion: There is strong evidence in the collective literature that AIT is cost-effective as compared to SDT alone. The magnitude of AIT's cost-effectiveness is likely underestimated because most of the studies considered during treatment costs and not AIT's long-term benefits or preventive/prophylactic effects or its impact on co-morbid conditions.
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Affiliation(s)
- Linda Cox
- Department of Medicine, Associate Professor of Medicine Nova Southeastern University, Ft. Lauderdale, Florida, USA
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8
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Amat F, Labbé A. [Allergic immunotherapy in children and adolescents]. REVUE FRANCAISE D ALLERGOLOGIE 2020; 60:554-558. [PMID: 32922566 PMCID: PMC7474839 DOI: 10.1016/j.reval.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 11/21/2022]
Abstract
L’immunothérapie spécifique allergénique nécessite l’administration répétée d’allergènes dans le but de provoquer une tolérance clinique et immunologique. C’est la seule thérapeutique à visée étiologique qui permet de modifier l’évolution de la maladie en assurant une rémission après l’interruption de la procédure. La prévention de nouvelles sensibilisations par l’immunothérapie reste discutée. Nous envisagerons dans cette revue les principaux mécanismes immunologiques et les indications de l’immunothérapie chez l’enfant et l’adolescent.
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Affiliation(s)
- F Amat
- Service de pneumologie et d'allergologie pédiatrique-CRCM, hôpital Robert-Debré, Inserm UMRS1136 EPAR, Paris, France
| | - A Labbé
- UFR de médecine et des professions paramédicales, université Clermont-Auvergne, France
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9
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Di Bona D, Bilancia M, Albanesi M, Caiaffa MF, Macchia L. Cost-effectiveness of grass pollen allergen immunotherapy in adults. Allergy 2020; 75:2319-2329. [PMID: 32096242 DOI: 10.1111/all.14246] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/21/2019] [Accepted: 12/09/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Major scientific societies, such as the EAACI or the AAAAI, do not express any suggestion on which form of allergen immunotherapy (AIT) is to be preferred (subcutaneous immunotherapy, SCIT, vs sublingual immunotherapy, SLIT). This choice could depend on their relative pharmacoeconomic value. OBJECTIVE To assess the cost-effectiveness of AIT for grass pollen, administered as SCIT or SLIT. METHODS We created a Markovian Model, to evaluate, in a hypothetical cohort of adult patients suffering from moderate-to-severe rhino-conjunctivitis with or without allergic asthma, the cost-effectiveness of SLIT (tablets, Grazax® and Oralair® ) or SCIT (various currently available products, plus indirect nonmedical costs, such as travel and productivity costs) in addition to pharmacological therapy, assuming a 9-year horizon to capture AIT long-term effects. The incremental cost-effectiveness ratio (ICER) was calculated assuming pharmacological therapy as the reference comparator. RESULTS In the base case, SCIT was slightly more expensive, but more effective than SLIT, being the most cost-effective option (ICER for SCIT, €11 418; ICER for SLIT, €15 212). ICERs greater than €120 000 for both SCIT and SLIT were demonstrated in a scenario assuming that low treatment persistence rates, which are common in real-life, lead to absence of long-term AIT clinical benefit. Considering indirect nonmedical costs SLIT resulted more cost-effective than SCIT (ICER for SCIT, €17 318; ICER for SLIT, €15 212). CONCLUSION In daily practice, AIT for grass pollens may be a cost-effective option only in patients with low discontinuation rates. SCIT, which is less affected by this limitation than SLIT, seems the most cost-effective AIT form.
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Affiliation(s)
- Danilo Di Bona
- Department of Emergency and Organ Transplantation School and Chair of Allergology and Clinical Immunology University of Bari Aldo Moro Bari Italy
| | - Massimo Bilancia
- Ionic Department in Legal and Economic System of Mediterranean: Society, Environment, Culture University of Bari Aldo Moro Bari Italy
| | - Marcello Albanesi
- Department of Emergency and Organ Transplantation School and Chair of Allergology and Clinical Immunology University of Bari Aldo Moro Bari Italy
| | | | - Luigi Macchia
- Department of Emergency and Organ Transplantation School and Chair of Allergology and Clinical Immunology University of Bari Aldo Moro Bari Italy
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Canonica GW, Devillier P, Casale T, Demoly P, Bos C, Karagiannis E, Passalacqua G, Wahn U, Mascarell L. Clinical efficacy of sublingual immunotherapy tablets for allergic rhinitis is unlikely to be derived from in vitro allergen-release data. Expert Rev Clin Immunol 2019; 15:921-928. [PMID: 31403823 DOI: 10.1080/1744666x.2019.1649597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Giorgio Walter Canonica
- Department of Internal Medicine, Humanitas University and Research Hospital ICH , Milan , Italy
| | - Philippe Devillier
- UPRES EA220, Foch Hospital, University Versailles Saint-Quentin, University Paris-Saclay , Suresnes , France
| | - Thomas Casale
- Department of Internal Medicine, University of South Florida , Tampa , FL , USA
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, University Hospital of Montpellier, Montpellier and INSERM UMRS 1136, Equipe - EPAR - IPLESP, Sorbonne Université, Hôpital Arnaud de Villeneuve , Paris , France
| | - Catherine Bos
- Department of Internal Medicine, Stallergenes Greer , Antony , France
| | | | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, University of Genoa , Genoa , Italy
| | - Ulrich Wahn
- Department of Paediatric Pneumology and Immunology, Charité Medical University , Berlin , Germany
| | - Laurent Mascarell
- Department of Internal Medicine, Stallergenes Greer , Antony , France
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Mösges R, Valero Santiago A, Allekotte S, Jahed N, Astvatsatourov A, Sager A, Sánchez-López J. Subcutaneous immunotherapy with depigmented-polymerized allergen extracts: a systematic review and meta-analysis. Clin Transl Allergy 2019; 9:29. [PMID: 31171962 PMCID: PMC6549305 DOI: 10.1186/s13601-019-0268-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 05/21/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Double-blind, placebo-controlled trials (DBPCTs) have confirmed the efficacy of allergen-specific immunotherapy (AIT) with depigmented-polymerized allergen extracts (DPAEs). This systematic review evaluates the efficacy of AIT using different allergens in different severity stages of rhinoconjunctivitis with or without asthma in the pollen studies and asthma and rhinitis in the house dust mite studies in comparison to placebo. METHODS We used MEDLINE, Embase, CENTRAL and LILACS databases to review DBPCTs published until July 2016. The combined symptom and medication score (cSMS) served as primary endpoint. The total rhinoconjunctivitis symptom score (RCSS) and total score in Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) were secondary efficacy endpoints. Solicited local and systemic adverse events were secondary safety endpoints. We assumed a random effects model with standardized mean differences (SMDs) or mean differences as summary statistics. In a subgroup analysis, we classified the studies following the GINA (Global Initiative for Asthma) and ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines for rhinoconjunctivitis and asthma severity. RESULTS Six DBPCTs in pollen and 2 trials in house dust mites (HDM) were selected. Patients (N = 915) with intermittent or mild persistent asthma were included in 3 (37.5%) and 5 (62.5%) trials, respectively. Two (25%) HDM studies included patients with moderate persistent asthma, 4 trials patients with moderate-to-severe rhinoconjunctivitis. Treatment periods ranged from 12 to 24 months. AIT with DPAEs yielded significantly lower cSMS (SMD: 1.9, 95% CI: 0.9-2.8) and RQLQ (SMD: 0.3, 95% CI: 0.1-0.5) values than did placebo. An exploratory analysis of cSMS and RCSS suggested that the efficacy of AIT treatment with DPAEs was higher in trials including patients with more severe rhinoconjunctivitis and asthma. A publication bias was not detected. Heterogeneity between individual studies was explained by differences in severity. Patients receiving DPAEs did not experience a significantly higher risk of local (OR: 1.55, 95% CI: 0.86-2.79) or systemic reactions (OR: 1.94, 95% CI: 0.98-3.84). CONCLUSIONS Compared to placebo, AIT with DPAEs is effective in patients with pollen- or HDM-induced rhinoconjunctivitis with or without allergic asthma and improves health-related quality of life. It does not differ significantly in safety and tolerability.
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Affiliation(s)
- Ralph Mösges
- CRI – Clinical Research International Ltd, Cologne, Germany
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Antonio Valero Santiago
- Department of Pulmonology and Respiratory Allergy, Hospital Clinic Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigaciones Biomedicas en Red de Enfermedades Respiratorias (CIBERES), Universitat de Barcelona, Barcelona, Spain
| | | | - Nilufar Jahed
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Anatoli Astvatsatourov
- Clinical Trials Centre Cologne, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Angelika Sager
- Laboratorios LETI, Gran Via de les Corts Catalanes 184, 08038 Barcelona, Spain
| | - Jaime Sánchez-López
- Laboratorios LETI, Gran Via de les Corts Catalanes 184, 08038 Barcelona, Spain
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12
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[Costs of allergic diseases and saving potential by allergen-specific immunotherapy : A personal assessment]. HNO 2019; 65:801-810. [PMID: 28900663 DOI: 10.1007/s00106-017-0410-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The burden of allergic diseases is of particular relevance for the economy and the social welfare and health insurance framework. Allergic rhinitis (AR) has a life-time prevalence of approximately 30% and is one of the most common chronic diseases with considerable socioeconomic impact thus leading to substantial direct, indirect and intangible costs. This article explores the common hypothesis that allergen-specific immunotherapy (ASIT) saves national economic expenses in the long term in comparison to other standard symptomatic treatment or no therapy. METHODS We conducted a selective search and analysis of the literature in PubMed and Medline including otherwise listed publications in German. Using a predefined model and data extrapolation over 9 years for data from different sources and short-term clinical studies we further discuss the problems and difficulties in analyzing heterogeneous datasets. RESULTS Using a health-economic model with currently available and accepted variables ASIT proves to be cost-effective in comparison to symptomatic treatment in allergic rhinitis; however, numerous parameters from other models have to be controlled, such as adherence to therapy and therapy discontinuation, heterogeneous costs for different treatment modalities, effect sizes with respect to symptoms including cross-influences with symptomatic rescue medication, duration of efficacy after treatment discontinuation and asthma protection. DISCUSSION The personal appraisal of the authors demonstrates not only the current knowledge but also the problems in health economical evaluation of ASIT in allergic diseases.
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Richter AK, Klimek L, Merk HF, Mülleneisen N, Renz H, Wehrmann W, Werfel T, Hamelmann E, Siebert U, Sroczynski G, Wasem J, Biermann-Stallwitz J. Impact of increasing treatment rates on cost-effectiveness of subcutaneous immunotherapy (SCIT) in respiratory allergy: a decision analytic modelling approach. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:1229-1242. [PMID: 29574666 DOI: 10.1007/s10198-018-0970-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 03/19/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Specific immunotherapy is the only causal treatment in respiratory allergy. Due to high treatment cost and possible severe side effects subcutaneous immunotherapy (SCIT) is not indicated in all patients. Nevertheless, reported treatment rates seem to be low. This study aims to analyze the effects of increasing treatment rates of SCIT in respiratory allergy in terms of costs and quality-adjusted life years (QALYs). METHODS A state-transition Markov model simulates the course of disease of patients with allergic rhinitis, allergic asthma and both diseases over 10 years including a symptom-free state and death. Treatment comprises symptomatic pharmacotherapy alone or combined with SCIT. The model compares two strategies of increased and status quo treatment rates. Transition probabilities are based on routine data. Costs are calculated from the societal perspective applying German unit costs to literature-derived resource consumption. QALYs are determined by translating the mean change in non-preference-based quality of life scores to a change in utility. Key parameters are subjected to deterministic sensitivity analyses. RESULTS Increasing treatment rates is a cost-effective strategy with an incremental cost-effectiveness ratio (ICER) of 3484€/QALY compared to the status quo. The most influential parameters are SCIT discontinuation rates, treatment effects on the transition probabilities and cost of SCIT. Across all parameter variations, the best case leads to dominance of increased treatment rates while the worst case ICER is 34,315€/QALY. Excluding indirect cost leads to a twofold increase in the ICER. CONCLUSIONS Measures to increase SCIT initiation rates should be implemented and also address improving adherence.
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Affiliation(s)
- Ann-Kathrin Richter
- Institute for Health Care Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany.
| | - Ludger Klimek
- Centre for Rhinology and Allergology, Wiesbaden, Germany
| | - Hans F Merk
- Clinic for Dermatology and Allergology, University Clinic RWTH, Aachen, Germany
| | | | - Harald Renz
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Philipps University, Marburg, Germany
| | - Wolfgang Wehrmann
- Dermatological Clinic Prof. Wehrmann, Dr. Rödder-Wehrmann and colleagues, Münster, Germany
| | - Thomas Werfel
- Division of Immunodermatology and Allergy Research, Dept of Dermatology and Allergy, Hannover Medical School, Hanover, Germany
| | - Eckard Hamelmann
- Children's Center Bethel, Protestant Hospital Bielefeld and Allergy Center Ruhr-University, Bochum, Germany
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, MGH-ITA, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Gaby Sroczynski
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Jürgen Wasem
- Institute for Health Care Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany
| | - Janine Biermann-Stallwitz
- Institute for Health Care Management and Research, University of Duisburg-Essen, Thea-Leymann-Str. 9, 45127, Essen, Germany
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Incorvaia C, Gritti BL, Ridolo E. The economic advantage of allergen immunotherapy over drug treatment in respiratory allergy. J Med Econ 2018; 21:553-555. [PMID: 29295630 DOI: 10.1080/13696998.2018.1423567] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
| | - Bruna L Gritti
- a Cardiac/Pulmonary Rehabilitation, ASST Pini/CTO , Milan , Italy
| | - Erminia Ridolo
- b Department of Clinical & Experimental Medicine , University of Parma , Parma , Italy
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Brüggenjürgen B, Reinhold T. Cost-effectiveness of grass pollen subcutaneous immunotherapy (SCIT) compared to sublingual immunotherapy (SLIT) and symptomatic treatment in Austria, Spain, and Switzerland. J Med Econ 2018; 21:374-381. [PMID: 29271271 DOI: 10.1080/13696998.2017.1419959] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND While specific immunotherapy (SIT) has been proven to be cost-effective for the treatment of allergic rhinitis compared to symptomatic treatment, there is a lack of European studies in which sublingual (SLIT) and subcutaneous (SCIT) immunotherapy were compared. The present analysis is focused on the cost-effectiveness of SCIT compared to SLIT and symptomatic treatment of grass pollen allergy in Austria, Spain, and Switzerland. It will address specific properties of the underlying healthcare systems. METHODS The investigation is based on a previously published health economic model calculation. This was designed as a Markov model with pre-defined health stages and a duration of 9 years covering specific preparations for SCIT (Allergovit) and SLIT (Oralair). The effectiveness was assessed as symptom-score based quality-adjusted life years (QALYs). Additionally, total cost has been determined as well as the cost-effectiveness of SCIT. The robustness of model results was proved in further sensitivity analyses. RESULTS With regard to the effectiveness of both SCIT and SLIT, preparations were dominant compared to pharmacological symptomatic therapy. Both strategies were associated with additional cost, but, combined with the results on effectiveness, both have to be regarded as cost-effective. A direct comparison of the SCIT (Allergovit) and SLIT (Oralair) showed lower total costs of SCIT vs SLIT for Austria, Spain, and Switzerland (€1,368 vs €2,012, €2,229 vs €2,547, and €1,901 vs €2,220) and superior effectiveness (SCIT =8.02 QALYs; SLIT =7.98 QALYs; and symptomatic therapy =7.90 QALYs). CONCLUSION In patients with allergic rhinitis, SIT offers cost-effective treatment options compared to symptomatic treatment. When comparing SCIT (Allergovit) and SLIT (Oralair), SCIT was dominant in terms of QALYs as well as costs, in particular due to a slightly higher patient compliance and lower drug costs.
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Affiliation(s)
- Bernd Brüggenjürgen
- a Institute for Health Economics, Steinbeis-Hochschule Berlin (SHB) , Berlin , Germany
| | - Thomas Reinhold
- b Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin , Germany
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Roberts G, Pfaar O, Akdis CA, Ansotegui IJ, Durham SR, Gerth van Wijk R, Halken S, Larenas-Linnemann D, Pawankar R, Pitsios C, Sheikh A, Worm M, Arasi S, Calderon MA, Cingi C, Dhami S, Fauquert JL, Hamelmann E, Hellings P, Jacobsen L, Knol E, Lin SY, Maggina P, Mösges R, Oude Elberink JNG, Pajno G, Pastorello EA, Penagos M, Rotiroti G, Schmidt-Weber CB, Timmermans F, Tsilochristou O, Varga EM, Wilkinson JN, Williams A, Zhang L, Agache I, Angier E, Fernandez-Rivas M, Jutel M, Lau S, van Ree R, Ryan D, Sturm GJ, Muraro A. EAACI Guidelines on Allergen Immunotherapy: Allergic rhinoconjunctivitis. Allergy 2018; 73:765-798. [PMID: 28940458 DOI: 10.1111/all.13317] [Citation(s) in RCA: 430] [Impact Index Per Article: 71.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2017] [Indexed: 12/12/2022]
Abstract
Allergic rhinoconjunctivitis (AR) is an allergic disorder of the nose and eyes affecting about a fifth of the general population. Symptoms of AR can be controlled with allergen avoidance measures and pharmacotherapy. However, many patients continue to have ongoing symptoms and an impaired quality of life; pharmacotherapy may also induce some side-effects. Allergen immunotherapy (AIT) represents the only currently available treatment that targets the underlying pathophysiology, and it may have a disease-modifying effect. Either the subcutaneous (SCIT) or sublingual (SLIT) routes may be used. This Guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on AIT for AR and is part of the EAACI presidential project "EAACI Guidelines on Allergen Immunotherapy." It aims to provide evidence-based clinical recommendations and has been informed by a formal systematic review and meta-analysis. Its generation has followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included involvement of the full range of stakeholders. In general, broad evidence for the clinical efficacy of AIT for AR exists but a product-specific evaluation of evidence is recommended. In general, SCIT and SLIT are recommended for both seasonal and perennial AR for its short-term benefit. The strongest evidence for long-term benefit is documented for grass AIT (especially for the grass tablets) where long-term benefit is seen. To achieve long-term efficacy, it is recommended that a minimum of 3 years of therapy is used. Many gaps in the evidence base exist, particularly around long-term benefit and use in children.
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Asaria M, Dhami S, van Ree R, Gerth van Wijk R, Muraro A, Roberts G, Sheikh A. Health economic analysis of allergen immunotherapy for the management of allergic rhinitis, asthma, food allergy and venom allergy: A systematic overview. Allergy 2018; 73:269-283. [PMID: 28718981 DOI: 10.1111/all.13254] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND The European Academy of Allergy and Clinical Immunology (EAACI) is developing guidelines for allergen immunotherapy (AIT) for the management of allergic rhinitis, allergic asthma, IgE-mediated food allergy and venom allergy. To inform the development of clinical recommendations, we undertook systematic reviews to critically assess evidence on the effectiveness, safety and cost-effectiveness of AIT for these conditions. This study focusses on synthesizing data and gaps in the evidence on the cost-effectiveness of AIT for these conditions. METHODS We produced summaries of evidence in each domain, and then, synthesized findings on health economic data identified from four recent systematic reviews on allergic rhinitis, asthma, food allergy and venom allergy, respectively. The quality of these studies was independently assessed using the Critical Appraisal Skills Programme tool for health economic evaluations. RESULTS Twenty-three studies satisfied our inclusion criteria. Of these, 19 studies investigated the cost-effectiveness of AIT in allergic rhinitis, of which seven were based on data from randomized controlled trials with economic evaluations conducted from a health system perspective. This body of evidence suggested that sublingual immunotherapy (SLIT) and subcutaneous immunotherapy (SCIT) would be considered cost-effective using the (English) National Institute for Health and Clinical Excellence (NICE) cost-effectiveness threshold of £20 000/quality-adjusted life year (QALY). However, the quality of the studies and the general lack of attention to characterizing uncertainty and handling missing data should be taken into account when interpreting these results. For asthma, there were three eligible studies, all of which had significant methodological limitations; these suggested that SLIT, when used in patients with both asthma and allergic rhinitis, may be cost-effective with an incremental cost-effectiveness ratio (ICER) of £10 726 per QALY. We found one economic modelling study for venom allergy which, despite being based largely on expert opinion and plausible assumptions, suggested that AIT for bee and wasp venom allergy is only likely to be cost-effective for very high-risk groups who may be exposed to multiple exposures to venom/year (eg bee keepers). We found no eligible studies investigating the cost-effectiveness of AIT for food allergy. CONCLUSIONS Overall, the evidence to support the cost-effectiveness of AIT is limited and of low methodological quality, but suggests that AIT may be cost-effective for people with allergic rhinitis with or without asthma and in high-risk subgroups for venom allergy. We were unable to draw any conclusions on the cost-effectiveness of AIT for food allergy.
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Affiliation(s)
- M. Asaria
- Centre for Health Economics; University of York; York UK
| | - S. Dhami
- Evidence-Based Health Care Ltd; Edinburgh UK
| | - R. van Ree
- Departments of Experimental Immunology and of Otorhinolaryngology; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - R. Gerth van Wijk
- Section of Allergology; Department of Internal Medicine; Erasmus MC; Rotterdam The Netherlands
| | - A. Muraro
- Food Allergy Referral Centre Veneto Region; Department of Women and Child Health; Padua General University Hospital; Padua Italy
| | - G. Roberts
- The David Hide Asthma and Allergy Research Centre; St Mary's Hospital, Newport Isle of Wight; NIHR Southampton Biomedical Research Centre; University Hospital Southampton NHS Foundation Trust; Southampton UK
- University of Southampton; Southampton UK
| | - A. Sheikh
- Asthma UK; Centre for Applied Research; Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; Edinburgh UK
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Dhami S, Nurmatov U, Arasi S, Khan T, Asaria M, Zaman H, Agarwal A, Netuveli G, Roberts G, Pfaar O, Muraro A, Ansotegui IJ, Calderon M, Cingi C, Durham S, Wijk RG, Halken S, Hamelmann E, Hellings P, Jacobsen L, Knol E, Larenas‐Linnemann D, Lin S, Maggina P, Mösges R, Oude Elberink H, Pajno G, Panwankar R, Pastorello E, Penagos M, Pitsios C, Rotiroti G, Timmermans F, Tsilochristou O, Varga E, Schmidt‐Weber C, Wilkinson J, Williams A, Worm M, Zhang L, Sheikh A. Allergen immunotherapy for allergic rhinoconjunctivitis: A systematic review and meta-analysis. Allergy 2017; 72:1597-1631. [PMID: 28493631 DOI: 10.1111/all.13201] [Citation(s) in RCA: 201] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing Guidelines on Allergen Immunotherapy (AIT) for Allergic Rhinoconjunctivitis. To inform the development of clinical recommendations, we undertook a systematic review to assess the effectiveness, cost-effectiveness, and safety of AIT in the management of allergic rhinoconjunctivitis. METHODS We searched nine international biomedical databases for published, in-progress, and unpublished evidence. Studies were independently screened by two reviewers against predefined eligibility criteria and critically appraised using established instruments. Our primary outcomes of interest were symptom, medication, and combined symptom and medication scores. Secondary outcomes of interest included cost-effectiveness and safety. Data were descriptively summarized and then quantitatively synthesized using random-effects meta-analyses. RESULTS We identified 5960 studies of which 160 studies satisfied our eligibility criteria. There was a substantial body of evidence demonstrating significant reductions in standardized mean differences (SMD) of symptom (SMD -0.53, 95% CI -0.63, -0.42), medication (SMD -0.37, 95% CI -0.49, -0.26), and combined symptom and medication (SMD -0.49, 95% CI -0.69, -0.30) scores while on treatment that were robust to prespecified sensitivity analyses. There was in comparison a more modest body of evidence on effectiveness post-discontinuation of AIT, suggesting a benefit in relation to symptom scores. CONCLUSIONS AIT is effective in improving symptom, medication, and combined symptom and medication scores in patients with allergic rhinoconjunctivitis while on treatment, and there is some evidence suggesting that these benefits are maintained in relation to symptom scores after discontinuation of therapy.
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Lombardi C, Melli V, Incorvaia C, Ridolo E. Pharmacoeconomics of sublingual immunotherapy with the 5-grass pollen tablets for seasonal allergic rhinitis. Clin Mol Allergy 2017; 15:5. [PMID: 28286421 PMCID: PMC5340071 DOI: 10.1186/s12948-017-0058-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 01/04/2017] [Indexed: 12/16/2022] Open
Abstract
Allergic rhinitis has a very high burden regarding both direct and indirect costs. This makes essential in the management of AR to reduce the clinical severity of the disease and thus to lessen its costs. This particularly concerns allergen immunotherapy (AIT), that, based on its immunological action on the causes of allergy, extends its benefit also after discontinuation of the treatment. From the pharmacoeconomic point of view, any treatment must be evaluated according to its cost-effectiveness, that is, the ratio between the cost of the intervention and its effect. A favorable cost-benefit ratio for AIT was defined, starting from the first studies in the 1990s on subcutaneous immunotherapy (SCIT) in AR patients, that highlighted a clear advantage on costs over the treatment with symptomatic drugs. Such outcome was confirmed also for sublingual immunotherapy (SLIT), that has also the advantage on SCIT to be free of the cost of the injections. Here we review the available literature on pharmacoeconomic data for SLIT with the 5-grass pollen tablets.
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Affiliation(s)
- Carlo Lombardi
- Allergy and Pneumology Departmental Unit, Fondazione Poliambulanza Hospital, Brescia, Italy
| | - Valerie Melli
- Department of Clinical & Experimental Medicine, University of Parma, Via Gramsci 14, Parma, Italy
| | | | - Erminia Ridolo
- Department of Clinical & Experimental Medicine, University of Parma, Via Gramsci 14, Parma, Italy
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Kosteneffektivität einer subkutanen Gräser-Pollen-Immuntherapie im Vergleich zu sublingualen und symptomatischen Therapieansätzen. ALLERGO JOURNAL 2017. [DOI: 10.1007/s15007-017-1272-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bas M. Evidence and evidence gaps of medical treatment of non-tumorous diseases of the head and neck. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2016; 15:Doc02. [PMID: 28025602 PMCID: PMC5169075 DOI: 10.3205/cto000129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Unfortunately, the treatment of numerous otolaryngological diseases often lacks of evidence base because appropriate studies are missing. Whereas sufficient high-quality trials exist for the specific immunotherapy of allergic rhinitis and in a limited measure also for the angiotensin-converting enzyme inhibitor induced angioedema, the evidence for Menière’s disease or for pharmacotherapy of postoperative laryngeal edema is rather poor. This contribution will discuss the trial situation and evidence of the respective diseases.
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Affiliation(s)
- Murat Bas
- Department of Otolaryngology, Technische Universität München, Germany
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Reinhold T, Brüggenjürgen B. Cost-effectiveness of grass pollen SCIT compared with SLIT and symptomatic treatment. ACTA ACUST UNITED AC 2016; 26:7-15. [PMID: 28217432 PMCID: PMC5288417 DOI: 10.1007/s40629-016-0002-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 06/13/2016] [Indexed: 01/26/2023]
Abstract
Background Whereas specific immunotherapy (SIT) has already been shown to be cost-effective in the treatment of allergic rhinitis compared with symptomatic treatment, only a small number of investigations have compared sublingual (SLIT) and subcutaneous (SCIT) immunotherapeutic approaches. This analysis discusses the cost-effectiveness of SCIT compared with SLIT and a symptomatic treatment modality. At the same time, particular attention is paid to preparation-specific characteristics. Methods The investigation is based on a previously published health economic model calculation. A Markov model, with predefined disease stages and a time period of 9 years, formed the basis of the analysis. The data on specific SCIT (Allergovit®) and SLIT (Oralair®) preparations required for the calculation were adjusted for the present analysis. Quality-adjusted life years (QALYs) based on symptom scores were calculated as the endpoint for effectiveness. Furthermore, the total costs and cost effectiveness of SCIT were determined. Model uncertainties were estimated by means of additional sensitivity analyses. Results With regard to effectiveness, both the SCIT and SLIT preparations proved superior compared to symptomatic treatment. Although more expensive, SIT seem to be cost-effective. A direct comparison of SCIT (Allergovit®) and SLIT (Oralair®) showed lower total costs for SCIT treatment over the study period (SCIT 1159 € versus SLIT 1322 €) and improved effectiveness (SCIT 7.112 QALYs versus SLIT 7.060 QALYs). Discussion SIT represents a cost-effective treatment option for patients with allergic rhinitis compared with symptomatic treatment. The comparison of SCIT (Allergovit®) and SLIT (Oralair®) showed SCIT to be predominant and cost-effective, due in particular to somewhat greater patient compliance and lower drug costs. It also became evident that, as far as possible, product-specific model variables are required for an economic evaluation of SIT treatment.
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Affiliation(s)
- Thomas Reinhold
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité - Universitätsmedizin Berlin, Luisenstraße 57, 10117 Berlin, Germany
| | - Bernd Brüggenjürgen
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité - Universitätsmedizin Berlin, Luisenstraße 57, 10117 Berlin, Germany.,Institute for Health Economy, Steinbeis University Berlin, Berlin, Germany
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International Consensus on Allergen Immunotherapy II: Mechanisms, standardization, and pharmacoeconomics. J Allergy Clin Immunol 2016; 137:358-68. [PMID: 26853128 DOI: 10.1016/j.jaci.2015.12.1300] [Citation(s) in RCA: 164] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 11/30/2015] [Accepted: 12/08/2015] [Indexed: 01/01/2023]
Abstract
This article continues the comprehensive international consensus (ICON) statement on allergen immunotherapy (AIT). The initial article also recently appeared in the Journal. The conclusions below focus on key mechanisms of AIT-triggered tolerance, requirements in allergen standardization, AIT cost-effectiveness, and regulatory guidance. Potential barriers to and facilitators of the use of AIT are described in addition to future directions. International allergy specialists representing the European Academy of Allergy and Clinical Immunology; the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the World Allergy Organization critically reviewed the existing literature and prepared this summary of recommendations for best AIT practice. The authors contributed equally and reached consensus on the statements presented herein.
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Abstract
PURPOSE OF REVIEW To evaluate the cost-effectiveness of allergen immunotherapy (AIT) in the treatment of allergic rhinitis and asthma. Individual studies and systematic reviews that included information on AIT economic outcomes as compared with symptomatic drug treatment (SDT) were evaluated. RECENT FINDINGS One systematic review that included 14 studies concluded that subcutaneous and sublingual immunotherapy may be cost-effective compared with SDT from around 6 years. Another systematic review of 24 studies comparing economic outcomes of subcutaneous allergy immunotherapy and/or sublingual allergy immunotherapy with SDT found compelling evidence for cost-savings with both forms of AIT over SDT. There was no strong evidence indicating superior cost-efficacy of subcutaneous allergy immunotherapy or sublingual allergy immunotherapy over SDT in either of these systematic reviews. Individual studies have demonstrated AIT cost-savings as high as 80% compared with SDT. Significant cost-savings were reported as early as 3 months after AIT initiation. In some studies, cost-efficacy time-point was not established until after treatment discontinuation - presumably due to time required for the clinical benefits to outweigh the AIT treatment costs. Although some economic modeling studies included the costs of 'asthma prevented', the collective literature of AIT economics provides very little to no information about the cost benefits of the preventive aspect of AIT. SUMMARY Overall, individual studies and systematic reviews provide strong evidence for the cost-effectiveness of AIT over SDT. The magnitude of cost-efficacy is likely underestimated in that few studies consider the cost-savings due to AIT's long-term benefits or preventive effect.
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Pre-Coseasonal vs Perennial Sublingual Immunotherapy for Seasonal Allergens Dosing Regimen: Long-Term Benefits, Adherence, and Cost-Effectiveness—Is There a Difference? CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0070-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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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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Comparative costs of subcutaneous and sublingual immunotherapy. Curr Opin Otolaryngol Head Neck Surg 2015; 23:226-9. [DOI: 10.1097/moo.0000000000000159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Demoly P, Calderon MA, Casale TB, Malling HJ, Wahn U. "The value of pre- and co-seasonal sublingual immunotherapy in pollen-induced allergic rhinoconjunctivitis". Clin Transl Allergy 2015; 5:18. [PMID: 25941566 PMCID: PMC4418040 DOI: 10.1186/s13601-015-0061-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/23/2015] [Indexed: 01/15/2023] Open
Abstract
Allergen immunotherapy (AIT) is a guidelines-approved, disease-modifying treatment option for respiratory allergies, including allergic rhinitis (AR) induced by pollen. The various AIT regimens employed to date in pollen-induced AR can be classified as continuous (i.e. year-round) or discontinuous (i.e. pre-seasonal alone, co-seasonal alone or pre- and co-seasonal). Pre-and co-seasonal regimens are typically used for sublingual allergen immunotherapy (SLIT) and have economic and compliance advantages over perennial (year-round) regimens. However, these advantages must not come at the expensive of poor efficacy or safety. The results of recent double-blind, placebo-controlled, randomized clinical trials show that pre- and co-seasonal SLIT is safe and effective in patients with AR induced by grass pollen (treated with a tablet formulation) or by birch pollen (treated with a liquid formulation). Progress in SLIT has been made in defining the optimal dose of major allergen, the administration frequency (daily), the duration of pre-seasonal treatment (four months) and the number of treatment seasons (at least three). Post-marketing, "real-life" trials of pre- and co-seasonal birch or grass pollen SLIT regimens have confirmed the efficacy and safety observed in the clinical trials. In the treatment of pollen-induced AR, pre- and co-seasonal SLIT regimens appear to be at least as effective and safe as perennial SLIT regimens, and are associated with lower costs and good compliance. Good compliance may mean that pre- and co-seasonal SLIT regimens are inherently more effective and safer than perennial SLIT regimens. When considering the pre- and co-seasonal discontinuous regimen in particular, a 300 IR five-grass-pollen formulation is the only SLIT tablet with a clinical development programme having provided evidence of short-term, sustained and post-treatment efficacy.
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Affiliation(s)
- Pascal Demoly
- />Allergy Division, Pulmonology Department, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
- />Sorbonne Universités, UPMC Paris 06, UMR-S 1136 INSERM, IPLESP, Equipe EPAR, Paris, France
| | - Moises A Calderon
- />Section of Allergy and Clinical Immunology, Imperial College London-NHLI, Royal Brompton Hospital, London, UK
| | - Thomas B Casale
- />Internal Medicine, Morsani College of Medicine University of South Florida, Tampa, FL, Omaha, NE USA
| | | | - Ulrich Wahn
- />Department of Paediatric Pneumology and Immunology, Charité Virchow-Klinikum, Humboldt University, Berlin, Germany
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Abstract
PURPOSE OF REVIEW Given the widespread prevalence of allergic disease, its substantially associated clinical and economic burden, the unique disease-modifying benefits of allergy immunotherapy (AIT), and increased availability of sublingual immunotherapy (SLIT), a critical update of the evidence for AIT-related cost savings [for both subcutaneous immunotherapy (SCIT) and SLIT] is particularly relevant and timely. The present article reviews the evidence for SCIT-related and SLIT-related cost savings derived from a systematic review of the published literature. RECENT FINDINGS Examined were 24 publications pertaining to the health economics of AIT. Except for one early study comparing the costs of AIT to symptomatic drug treatment (SDT), the remainder provide compelling evidence for AIT cost savings (whether SCIT or SLIT) over SDT. Furthermore, of the six studies comparing cost outcomes of SLIT to SCIT, four reported cost savings favoring SLIT. SUMMARY This review, spanning research from Southern Europe, Scandinavia, Northern Europe, North America, and the Czech Republic, encompasses a range of perennial and seasonal allergic conditions, including allergic asthma, allergic rhinitis with or without asthma, and rhinoconjunctivitis with or without allergic rhinitis due to house dust mite, grass or ragweed pollen, or a mixture of various allergens. All but one study compellingly demonstrate cost savings conferred by AIT over SDT.
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Verheggen BG, Westerhout KY, Schreder CH, Augustin M. Health economic comparison of SLIT allergen and SCIT allergoid immunotherapy in patients with seasonal grass-allergic rhinoconjunctivitis in Germany. Clin Transl Allergy 2015; 5:1. [PMID: 25691953 PMCID: PMC4330981 DOI: 10.1186/s13601-015-0045-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 01/02/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Allergoids are chemically modified allergen extracts administered to reduce allergenicity and to maintain immunogenicity. Oralair® (the 5-grass tablet) is a sublingual native grass allergen tablet for pre- and co-seasonal treatment. Based on a literature review, meta-analysis, and cost-effectiveness analysis the relative effects and costs of the 5-grass tablet versus a mix of subcutaneous allergoid compounds for grass pollen allergic rhinoconjunctivitis were assessed. METHODS A Markov model with a time horizon of nine years was used to assess the costs and effects of three-year immunotherapy treatment. Relative efficacy expressed as standardized mean differences was estimated using an indirect comparison on symptom scores extracted from available clinical trials. The Rhinitis Symptom Utility Index (RSUI) was applied as a proxy to estimate utility values for symptom scores. Drug acquisition and other medical costs were derived from published sources as well as estimates for resource use, immunotherapy persistence, and occurrence of asthma. The analysis was executed from the German payer's perspective, which includes payments of the Statutory Health Insurance (SHI) and additional payments by insurants. Comprehensive deterministic and probabilistic sensitivity analyses and different scenarios were performed to test the uncertainty concerning the incremental model outcomes. RESULTS The applied model predicted a cost-utility ratio of the 5-grass tablet versus a market mix of injectable allergoid products of € 12,593 per QALY in the base case analysis. Predicted incremental costs and QALYs were € 458 (95% confidence interval, CI: € 220; € 739) and 0.036 (95% CI: 0.002; 0.078), respectively. Compared to the allergoid mix the probability of the 5-grass tablet being the most cost-effective treatment option was predicted to be 76% at a willingness-to-pay threshold of € 20,000. The results were most sensitive to changes in efficacy estimates, duration of the pollen season, and immunotherapy persistence rates. CONCLUSIONS This analysis suggests the sublingual native 5-grass tablet to be cost-effective relative to a mix of subcutaneous allergoid compounds. The robustness of these statements has been confirmed in extensive sensitivity and scenario analyses.
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Affiliation(s)
- Bram G Verheggen
- Pharmerit International, Marten Meesweg, 107 3068AV Rotterdam, The Netherlands
| | | | | | - Matthias Augustin
- University Medical Center and Hamburg Center for Health Economics, Hamburg, Germany
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Leitlinie zur (allergen-)spezifischen Immuntherapie bei IgE-vermittelten allergischen Erkrankungen. ALLERGO JOURNAL 2014. [DOI: 10.1007/s15007-014-0707-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Didier A, Wahn U, Horak F, Cox LS. Five-grass-pollen sublingual immunotherapy tablet for the treatment of grass-pollen-induced allergic rhinoconjunctivitis: 5 years of experience. Expert Rev Clin Immunol 2014; 10:1309-24. [PMID: 25205329 DOI: 10.1586/1744666x.2014.957677] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Oralair(®) (OA) (Stallergenes, Antony, France) is a unique pre- and co-seasonal 5-grass-pollen sublingual immunotherapy tablet launched in 2008, and now approved in 31 countries worldwide for the treatment of grass-pollen allergic rhinitis and rhinoconjunctivitis. OA is the first oral treatment with a consistent, well-balanced allergen extract that mimics natural exposure and sensitization. A wealth of data exists from over 5 years of clinical and real-world experience demonstrating the efficacy and safety of OA for grass-pollen-allergy treatment. OA is highly effective from the first pollen season in all patient subgroups, including children and those with comorbid mild asthma, irrespective of sensitization status and symptom severity. OA also has sustained long-term benefits for symptom control and quality of life. This article provides an overview of the pharmacodynamics and pharmacology of OA; its efficacy, safety, tolerability and cost-effectiveness for the treatment of allergic rhinitis and rhinoconjunctivitis and its role in clinical practice.
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Affiliation(s)
- Alain Didier
- Department of Respiratory Diseases, Rangueil-Larrey Hospital, 24 Chemin de Pouvourville - TSA 30030, 31059 Toulouse Cedex 9, France
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Dranitsaris G, Ellis AK. Sublingual or subcutaneous immunotherapy for seasonal allergic rhinitis: an indirect analysis of efficacy, safety and cost. J Eval Clin Pract 2014; 20:225-38. [PMID: 24444390 DOI: 10.1111/jep.12112] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2013] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES The standard of preventive care for poorly controlled seasonal allergic rhinitis (AR) is subcutaneous immunotherapy (SCIT) with allergen extracts, administered in a physician's office. As an alternative to SCIT, sublingual immunotherapy (SLIT) is now an option for patients with seasonal AR. Oralair, a SLIT tablet containing freeze-dried allergen extracts of five grasses [cocksfoot (Dactylis glomerata), meadow grass (Poa pratensis), rye grass (Lolium perenne), sweet vernal grass (Anthoxanthum odoratum) and timothy grass (Phleum pratense)], and Grazax, a SLIT tablet containing a standardized extract of grass pollen allergen from timothy grass (P pratenase), are two such agents currently available in many countries. However, head-to-head comparative data are not available. In this study, an indirect comparison on efficacy, safety and cost was undertaken between Oralair, Grazax and SCIT. METHODS A systematic review was conducted for double-blind placebo-controlled randomized trials evaluating Oralair, Grazax or SCIT in patients with grass-induced seasonal AR. Using placebo as the common control, an indirect statistical comparison between treatments was performed using meta regression analysis with active drug as the primary independent variable. An economic analysis, which included both direct and indirect costs for the Canadian setting, was also undertaken. RESULTS Overall, 20 placebo-controlled trials met the study inclusion criteria. The indirect analysis suggested improved efficacy with Oralair over SCIT [standardized mean difference (SMD) in AR symptom control = -0.21; P = 0.007] and Grazax (SMD = -0.18; P = 0.018). In addition, there were no significant differences in the risk of discontinuation due to adverse events between therapies. Oralair was associated with cost savings against year-round SCIT ($2471), seasonal SCIT ($948) and Grazax ($1168) during the first year of therapy. CONCLUSIONS Oralair has at least non-inferior efficacy and comparable safety against SCIT and Grazax at a lower annual cost.
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Sublingual five-grass pollen tablets (Oralair®): a guide to their use as allergen immunotherapy for grass pollen-induced allergic rhinoconjunctivitis. DRUGS & THERAPY PERSPECTIVES 2014. [DOI: 10.1007/s40267-014-0131-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Pfaar O, Bachert C, Bufe A, Buhl R, Ebner C, Eng P, Friedrichs F, Fuchs T, Hamelmann E, Hartwig-Bade D, Hering T, Huttegger I, Jung K, Klimek L, Kopp MV, Merk H, Rabe U, Saloga J, Schmid-Grendelmeier P, Schuster A, Schwerk N, Sitter H, Umpfenbach U, Wedi B, Wöhrl S, Worm M, Kleine-Tebbe J, Kaul S, Schwalfenberg A. Guideline on allergen-specific immunotherapy in IgE-mediated allergic diseases: S2k Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Society for Pediatric Allergy and Environmental Medicine (GPA), the Medical Association of German Allergologists (AeDA), the Austrian Society for Allergy and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Dermatology (DDG), the German Society of Oto- Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), the German Society of Pediatrics and Adolescent Medicine (DGKJ), the Society for Pediatric Pneumology (GPP), the German Respiratory Society (DGP), the German Association of ENT Surgeons (BV-HNO), the Professional Federation of Paediatricians and Youth Doctors (BVKJ), the Federal Association of Pulmonologists (BDP) and the German Dermatologists Association (BVDD). ALLERGO JOURNAL INTERNATIONAL 2014; 23:282-319. [PMID: 26120539 PMCID: PMC4479478 DOI: 10.1007/s40629-014-0032-2] [Citation(s) in RCA: 247] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The present guideline (S2k) on allergen-specific immunotherapy (AIT) was established by the German, Austrian and Swiss professional associations for allergy in consensus with the scientific specialist societies and professional associations in the fields of otolaryngology, dermatology and venereology, pediatric and adolescent medicine, pneumology as well as a German patient organization (German Allergy and Asthma Association; Deutscher Allergie- und Asthmabund, DAAB) according to the criteria of the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). AIT is a therapy with disease-modifying effects. By administering allergen extracts, specific blocking antibodies, toler-ance-inducing cells and mediators are activated. These prevent further exacerbation of the allergen-triggered immune response, block the specific immune response and attenuate the inflammatory response in tissue. Products for SCIT or SLIT cannot be compared at present due to their heterogeneous composition, nor can allergen concentrations given by different manufacturers be compared meaningfully due to the varying methods used to measure their active ingredients. Non-modified allergens are used for SCIT in the form of aqueous or physically adsorbed (depot) extracts, as well as chemically modified allergens (allergoids) as depot extracts. Allergen extracts for SLIT are used in the form of aqueous solutions or tablets. The clinical efficacy of AIT is measured using various scores as primary and secondary study endpoints. The EMA stipulates combined symptom and medication scores as primary endpoint. A harmonization of clinical endpoints, e. g., by using the combined symptom and medication scores (CSMS) recommended by the EAACI, is desirable in the future in order to permit the comparison of results from different studies. The current CONSORT recommendations from the ARIA/GA2LEN group specify standards for the evaluation, presentation and publication of study results. According to the Therapy allergen ordinance (TAV), preparations containing common allergen sources (pollen from grasses, birch, alder, hazel, house dust mites, as well as bee and wasp venom) need a marketing authorization in Germany. During the marketing authorization process, these preparations are examined regarding quality, safety and efficacy. In the opinion of the authors, authorized allergen preparations with documented efficacy and safety, or preparations tradeable under the TAV for which efficacy and safety have already been documented in clinical trials meeting WAO or EMA standards, should be preferentially used. Individual formulations (NPP) enable the prescription of rare allergen sources (e.g., pollen from ash, mugwort or ambrosia, mold Alternaria, animal allergens) for specific immunotherapy. Mixing these allergens with TAV allergens is not permitted. Allergic rhinitis and its associated co-morbidities (e. g., bronchial asthma) generate substantial direct and indirect costs. Treatment options, in particular AIT, are therefore evaluated using cost-benefit and cost-effectiveness analyses. From a long-term perspective, AIT is considered to be significantly more cost effective in allergic rhinitis and allergic asthma than pharmacotherapy, but is heavily dependent on patient compliance. Meta-analyses provide unequivocal evidence of the efficacy of SCIT and SLIT for certain allergen sources and age groups. Data from controlled studies differ in terms of scope, quality and dosing regimens and require product-specific evaluation. Therefore, evaluating individual preparations according to clearly defined criteria is recommended. A broad transfer of the efficacy of certain preparations to all preparations administered in the same way is not endorsed. The website of the German Society for Allergology and Clinical Immunology (www.dgaki.de/leitlinien/s2k-leitlinie-sit; DGAKI: Deutsche Gesellschaft für Allergologie und klinische Immunologie) provides tables with specific information on available products for AIT in Germany, Switzerland and Austria. The tables contain the number of clinical studies per product in adults and children, the year of market authorization, underlying scoring systems, number of randomized and analyzed subjects and the method of evaluation (ITT, FAS, PP), separately given for grass pollen, birch pollen and house dust mite allergens, and the status of approval for the conduct of clinical studies with these products. Strong evidence of the efficacy of SCIT in pollen allergy-induced allergic rhinoconjunctivitis in adulthood is well-documented in numerous trials and, in childhood and adolescence, in a few trials. Efficacy in house dust mite allergy is documented by a number of controlled trials in adults and few controlled trials in children. Only a few controlled trials, independent of age, are available for mold allergy (in particular Alternaria). With regard to animal dander allergies (primarily to cat allergens), only small studies, some with methodological deficiencies are available. Only a moderate and inconsistent therapeutic effect in atopic dermatitis has been observed in the quite heterogeneous studies conducted to date. SCIT has been well investigated for individual preparations in controlled bronchial asthma as defined by the Global Initiative for Asthma (GINA) 2007 and intermittent and mild persistent asthma (GINA 2005) and it is recommended as a treatment option, in addition to allergen avoidance and pharmacotherapy, provided there is a clear causal link between respiratory symptoms and the relevant allergen. The efficacy of SLIT in grass pollen-induced allergic rhinoconjunctivitis is extensively documented in adults and children, whilst its efficacy in tree pollen allergy has only been shown in adults. New controlled trials (some with high patient numbers) on house dust mite allergy provide evidence of efficacy of SLIT in adults. Compared with allergic rhinoconjunctivitis, there are only few studies on the efficacy of SLIT in allergic asthma. In this context, newer studies show an efficacy for SLIT on asthma symptoms in the subgroup of grass pollen allergic children, adolescents and adults with asthma and efficacy in primary house dust mite allergy-induced asthma in adolescents aged from 14 years and in adults. Aspects of secondary prevention, in particular the reduction of new sensitizations and reduced asthma risk, are important rationales for choosing to initiate treatment early in childhood and adolescence. In this context, those products for which the appropriate effects have been demonstrated should be considered. SCIT or SLIT with pollen or mite allergens can be performed in patients with allergic rhinoconjunctivitis using allergen extracts that have been proven to be effective in at least one double-blind placebo-controlled (DBPC) study. At present, clinical trials are underway for the indication in asthma due to house dust mite allergy, some of the results of which have already been published, whilst others are still awaited (see the DGAKI table "Approved/potentially completed studies" via www.dgaki.de/Leitlinien/s2k-Leitlinie-sit (according to www.clinicaltrialsregister.eu)). When establishing the indication for AIT, factors that favour clinical efficacy should be taken into consideration. Differences between SCIT and SLIT are to be considered primarily in terms of contraindications. In individual cases, AIT may be justifiably indicated despite the presence of contraindications. SCIT injections and the initiation of SLIT are performed by a physician experienced in this type of treatment and who is able to administer emergency treatment in the case of an allergic reaction. Patients must be fully informed about the procedure and risks of possible adverse events, and the details of this process must be documented (see "Treatment information sheet"; available as a handout via www.dgaki.de/Leitlinien/s2k-Leitlinie-sit). Treatment should be performed according to the manufacturer's product information leaflet. In cases where AIT is to be performed or continued by a different physician to the one who established the indication, close cooperation is required in order to ensure that treatment is implemented consistently and at low risk. In general, it is recommended that SCIT and SLIT should only be performed using preparations for which adequate proof of efficacy is available from clinical trials. Treatment adherence among AIT patients is lower than assumed by physicians, irrespective of the form of administration. Clearly, adherence is of vital importance for treatment success. Improving AIT adherence is one of the most important future goals, in order to ensure efficacy of the therapy. Severe, potentially life-threatening systemic reactions during SCIT are possible, but - providing all safety measures are adhered to - these events are very rare. Most adverse events are mild to moderate and can be treated well. Dose-dependent adverse local reactions occur frequently in the mouth and throat in SLIT. Systemic reactions have been described in SLIT, but are seen far less often than with SCIT. In terms of anaphylaxis and other severe systemic reactions, SLIT has a better safety profile than SCIT. The risk and effects of adverse systemic reactions in the setting of AIT can be effectively reduced by training of personnel, adhering to safety standards and prompt use of emergency measures, including early administration of i. m. epinephrine. Details on the acute management of anaphylactic reactions can be found in the current S2 guideline on anaphylaxis issued by the AWMF (S2-AWMF-LL Registry Number 061-025). AIT is undergoing some innovative developments in many areas (e. g., allergen characterization, new administration routes, adjuvants, faster and safer dose escalation protocols), some of which are already being investigated in clinical trials. Cite this as Pfaar O, Bachert C, Bufe A, Buhl R, Ebner C, Eng P, Friedrichs F, Fuchs T, Hamelmann E, Hartwig-Bade D, Hering T, Huttegger I, Jung K, Klimek L, Kopp MV, Merk H, Rabe U, Saloga J, Schmid-Grendelmeier P, Schuster A, Schwerk N, Sitter H, Umpfenbach U, Wedi B, Wöhrl S, Worm M, Kleine-Tebbe J. Guideline on allergen-specific immunotherapy in IgE-mediated allergic diseases - S2k Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Society for Pediatric Allergy and Environmental Medicine (GPA), the Medical Association of German Allergologists (AeDA), the Austrian Society for Allergy and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Dermatology (DDG), the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), the German Society of Pediatrics and Adolescent Medicine (DGKJ), the Society for Pediatric Pneumology (GPP), the German Respiratory Society (DGP), the German Association of ENT Surgeons (BV-HNO), the Professional Federation of Paediatricians and Youth Doctors (BVKJ), the Federal Association of Pulmonologists (BDP) and the German Dermatologists Association (BVDD). Allergo J Int 2014;23:282-319.
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Affiliation(s)
- Oliver Pfaar
- />Center for Rhinology and Allergology, Wiesbaden, Germany
- />Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany
- />Center for Rhinology and Allergology Wiesbaden, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, An den Quellen 10, 65189 Wiesbaden, Germany
| | - Claus Bachert
- />Department of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
| | - Albrecht Bufe
- />Department of Experimental Pneumology, Ruhr-University Bochum, Bochum, Germany
| | - Roland Buhl
- />Pulmonary Department, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Christof Ebner
- />Outpatient Clinic for Allergy and Clinical Immunology, Vienna, Austria
| | - Peter Eng
- />Department of Children and Adolescent Medicine, Aarau and Children‘s Hospital Lucerne, Lucerne, Switzerland
| | - Frank Friedrichs
- />Pediatric and Adolescent Medicine Practice, Laurensberg, Germany
| | - Thomas Fuchs
- />Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Eckard Hamelmann
- />Department of Pediatric and Adolescent Medicine, Pediatric Center Bethel, Evangelical Hospital, Bielefeld, Germany
| | | | - Thomas Hering
- />Pulmonary Outpatient Practice, Tegel, Berlin, Germany
| | - Isidor Huttegger
- />Department of Pediatric and Adolescent Medicine, Paracelsus Private Medical University, Salzburg Regional Hospitals, Salzburg, Austria
| | | | - Ludger Klimek
- />Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Matthias Volkmar Kopp
- />Clinic of Pediatric and Adolescent Medicine, Lübeck University, Airway Research Center North (ARCN), Member of the German Lung Center (DZL), Lübeck, Germany
| | - Hans Merk
- />Department of Dermatology and Allergology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Uta Rabe
- />Department of Allergology, Johanniter-Krankenhaus im Fläming Treuenbrietzen GmbH, Treuenbrietzen Germany, Treuenbrietzen, Germany
| | - Joachim Saloga
- />Department of Dermatology, University Medical Center, Johannes-Gutenberg University, Mainz, Germany
| | | | - Antje Schuster
- />Center for Pediatric and Adolescent Medicine, University Medical Center, Düsseldorf, Germany
| | - Nicolaus Schwerk
- />University Children’s hospital, Department of Pediatric Pneumology, Allergology and Neonatology, Hanover Medical University, Hannover, Germany
| | - Helmut Sitter
- />Institute for Theoretical Surgery, Marburg University, Marburg, Germany
| | | | - Bettina Wedi
- />Department of Dermatology, Allergology and Venereology, Hannover Medical University, Hannover, Germany
| | | | - Margitta Worm
- />Allergy-Centre-Charité, Department of Dermatology, Venereology, and Allergology, Charité University Hospital, Berlin, Germany
| | | | - Susanne Kaul
- />Division of Allergology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
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Economic evaluation of 5-grass pollen tablets versus placebo in the treatment of allergic rhinitis in adults. Clin Drug Investig 2013; 33:343-9. [PMID: 23532801 PMCID: PMC3634979 DOI: 10.1007/s40261-013-0067-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Allergen immunotherapy (AIT) is aimed at modifying the immune response to a causative allergen, thereby reducing clinical symptoms and symptomatic medication intake and improving quality of life. Long-term AIT research has led to the development of 5-grass pollen tablets, currently indicated for the treatment of grass pollen-induced allergic rhinitis (AR). Methods A post-hoc analysis was conducted using the Average Adjusted Symptom Score (AAdSS) to compare the effect of treatment of AR with 5-grass pollen tablets versus placebo treatment. Using the results of the VO34.04 and VO53.06 trials and economic data, cost-effectiveness analysis of 5-grass pollen tablet treatment was performed from the Italian third-party payer perspective with cost data derived from a study of 2008 updated to 2011. Also a societal perspective was considered by using the costs related to the losses of productivity by following the human capital approach. Using the results of the analysis, the estimated receiver-operating characteristic curve was plotted to evaluate medication effectiveness in terms of quality-adjusted life years (QALYs) and a decision tree constructed to model the possible outcomes and costs for adults and paediatric patients with a low, medium, and high AAdSS. Finally, probabilistic sensitivity analysis was conducted to test the robustness of the results as well as their consistency at an assumed cost-effectiveness threshold of € 30,000/QALY. Results The results indicate that compared to the placebo, the 5-grass pollen tablet treatment provides a benefit of 0.127 QALYs in medium AAdSS patients and of 0.143 QALYs in high AAdSS patients. The 5-grass pollen tablet treatment was found to cost € 1,024/QALY for patients with a medium AAdSS and € 1,035/QALY for patients with a high AAdSS. Of all the simulations performed in the probabilistic sensitivity analysis, 99 % indicated that the incremental cost-effectiveness ratio of the 5-grass pollen tablet treatment was below the threshold of € 30,000/QALY in patients with medium and high AAdSS, whereas it was found to be dominated in 67 % of simulations related to patients with low AAdSS. Conclusion The 5-grass pollen tablet is a cost-effective treatment for adult AR patients with a medium or high AAdSS. This finding should be carefully considered when deciding the management strategy for these patients.
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Reinhold T, Ostermann J, Thum-Oltmer S, Brüggenjürgen B. Influence of subcutaneous specific immunotherapy on drug costs in children suffering from allergic asthma. Clin Transl Allergy 2013; 3:30. [PMID: 24004637 PMCID: PMC3868309 DOI: 10.1186/2045-7022-3-30] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 08/30/2013] [Indexed: 11/30/2022] Open
Abstract
Background Subcutaneous specific immunotherapy (SCIT) is an effective treatment attenuating
the progression of allergic asthma. To date, there is a lack of studies
investigating the economic consequences of SCIT on health care expenditures. Methods A health-economic piggy-back analysis of SCIT was conducted based on a RCT that
enrolled 65 children and adolescents with allergic asthma. Patients were allocated
into two groups: A group receiving SCIT with a high-dose hypoallergenic house dust
mite preparation plus asthma medication and a control group receiving only asthma
medication. For both groups asthma control was achieved before the start of the
SCIT treatment and was maintained during the study. Both, costs and
cost-effectiveness of SCIT with the high-dose hypoallergenic house dust mite
preparation were investigated based on total medication costs, incremental
medication costs and treatment effects (measured as lung function), respectively.
A bootstrap analysis was performed to validate the results. Results A steady decline in medication costs could be observed in the SCIT group one year
after treatment start compared to the control group. This cost trend became
statistically significant 3 years after SCIT started. The calculated potential
savings in the SCIT group correlated with an improved lung function. The
distribution of the bootstrap results revealed that the probability of SCIT having
a superior effectiveness compared to the control group is around 90%. Conclusion SCIT with a high-dose hypoallergenic preparation received by children and
adolescents suffering from mite induced allergic asthma reduces the allergic
medication intake and has cost-saving effects. Additional costs associated with
SCIT may be completely compensated by drug cost savings 4 years after end of SCIT.
Additionally, SCIT is superior compared to routine care as measured by the lung
function that improved in SCIT-treated patients. Trial registration: (EudraCT no.
2004 – 003892 – 35).
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Affiliation(s)
- Thomas Reinhold
- Institute for Social Medicine, Epidemiology and Health Economics, Charité, University Medical Center, Berlin, Germany.
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