Systemic Reactions to Dust Mite Subcutaneous Immunotherapy: A 3-Year Follow-up Study

Predicting allergen immunotherapy efficacy based on early maintenance phase response in routine clinical practice

Background

While allergen-specific immunotherapy (AIT) is acknowledged as an effective treatment, its efficacy varies, and consensus on predictive indicators for AIT responders remains elusive.

Objective

This study aimed to identify alternative parameters for predicting AIT responders based on clinical data collected in daily practice.

Method

We conducted a retrospective analysis of patients with house-dust-mite-driven asthma and/or rhinitis who completed 3 years of subcutaneous AIT (3y-AIT). We assessed the efficacy of AIT using the estimated daily symptom and medication score (edSMS) during different treatment periods, including up-dosing, maintenance I, II, and III phases. These scores were derived from detailed records of symptoms and medication use for AIT injections. A responder was defined as an individual with a reduction in edSMS of at least 30% from up-dosing to maintenance III phase (ΔedSMSU-M3).

Results

A cohort of 133 patients was analyzed, revealing a significant overall improvement in the disease condition after 3y-AIT. Responders demonstrated lower rates of polysensitization, daily tobacco smoke exposure, and milder pretreatment disease severity compared to non-responders (p = 0.003, p = 0.001, and p = 0.019, respectively). We observed 8 clinical response patterns among included subjects, but only a small group of patients (16/133, 12.03%) demonstrated consistent improvement throughout the 3y-AIT. Serum total immunoglobulin E (tIgE), specific immunoglobulin E (sIgE), sIgE/tIgE ratios, and edSMS during the up-dosing phase failed to differentiate the clinical response patterns or correlate with 3y-AIT efficacy. Notably, the reduction in edSMS from up-dosing phase to maintenance I phase (ΔedSMSU-M1) significantly associated with the 3y-AIT outcome (r = 0.443, p < 0.001). Receiver-operating characteristic curves indicated that ΔedSMSU-M1, with a cut-off of 18.40%, effectively predicted responders (AUC: 0.75, sensitivity: 76.20%, specificity: 76.70%).

Conclusion

The individualized clinical responses to AIT may pose challenges in identifying predictors for treatment efficacy. Nonetheless, despite this complexity, our study highlights that the effectiveness observed in the early maintenance phase serves as a suitable predictor of 3y-AIT outcomes.

Augmented type 2 inflammatory response in allergic rhinitis patients experiencing systemic reactions to house dust mite subcutaneous immunotherapy

BACKGROUND

Subcutaneous immunotherapy (SCIT) can induce systemic reactions (SRs) in certain patients, but the underlying mechanisms remain to be fully elucidated.

METHODS

AR patients who were undergoing standardized HDM SCIT (Alutard, ALK) between 2018 and 2022 were screened. Those who experienced two consecutive SRs were included in the study group. A control group was established, matched 1:1 by gender, age, and disease duration with the study group, who did not experience SRs during SCIT. Clinical and immunological parameters were recorded and analyzed both before SCIT and after 1 year of treatment.

RESULTS

A total of 161 patients were included, with 79 (49.07%) in the study group. The study group had a higher proportion of AR combined asthma (26.8% vs. 51.8%, p < 0.001) and higher levels of sIgE to HDM and HDM components (all p < .001). Serum IL-4 and IL-13 levels in the study group were higher than those in the control group (p < .05). The study group received a lower maintenance dosage of HDM extracts injections than control group due to SRs (50000SQ vs. 100000SQ, p < .05). After 1 year of SCIT, the VAS score, the lung function parameters of asthmatic patients over 14 years old significantly improved in both groups (all p < .05). After a 7-day exposure to 20 μg/mL HDM extracts, the percentages of Th1, Th17, Tfh10, and Th17.1 in PBMCs decreased, while the Tfh13 cells significantly increased in the study group (p < .05).

CONCLUSION

The type 2 inflammatory response is augmented in HDM-induced AR patients who experienced SRs during SCIT. Despite this, SCIT remains effective in these patients when administered with low-dosage allergen extracts.

Modification of allergen subcutaneous immunotherapy safety precautions and systemic allergic reaction rate reduction

Background: Despite their life-threatening potential, medical team mistakes during subcutaneous immunotherapy are rarely discussed. Real data are missing, and a survey study estimated that dosing errors are responsible for 25% of systemic reactions during immunotherapy. To minimize errors, we modified our safety precautions and compared the rates of systemic allergic reactions before and after the change. Methods: Our retrospective comparative cohort study compared systemic allergic reaction rates during 2012-2015 and 2016-2019, after a second check of the injected allergen/s by another nurse/physician was added to the treatment protocol. Results: The rate of systemic allergic reaction per injection was reduced from 0.93 to 0.71%; p = 0.023. Conclusion: A second check prior to injection is beneficial and can reduce the allergic reaction rate during immunotherapy.

A Survey of Airborne Fungi and Their Sensitization Profile in Wuhan, China

INTRODUCTION

Airborne fungi induce allergic symptoms in 3-10% of the population worldwide. To better prevent and manage fungi-related allergic diseases, it is essential to identify the genus and the distribution profile of airborne fungi.

METHODS

With this purpose in mind, we carried out a 12-month volumetric sampling study to monitor the airborne fungi and retrospectively analyzed the sensitization profile of four dominant fungi (Cladosporium, Alternaria, Aspergillus, and Penicillium) among respiratory allergies during the same study period in Wuhan, China.

RESULTS

A total of 29 different fungal genuses were identified, and the peak fungal concentration period was found to be in September and October, followed by May and June. The most prevalent fungi in this area were Cladosporium (36.36%), Ustilago (20.12%), and Alternaria (13.87%). In addition, the skin prick test data from 1,365 respiratory allergies patients showed that 202 (14.80%) of them were sensitized to fungi. The sensitization rates to Cladosporium, Alternaria, Aspergillus, and Penicillium were 11.72%, 4.69%, 1.98%, and 4.76%, respectively. The seasonal fluctuation of Alternaria and Aspergillus correlated with their sensitization rates. Among the fungal sensitized patients, 76 (37.62%) were sensitized to two or more kinds of fungi. The serum-specific IgE tests suggested low to high correlations existed between these fungi; however, these correlations were not found between fungi and other allergens.

CONCLUSION

Our study provides the distribution profile and reveals the clinical significance of the airborne fungi in Wuhan, which will facilitate the precise management of fungal allergy.

The early-phase transcriptome and the clinical efficacy analysis in three modes of subcutaneous immunotherapy for allergic rhinitis

Background

Allergen immunotherapy is the only etiological treatment for allergic rhinitis.

Objective

To analyze the efficacy, safety, and mechanism of subcutaneous immunotherapy (SCIT).

Methods

The efficacy, safety, and serum immunological changes of 3 modes of subcutaneous immunotherapy were compared. Peripheral blood mononuclear cells (PBMC) transcriptome changes were obtained on the Illumina sequencing platforms. We confirmed differentially expressed genes (DEGs) by quantitative real-time polymerase chain reaction (PCR). The DEGs were analyzed by gene ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and protein-protein interaction (PPI) networks. The correlation between the common DEGs and clinical indicators was analyzed by Origin 2022.

Results

The 3 SCITs were all effective after 1 year. The Combined Symptom and Medication Score (CSMS) and Visual Analog Score (VAS) in rush immunotherapy (RIT) are lowest after 24 and 48 weeks of treatment among the 3 groups. After treatment, the levels of sIgE, sIgE/tIgE, Th2 cytokines, Th17 cytokines, and percentage of peripheral eosinophils (EOS%) decreased significantly (P＜0.05), while the levels of Th1 type cytokines did not change significantly. Transcriptome analysis identified 24, 24, and 91 DEGs at W3 and 42, 52, 175 DEGs at W7 in conventional immunotherapy (CIT), cluster immunotherapy (CLIT), and RIT groups, respectively. The pathways and functions involved in SCIT include secretion of Th1/2 cytokines, immune cell differentiation. Unlike CIT and CLIT, DEGs are also involved in T cell tolerance induction, T cell anergy, and lymphocyte anergy in RIT. CXCR1, CXCR2, and IER3 had a specific effect on reflecting the improvement of symptoms in allergic rhinitis patients with SCIT.

Conclusion

The clinical efficacy of RIT appeared earlier than CIT and CLIT. Clinicians can use the highly conserved gene expression profile to evaluate responses to immunotherapy.

Efficacy and safety of house dust mite subcutaneous immunotherapy in polysensitized children with allergic asthma

INTRODUCTION

The aim of this study was to compare the efficacy and safety of 3 years of HDM subcutaneous immunotherapy (HDM-SCIT) in allergic asthma (AA) children with mono- and polysensitized.

METHODS

This was a retrospective observational study, 51 AA children (aged 4-14 years) who had completed 3 years of standardized HDM-SCIT were enrolled in. Based on skin prick tests (SPT) and allergen-specific IgE antibody (sIgE) test results, children were classified into two groups: the monosensitized group (n = 31) and the polysensitized group (n = 20). Total asthma symptoms score (TASS), total medication score (TMS), visual analog scale (VAS) scores, fractional exhaled nitric oxide (FeNO), lung function parameters, and adverse reactions were evaluated before treatment and at 6 months, 1, 2, 3 years of HDM-SCIT.

RESULTS

In terms of effectiveness, compared to baseline, TASS, TMS, VAS, FeNO and lung function parameters were significantly improved in both groups after 3 years of HDM-SCIT (all P < 0.05). The comparison between the two groups showed that efficacy indicators were no statistically significant difference at follow-up time points (all P > 0.05) except PEF%pred at 6 months (P = 0.048). In terms of security, the number of adverse reactions in both groups also no statistical difference between the two groups (all P > 0.05).

CONCLUSION

This study confirmed that no significant difference was observed in the clinical efficacy and safety of HDM-SCIT between mono-and polysensitized children with allergic asthma.

A single center retrospective study of systemic reactions' distribution and risk factors to subcutaneous immunotherapy with dust mite extract in patients with allergic rhinitis and/ or asthma

To analyze various risk factors including causes that may lead to adverse reactions, especially systemic adverse reactions（SRs）, before and after mite allergen subcutaneous immunotherapy (SCIT), so as to provide real-world reference data for further improving the safety of mite allergen SCIT. Methods: The local adverse reactions（LRs）and SRs of 230 patients with allergic rhinitis and/or asthma who received SCIT in Weifang people's hospital were analyzed retrospectively. The data of patient characteristics, drug factors and environmental elements of adverse reactions were collected and statistically analyzed. Results: There were 28 cases (12.2%) of SRs in 230 patients. All the patients received a total of 7515 injections and 37 SRs (0.49%) were observed. 32.4% (12/37) of SRs could identify their external and subjective triggers. SRs patients had higher 2-year SCIT compliance than no-SRs patients (p = 0.026). The prevalence of SRs in SCIT patients with atopic dermatitis or simple allergic asthma are no statistical significance (P = 0.111). Conclusion: the incidence of SRs in this study is within an ideal range. Through professional patient education and pre injection risk factor assessment, Compliance is still well-controlled and guaranteed although SRs occurred.

Chinese Guideline on Allergen Immunotherapy for Allergic Rhinitis: The 2022 Update

In the last few decades, there has been a progressive increase in the prevalence of allergic rhinitis (AR) in China, where it now affects approximately 250 million people. AR prevention and treatment include allergen avoidance, pharmacotherapy, allergen immunotherapy (AIT), and patient education, among which AIT is the only curative intervention. AIT targets the disease etiology and may potentially modify the immune system as well as induce allergen-specific immune tolerance in patients with AR. In 2017, a team of experts from the Chinese Society of Allergy (CSA) and the Chinese Allergic Rhinitis Collaborative Research Group (C2AR2G) produced the first English version of Chinese AIT guidelines for AR. Since then, there has been considerable progress in basic research of and clinical practice for AIT, especially regarding the role of follicular regulatory T (TFR) cells in the pathogenesis of AR and the use of allergen-specific immunoglobulin E (sIgE) in nasal secretions for the diagnosis of AR. Additionally, potential biomarkers, including TFR cells, sIgG4, and sIgE, have been used to monitor the incidence and progression of AR. Moreover, there has been a novel understanding of AIT during the coronavirus disease 2019 pandemic. Hence, there was an urgent need to update the AIT guideline for AR by a team of experts from CSA and C2AR2G. This document aims to serve as professional reference material on AIT for AR treatment in China, thus improving the development of AIT across the world.

Effectiveness and adverse reactions to subcutaneous immunotherapy in children with allergic rhinitis/asthma

OBJECTIVE

Adverse reactions, which are mostly local and rarely systemic, can be seen during subcutaneous immunotherapy (SCIT). It was not possible to continue SCIT at times due to systemic reactions. The purpose of the present study was to identify the incidence and risk factors associated with adverse reactions during subcutaneous allergen-specific immunotherapy (AIT).

METHODS

A total number of 344 patients under 18 years old with allergic rhinitis and/or asthma who underwent SCIT between 2005 and 2021 were included in the study. Demographic characteristics of the patients, laboratory findings [Total Immunglobulin E(IgE), aeroallergen prick test, inhaler, and allergen specific IgE(sIgE) and eosinophil counts], and adverse events observed during AIT were recorded retrospectively. Descriptive and univariate/multivariate logistic regression analyses were used to identify risk factors for adverse events.

RESULTS

Among 344 patients, 33.4% (n = 115) were female, mean age was 133.1 ± 41.0 months, and 42.2% (n = 145) were >12 years old. One hundred-thirty eight (40.1%) of the patients were mono-sensitized, 47 (13.7%) had asthma, 207 (60.2%) allergic rhinitis, and 90 (26.2%) asthma and allergic rhinitis. Single allergen content was administered to 187 (54.4%) patients (62 mite, 114 grass mix, 11 olea), and multiple allergens to 157 (45.6%) patients (121 pollen mix, 36 other (mite/alternaria)]. A total number of 33.008 injections were administered. 840 adverse reactions (262 (31.1%) at up-dosing phase, 578 (68.8%) at maintenance phase) in 195 (56.7%) patients were observed. Among the adverse reactions, 632 (75.2%) were local, 160 (19%) large local, and 48 (5.7%) (39 at maintenance, 9 at up-dosing) (in 31 patients) were systemic (28 Grade 1, 12 Grade 2, 8 Grade 3). Adrenalin was administered to 8 patients with Grade 3 systemic reaction (8/33008; %0.024). Adverse reactions, especially local ones, were seen more frequently in children under 12 years old (p < 0.001). Patients sensitized with grass pollen (p:0.01) and mite (p:0.004), and those who had received SCIT with pollen mixture had more adverse reactions than the others. More adverse reactions were observed in SCIT containing calcium-phosphate as adjuvant (p: 0.01). Local reactions were risk factors for large local (OR = 3.591, %95 CI:2.064-6.247, p < 0.001) and systemic (OR = 2.190, %95 CI:1.005-4.722 p = 0.046) reactions at univariate analyses. Total nasal symptom scores, Visual Analog Scale and asthma symptom control test decreased after one year of treatment (p < 0.01).

CONCLUSION

SCIT is a safe and effective treatment method in childhood that leads to improvements in all nasal symptoms and asthma after one year of treatment.

Effectiveness of Sublingual Immunotherapy in the Treatment of HDM-Induced Nasobronchial Allergies: A 3-Year Randomized Case-Control Study From Kashmir

Allergen immunotherapy (AIT) is the only disease-modifying treatment for allergic disorders that induces immunological tolerance through administration of specific allergens. Studies on AIT for subcutaneous route are in abundance; however, the efficacy of AIT in tablet form through sublingual route has not been well elucidated. The present prospective, parallel-group, controlled study sought to compare the efficacy of sublingual immunotherapy (SLIT) tablets with pharmacotherapy (PT) in 332 house dust mite (HDM)-specific allergic asthma and/or rhinitis patients over a period of 3 years. Patients were followed up for a 6-month run-in period and then randomly stratified as those who would receive SLIT, SLIT in addition to PT (SLIT+PT), and PT alone. AIT was administered in the form of sublingual tablets. Symptom and medication scores were measured every 3 months. In vitro evaluation of serum total and HDM specific immunoglobulin E (HDM sIgE) levels was carried out every 3 months, whereas in vivo skin prick test was performed annually for 3 years. Our study demonstrated sustained clinical improvement, reduction in inhaled corticosteroid (ICS) dose and duration as well as prevention from development of neosensitization to other aero allergens in HDM-allergic asthmatics and/or rhinitis patients treated with 3 years SLIT. Despite a remarkable clinical improvement with AIT, we observed that SLIT did not significantly change the skin reactivity to HDM at 3 years and there was no significant change in the ratio of serum total and HDM sIgE. Given the immune and disease modifying effects of AIT in allergic diseases, the present study supports the notion of its sublingual mode being an effective long-term immunomodulator in HDM-sensitized nasobronchial allergies.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Systemic reactions to subcutaneous immunotherapy for bronchial asthma and/or allergic rhinitis in children and their risk factors]

OBJECTIVE

To investigate the incidence of systemic reactions (SR) to subcutaneous immunotherapy (SCIT) for bronchial asthma and/or allergic rhinitis in children and their risk factors.

METHODS

A retrospective analysis was performed on 198 children with bronchial and/or allergic rhinitis. According to the presence or absence of SR and local reactions (LR) during SCIT, the patients were divided into two groups: SR (with SR and LR, n=31) and control (without SR or LR, n=142). A multivariate logistic regression analysis was used to determine the risk factors associated with SR.

RESULTS

Among the 198 patients who received 8 157 injections of SCIT, 25 (12.6%) experienced SR (31 times, 0.38%), including grade I SR (18 times, 58%), grade II SR (10 times, 32%), grade III SR (3 times, 10%), and no grade IV SR. The multivariate logistic regression analysis showed that multiple sensitization with both food and inhaled allergens, specific IgE to dust mites (grade 6), total IgE (grade 6), and a history of LR were independent risk factors for SR (P<0.05).

CONCLUSIONS

SCIT is a safe treatment for bronchial asthma and/or allergic rhinitis in children, with a low incidence of SR. Children with multiple sensitization with both food and inhaled allergens, a hypersensitive state (specific IgE to dust mites, grade 6; total IgE, grade 6), and a history of LR have an increased risk of SR to SCIT.

Systemic and large local reactions during subcutaneous grass pollen immunotherapy in children

BACKGROUND

Subcutaneous immunotherapy (SCIT) is the allergen-specific curative treatment of allergic rhinitis. Adverse effects, most of which are local, can be observed during the immunotherapy. These adverse effects have been reported more frequently during the pollen season. The purpose of this study was to estimate the rate of local, large local, and systemic reactions during the treatment, to determine the relationship between adverse reactions and the season in which these reactions occur, as well as the risk factors for adverse reactions during the grass pollen-specific SCIT treatment in children.

METHODS

We retrospectively collected and analyzed the data of 261 children who administered grass pollen SCIT between 2008 and 2018.

RESULTS

A total of 261 children (177, 67.8% male), who received grass pollen SCIT, with a mean (±SD) age of 12.0 ± 3.0 years at the initiation of SCIT were enrolled to the study. The number of the patients who experienced local and large local reactions was 109 and 30, respectively. In addition, the number of the patients with systemic reactions was 35. After the 12 284 injections, local reactions occurred in 357 (2.9%), and this was followed by systemic reaction as 55 (0.4%) and large local reactions as 40 (0.3%). Frequency of local (P < .001) and systemic reactions (P = .003) was higher during grass pollen season than out of the grass pollen season. In multivariate analysis, initiation of SCIT during the grass pollen season [OR:7.351, 95%CI:1.532-35.279, P = .013] and experiencing local reactions [OR:4.214, 95%CI:2.159-8.224, P < .001] were independent predictors for the development of large local and systemic reactions.

CONCLUSION

SCIT, in which only mild-to-moderate systemic reactions occurred, is safe for the treatment of allergic rhinitis in children. Our study revealed that previous local reactions and initiation of immunotherapy during the grass pollen season were the predictors for large local and systemic reactions during SCIT in children.

The efficacy and safety of two commercial house dust mite extracts for allergic rhinitis: a head-to-head study

BACKGROUND

Several studies have demonstrated the efficacy of house dust mite (HDM) immunotherapy in allergic rhinitis (AR). We aimed to compare the efficacy and safety of 2 commercial HDM extracts in a Chinese AR population.

METHODS

This was an open-label study. HDM-associated AR patients were randomized into Dermatophagoides pteronyssinus (Dp) extracts (Alutard SQ; ALK, Hørsholm, Denmark) and Dp/Dermatophagoides farinae (Df) extracts (NovoHelisen Depot [NHD]; Allergopharma, Reinbek, Germany) groups. All patients received subcutaneous injections for 1 year, and were followed every 3 months during that 1-year period. Symptom score, medication score, and adverse reactions were recorded. The primary endpoint was the total combined symptom and medication score (CSMS) during the efficacy evaluation period. Blood samples were taken for specific immunoglobulin E (IgE), IgG4, and IgE-blocking factor tests at baseline and after the 1-year treatment.

RESULTS

A total of 230 AR patients were randomized; 29 patients dropped out. Analysis of the primary endpoint demonstrated significant reductions in CSMS of 1.8 vs 3.1 (p < 0.001) in the Alutard group and 1.8 vs 3.3 (p < 0.001) in the NHD group compared with baseline. The 2 groups presented equal effectiveness with regard to CSMS, symptom score, and medication score (p > 0.05). The treatment was well tolerated in both groups; 17 (14.8%) patients experienced systemic reactions (SRs) in the Alutard group and 13 (11.3%) in the NHD group. The rates of SRs showed no difference in the 2 groups (p > 0.05), and no anaphylaxis occurred. IgG4 and IgE-blocking factor to Dp and Df were increased significantly in both groups after the 1-year treatment.

CONCLUSION

Our study confirmed the equal efficacy and safety profile of both commercial extracts in HDM-associated AR patients.

Alternaria B Cell Mimotope Immunotherapy Alleviates Allergic Responses in a Mouse Model

Alternaria is a major outdoor allergen. Immunotherapy with Alternaria extracts has been documented to be effective in the sensitized patients. However, Alternaria extracts are notoriously difficult to standardize. Our aim is to screen the B cell mimotopes of Alternaria and to evaluate the therapeutic effects of B cell mimotope peptides on a BALB/c mouse model of Alternaria allergy. After a human sera pool from Alternaria monosensitized patients was established, B cell mimotopes were screened by a phage-displayed random heptamer peptide library that was identified via mixed Alternaria-specific IgE in the sera pool. B cell mimotopes with phage as a carrier were used to perform immunotherapy in an Alternaria allergy mouse model. Serological Ab levels, lung histology, and cytokine profiles were compared in the mimotope immunotherapy group, natural extract immunotherapy group, irrelevant phage control group, Alternaria-sensitized model group, and saline-blank group. Two mimotopes (MISTSRK and QKRNTIT) presented high binding ability with the sera of the Alternaria-allergic patients and mice and, therefore, were selected for immunotherapy in the mouse model. Compared with irrelevant phage control, model, and natural extract immunotherapy group, mimotope immunotherapy group significantly reduced serum IgE levels, inflammatory cells infiltration in the lung tissue, and IL-4 levels in bronchoalveolar lavage fluid, whereas serum IgG1 and IFN-γ levels in bronchoalveolar lavage fluid were increased. Our results indicate that B cell mimotopes of Alternaria alleviates allergic response in a mouse model and have potential as novel therapeutic agents for IgE-mediated Alternaria-allergic diseases.

Risk factors and strategies in nonadherence with subcutaneous immunotherapy: a real-life study

BACKGROUND

Allergen immunotherapy (AIT) is still the only causal treatment for allergic diseases. However, conventional subcutaneous immunotherapy (SCIT) administration schedules are time-consuming and patient nonadherence is a major barrier to achieving a satisfactory therapeutic effect. Our study aimed to analyze the causes leading to discontinuation of SCIT and to determine risk factors associated with nonadherence in respiratory allergies.

METHODS

This was a prospective study. Patients with respiratory allergies who had received standardized dust mite SCIT were enrolled from January 2012 to January 2014. And a follow-up study on these subjects was conducted via telephone interviews on an interval of 3 months and online communication through social network applications. Reasons for discontinuation were documented when patients claimed to stop treatment.

RESULTS

A total of 311 patients were enrolled in the study. The adherence rate at year 3 was 64.6%. Fifty-nine patients (19.0%) dropped out in year 1, 31 (10.0%) in year 2, and 20 (6.4%) in year 3. Reasons for nonadherence included inconvenience (32.7%), ineffectiveness (25.5%), improvement of symptoms (22.7%), and adverse reactions (14.5%). Children had higher adherence than adults (70.7% vs 55.0%) (p < 0.05). The dropout reasons were different among the children and adults groups (p < 0.005). The follow-up work was carefully and thoroughly done. All the 311 (100%) patients accepted the telephone interview, and 296 (95.2%) patients submitted questions and got rapid replies from doctors online.

CONCLUSION

Adherence to SCIT was less than satisfactory in the real-life study. A close communication between doctors and patients is helpful in enhancing adherence with AIT in clinical practice.

Sublingual immunotherapy for treating adult patients with allergic rhinitis induced by house dust mite among Chinese Han population: A retrospective study

The objective of this retrospective study was to evaluate the efficacy and safety of sublingual immunotherapy (SLIT) for treating adult patients with allergic rhinitis (AR) induced by house dust mite (HDM) among Chinese Han population.A total of 201 adult patients with AR induced by HDM were included. All of them received SLIT treatment. The outcomes consisted of AR symptoms, and quality of life. In addition, any adverse events were also recorded in this study.Compared with the AR symptoms and quality of life before the treatment, significant differences were found after 1-year treatment (P < .01), and 2-year treatment (P < .01). Additionally, only mild and acceptable adverse events were observed in this study.This study demonstrated that SLIT may be efficacious and safety for adult patients with HDM induced by AR among Chinese Han population.

Immunotherapy of house dust mite allergy

House dust mite (HDM) is a predominant source of indoor aeroallergen worldwide, which induces allergic diseases including allergic rhinoconjunctivitis, allergic asthma, atopic eczema and other allergic skin diseases. Allergen specific immunotherapy (AIT) is the only potential disease-modifying treatment of HDM allergic subjects. However, AIT remains underused due to no universally accepted allergen standardization and a shortage of rigorous clinical studies to confirm safety and efficacy. With the effort of doctors and researchers in allergy field, efficacy, safety, standardization and strategy of AIT are being continuously developed. This review presents the updated research based on recently published trials and meta-analyses.

Long-term efficacy of standardised specific subcutaneous immunotherapy in children with persistent allergic rhinitis due to multiple allergens including house dust mites

Objectives:

To observe the five-year efficacy of standardised specific subcutaneous immunotherapy for house dust mite allergy in monosensitised and polysensitised children with persistent allergic rhinitis.

Methods:

From January 2007 to August 2009, 236 children with persistent allergic rhinitis were divided into 2 groups: 1 group received standardised specific subcutaneous immunotherapy using house dust mite extract; the other received pharmacotherapy with intranasal corticosteroids and oral antihistamines. A total of 193 patients (106 in the immunotherapy group and 87 in the pharmacotherapy group) completed treatment. Scores for symptoms, total medication and quality of life were evaluated.

Results:

The subcutaneous immunotherapy group demonstrated a significant reduction in visual analogue scale scores, Rhinoconjunctivitis Quality of Life Questionnaire scores and total medication scores (p < 0.05) compared with the pharmacotherapy group. No significant differences in the visual analogue scale and Rhinoconjunctivitis Quality of Life Questionnaire scores were found between the polysensitised and monosensitised subgroups (p > 0.05). No serious adverse events occurred.

Conclusion:

Standardised subcutaneous immunotherapy has long-term efficacy for children with persistent allergic rhinitis. Single-allergen subcutaneous immunotherapy was appropriate for allergic rhinitis caused by multiple allergens, including house dust mites, in the paediatric population.

Chinese Guideline on allergen immunotherapy for allergic rhinitis

The present document is based on a consensus reached by a panel of experts from Chinese Society of Allergy (CSA) and Chinese Allergic Rhinitis Collaborative Research Group (C2AR2G). Allergen immunotherapy (AIT), has increasingly been used as a treatment for allergic rhinitis (AR) globally, as it has been shown to provide a long-term effect in improving nasal and ocular symptoms, reducing medication need, and improving quality of life. AIT is currently the only curative intervention that can potentially modify the immune system in individuals suffering from AR and prevent the development of new sensitization and the progression of disease from AR to asthma. Although the use of AIT is becoming more acceptable in China, to date no AR immunotherapy guideline from China is available for use by the international community. This document has thus been produced and covers the main aspects of AIT undertaken in China; including selection of patients for AIT, the allergen extracts available on the Chinese market, schedules and doses of allergen employed in different routes of AIT, assessment of effect and safety, patients' administration and follow-up, and management of adverse reactions. The Chinese guideline for AR immunotherapy will thus serve as a reference point by doctors, healthcare professionals and organizations involved in the AIT of AR in China. Moreover, this guideline will serve as a source of information for the international community on AIT treatment strategies employed in China.

Eight Aeroallergen Skin Extracts May Be the Optimal Panel for Allergic Rhinitis Patients in Central China

BACKGROUND

The prevalence of allergic rhinitis (AR) is increasing rapidly in Central China. The skin prick test (SPT) is the standard tool with which to determine the allergen sensitization status in AR patients. Changes in allergen sensitization patterns have been observed within countries and regions due to geographical and seasonal variations.

OBJECTIVE

The aim of this study was to evaluate the profile of SPT reactivity to different aeroallergens in AR patients and to suggest a minimal panel of allergens to detect sensitized patients in Central China.

METHODS

From January 2015 to December 2016, patients who presented to Tongji Hospital with suspected AR were tested with the same panel of 19 aeroallergens. The results of SPT were analyzed to determine the minimum test battery panel necessary to cover 99% of the cases of SPT sensitization in different age subgroups.

RESULTS

A total of 2,416 patients (male:female ratio 1.2:1) were enrolled in our study with an average age of 22.0 years. The overall rate of sensitization to any allergen was 79.0%, and 64.3% of the subjects were monosensitized. The highest sensitized rate was found in the subgroup aged 14-18 years (92.0%), followed by the subgroups of 6-14 years (86.4%), >18 years (75.6%), and ≤6 years (74.9%). The most common sensitization was to Dermatophagoides farinae (71.1%). Testing with 8 allergens (D. pteronyssinus, D. farinae, Platanus, Artemisia, Cryptomeria, Blatella germanica, Humulus, and Alternaria) was sufficient to identify over 99% of the sensitized patients.

CONCLUSION

An SPT panel covering 8 allergen extracts was able to detect almost all sensitized patients suffering from AR symptoms in Central China.

Extracellular heat shock protein 90α mediates HDM-induced bronchial epithelial barrier dysfunction by activating RhoA/MLC signaling

Background

The disruption and hyperpermeability of bronchial epithelial barrier are closely related to the pathogenesis of asthma. House dust mite (HDM), one of the most important allergens, could increase the airway epithelial permeability. Heat shock protein (Hsp) 90α is also implicated in the lung endothelial barrier dysfunction by disrupting RhoA signaling. However, the effect of extracellular Hsp90α (eHsp90α) on the bronchial epithelial barrier disruption induced by HDM has never been reported.

Methods

To investigate the involvement of eHsp90α in the bronchial epithelial barrier disruption induced by HDM, normal human bronchial epithelial cell line 16HBE14o- (16HBE) cells were treated by HDM, human recombinant (hr) Hsp90α and hrHsp90β respectively and pretreated by1G6-D7, a specific anti-secreted Hsp90α monoclonal antibody (mAb). Hsp90α-silencing cells were also constructed. To further evaluate the role of RhoA signaling in this process, cells were pretreated by inhibitors of Rho kinase, GSK429286A and Y27632 2HCl. Transepithelial electrical resistance (TEER) and FITC-dextran flux (FITC-DX) were examined as the epithelial barrier function. Expression and localization of adherens junctional proteins E-cadherin and β-catenin were evaluated by western blotting and immunofluorescence respectively. The level of eHsp90α was investigated by concentration and purification of condition media. RhoA activity was determined by using a Rho G-LISA® RhoA activation assay kit^TM biochem kit, and the phosphorylation of myosin light chain (MLC), the downstream signal molecule of RhoA, was assessed by western blotting.

Results

The epithelial barrier disruption and the loss of adherens junctional proteins E-cadherin and β-catenin in cytomembrane were observed in HDM-treated 16HBE cells, paralleled with the increase of eHsp90α secretion. All of which were rescued in Hsp90α-silencing cells or by pretreating 16HBE cells with 1G6-D7. Also, 1G6-D7 suppressed RhoA activity and MLC phosphorylation induced by HDM. Furthermore, inhibitors of Rho kinase prevented and restored the airway barrier disruption. Consistently, it was hrHsp90α instead of hrHsp90β that promoted barrier dysfunction and activated RhoA/MLC signaling in 16HBE cells.

Conclusions

The eHsp90α mediates HDM-induced human bronchial epithelial barrier dysfunction by activating RhoA/MLC signaling, suggesting that eHsp90α is a potential therapeutic target for treatment of asthma.

Early Intervention Improves Clinical Responses to House Dust Mite Immunotherapy in Allergic Rhinitis Patients

BACKGROUND

Allergen immunotherapy (AIT) is the unique causal treatment for respiratory allergy. As AIT is expensive and of long duration, the availability of a marker predicting AIT responders is of crucial relevance.

OBJECTIVE

To investigate clinical parameters correlated with effective AIT in allergic rhinitis (AR) patients.

METHODS

This is a prospective, nonrandomized open study in which a total of 284 AR patients who had received house dust mite (HDM) subcutaneous AIT were enrolled from January 2011 to December 2015, and then followed up for 3 consecutive years. Demographic data, clinical history, laboratory tests (specific and total IgE levels), symptoms score, concomitant medication, and adverse reactions during AIT were collected. An AIT responder patient was defined when a visual analog score (assessing global symptoms) had decreased by >30% compared to baseline and concomitant medication was equal to or less than before AIT.

RESULTS

Thirty-three patients dropped out, so 251 patients were analyzed; 175 (69.7%) patients were responders. This group had a higher baseline symptom score than the AIT nonresponder group (7.5 vs. 6.9). A significant negative correlation was found between AR symptom duration and the clinical response to AIT. Local reactions (LRs) during AIT had a positive correlation. Other variables such as a family history of atopy, combined asthma history, and the levels of specific and total IgE had no correlations with effective AIT.

CONCLUSION

Early intervention with AIT helps to improve the efficacy of AR treatment. LRs might predict successful AIT. Highly symptomatic AR patients may develop increased clinical responses to AIT.

Efficacy of Sublingual Immunotherapy for House Dust Mite-Induced Allergic Rhinitis: A Meta-Analysis of Randomized Controlled Trials

Purpose

Allergic rhinitis (AR) has become a global issue for a large part of the general population. Sublingual immunotherapy (SLIT) has been used extensively to treat persistent allergic rhinitis (PAR). Although systematic reviews have confirmed the effectiveness of SLIT for the treatment of AR, a considerable number of studies using extracts of house dust mites (HDMs) for immunotherapy found no consensus on basic treatment parameters and questioned the efficacy of SLIT.

Methods

In this study, we evaluated SLIT for PAR by a meta-analysis of randomized controlled trials (RCTs). Medline, Embase, and Cochrane Library database searches were performed for RCTs on the treatment of PAR by SLIT that assessed clinical outcomes related to efficacy through May 2016. Descriptive and quantitative information was abstracted. An analysis was performed with standardized mean differences (SMDs) under a fixed or random effects model. Subgroup analyses were performed. Heterogeneity was assessed using the I² metric.

Results

In total, 25 studies were eligible for inclusion in the meta-analysis for symptom scores and 15 studies for medication scores. SLIT was significantly different from the controls for symptom scores (SMD=1.23; 95% confidence interval [CI]=1.74 to 0.73; P<0.001). For medication scores, significant differences for SLIT were also observed versus the controls (SMD=-1.39; 95% CI=-1.90 to -0.88; P<0.001).

Conclusions

Our meta-analysis indicates that SLIT provided significant symptom relief and reduced the need for medications in PAR. In this study, significant evidence was obtained despite heterogeneity with regard to the use of mite extract. Specifically, the mite extract used was provided by the patients with PAR. Furthermore, to confirm both the objective outcomes and the effective doses of HDM allergen extracts, experimental data should be obtained from large high-quality population-based studies.