Safety and immunogenicity of immunotherapy with accelerated dosage schedules of polymerized grass and ragweed in patients with dual inhalant sensitivity

Immunotherapy with individually polymerized grasses (IPG) and immunotherapy with polymerized ragweed (PRW) have been demonstrated to be immunogenic and safe and to result in lowering of symptom-medication scores compared to placebo. We conducted this study to evaluate the immunogenicity and safety of immunotherapy with concomitantly administered accelerated dosage schedules of IPG and PRW in 12 patients with dual inhalant sensitivities. Patients were treated in nine weekly visits with IPG, comprising 71,950 PNU; they were treated in 11 weekly visits with PRW comprising 2955 allergy units. Eleven additional patients who had been previously treated with IPG received only PRW. There were no systemic reactions and no clinically significant changes in routine laboratory parameters, including hepatic and renal functions, with injections. There were significant rises in IgG titers by ELISA to each grass-pollen allergen administered, orchard, timothy, and Bermuda, and in total antibody binding of antigen E. Changes in IgE against orchard, timothy, Bermuda, and antigen E were minor. Thus, IPG and PRW administered concomitantly in accelerated dosage schedules are safe and immunogenic in patients with dual inhalant sensitivities.

Prevention of chymopapain anaphylaxis by screening chemonucleolysis candidates with cutaneous chymopapain testing

With chymopapain at a concentration of 10 mg/ml, the authors skin tested 540 chemonucleolysis candidates; six were positive, and 534 were negative. None of the positive patients received therapeutic injections of chymopapain. There were no instances of unequivocal anaphylaxis to chymopapain in the patients with negative skin tests treated with chymopapain. When this 0% incidence of systemic reactions in skin test negative patients is compared with the historical rate of 1%, this difference is statistically significant (p less than 0.05). Restriction of chymopapain treatment to patients with negative prick tests can reduce the incidence of systemic reactions.

Prevention of chymopapain anaphylaxis by screening chemonucleolysis candidates with cutaneous chymopapain testing. A preliminary report

The risk of anaphylaxis in candidates for chemonucleolysis for herniated lumbar discs is approximately 1%. An investigation was designed to eliminate or reduce the incidence of chymopapain anaphylaxis. The procedure was to restrict chemonucleolysis to patients who are prick test-negative to chymopapain at a concentration of 10 mg/ml. The authors skin-tested 292 chemonucleolysis candidates; five were positive and 287 were negative. None of the positive patients were injected with chymopapain. There were no instances of unequivocal chymopapain anaphylaxis in the skin test-negative group. This 0% incidence of anaphylaxis in skin test-negative patients was compared with a population estimate of 1%, based on historical data. The resulting value of p = 0.08 value fell short of the conventional level of significance of 0.05. The p value will reach 0.05 when the series of skin test-negative patients without anaphylaxis reaches 360. It is important that this information is readily available to physicians concerned about anaphylactic reactions to chymopapain.

Practices in cat and dog immunotherapy among allergists

Allergists in each of four groups, board certified with academic affiliation (A), board certified without academic affiliation (B), non-board certified (NB), and previous trainees of our program (PT)--were queried as to their practices and philosophies in cat and dog epidermal immunotherapy (CDI) and pollen immunotherapy (PI). The four groups were similar in numbers of new patients seen and practices of PI. In several instances, with respect to CDI, however, the PT and A groups segregated from the B and NB groups. Most of B and NB allergists would administer CDI to a patient who refused to give up a pet, while most physicians in the PT or the A groups would not. Overall the number of patients placed on CDI was higher and the degree of efficacy was perceived as higher among the NB and B groups than in the PT or A groups.

A double-blind placebo-controlled trial of polymerized whole grass administered in an accelerated dosage schedule for immunotherapy of grass pollinosis

Forty-four patients were entered into a study of the efficacy and safety of individually polymerized grass (IPG) immunotherapy with an accelerated dosage schedule. Patients were paired on the basis of cutaneous end point titrations to timothy, orchard, and Bermuda grass-pollen extracts. In a double-blind manner, one patient in each pair was treated in nine weekly visits with 13 injections that totaled 24,000 PNU of each grass to which the patient had cutaneous reactivity. The other patient in each pair received caramelized glucose histamine placebo. Symptom and medication score sheets were completed by 33 patients each day of the grass season. Blocking antibody rose significantly in the IPG-treated group but was unchanged in the placebo-treated group. By Wilcoxon paired signed-rank test, the symptom medication scores in the IPG-treated group were significantly lower than those in the placebo-treated group. There were no systemic reactions and no clinically significant changes in routine laboratory tests in either group. In summation, this study demonstrates the safety, immunogenicity, and efficacy of IPG therapy in an accelerated dosage schedule for treatment of grass pollinosis.

Safety and immunogenicity of immunotherapy with polymerized tree, grass, and ragweed in patients with multiple inhalant sensitivities

Immunotherapy with polymerized ragweed (PRW) and individually polymerized grasses (IPG) previously has been demonstrated to be safe and effective. We conducted this trial in order to assess safety and immunogenicity of individually polymerized trees (IPT) and to assess safety of concomitantly administering IPT, IPG, and PRW in patients with multiple inhalant sensitivities. Sixteen patients with typical tree pollinosis were recruited; all but one had grass pollinosis, and all had ragweed pollinosis. Patients were treated in 12 weekly visits with allergens to which they were sensitive, 48,850 PNU of IPT; 2668 AU (50,000 PNU) of PRW; and 48,850 PNU of IPG. There were no systemic reactions and no changes in laboratory parameters, including renal and hepatic functions with injections. Blood was drawn for immunologic studies before and after the injection series. There were significant rises in IgG titers by ELISA to each tree allergen administered, oak, elm, and box elder. There were significant rises in total antibody binding of ragweed AgE and rye grass group I in patients treated with PRW and IPG, respectively. Changes in IgE to oak, elm, box elder, AgE, and rye grass group I were minimal. In summary, IPT is safe, immunogenic, and can be administered concomitantly with PRW and IPG in patients with multiple inhalant sensitivities.

Allergenicity, immunogenicity, and safety of immunotherapy with various molecular weight ranges of polymerized ragweed

Since the observation had been made that allergenicity of polymerized ragweed (PRW) varies inversely with molecular weight over ranges we had studied previously, we conducted this study to determine the utility of immunotherapy with PRW molecular weight greater than 20,000,000 alone or as part of a final product pool. Twenty-one patients with ragweed pollinosis were randomized into three groups on the basis of ragweed skin test titration. Each patient received 500 micrograms AgE (50,000 PNU) of one of the following molecular-weight ranges: PRW A greater than 500,000; PRW B 200,000 to 20,000,000; and PRW C greater than 20,000,000. There was no difference between PRW A, B, and C by intradermal end point titration, by incidence of large local reactions, by amount of erythema or induration from injections, or by rise in blocking antibody that was significant in each group. There were no systemic reactions nor any changes in clinical laboratory parameters. In summary, each of the molecular-weight ranges of PRW studied was similarly allergenic, immunogenic, and safe to administer, and thus PRW greater than 20,000,000 can be used for immunotherapy as a part of the final product pool. This has the advantages of increasing yields and of simplifying the fractionation by eliminating one chromatographic process.

Brief report: evaluation of polymerized ragweed extracts by intradermal end point titration, RAST inhibition, and parallel line bioassay

We have evaluated six polymerized ragweed extracts on the basis of RAST inhibition, parallel line bioassay, and intradermal end point titration. The results of the parallel line bioassay and intradermal end point titration are highly correlated (r = 0.995, df = 2, p less than 0.01). Both intradermal end point titration (r = 0.973, df = 4, p less than 0.01) and parallel line bioassay (r = 0.985, df = 2, p less than 0.05) are highly correlated with RAST inhibition. We have evaluated the utility of intradermal end point titration as a quantitative assay of relative allergenicity of polymerized extracts. The between assay reproducibility was derived by comparing a reference polymerized ragweed extract against itself. The 99% confidence limits of relative allergenicity were 53% to 188% when four assays were used. This compares favorably to the published 99% confidence limits of the parallel line bioassay 60% to 166% when three assays were used. Intradermal end point titration is highly reproducible, is highly correlated with RAST inhibition or parallel line bioassay, and thus is an appropriate bioassay of allergenic activity.

Asthma as a variable in a study of immunotherapy for allergic rhinitis

Fifty patients recruited with ragweed allergic rhinitis were studied. Twenty-three of these patients had asthma. On the basis of cutaneous end point titration to ragweed, patients were randomly assigned to polymerized ragweed (PRW), placebo, or untreated groups. PRW patients received the equivalent of 1200 micrograms AgE in 15 weekly injections. All patients were followed through the ragweed season with daily rhinitis symptom-medication diaries. All patients had determinations of IgE against AgE and total (blocking) antibody to AgE before and after the injection series. In these patients selected for allergic rhinitis, the presence or absence of asthma did not significantly influence rhinitis symptom-medication scores or the values of immunologic parameters. Moreover, whether or not patients had asthma, those who received PRW had an increase in total AgE binding with no increase in IgE-a-AgE and significantly lower rhinitis scores than those who did not.

Persistence of efficacy after a brief course of polymerized ragweed allergen: a controlled study

Immunotherapy with PRW has been demonstrated to be safe and effective. To determine whether the efficacy would remain in successive ragweed seasons without further therapy, a trial was conducted comparing PRW to histamine placebo therapy in patients that had received courses of PRW previously. Those patients were also compared to previously untreated ragweed-sensitive patients. In a double-blind fashion, 21 previously treated patients were treated before the 1982 ragweed season with four injections of PRW therapy, whereas 21 previously treated patients were treated with four injections of placebo therapy. An additional control group of 21 previously untreated ragweed-sensitive patients received no injections. Daily symptom and medication score sheets were completed by patients each day of the ragweed season. Blocking antibody rose elevenfold with treatment (p less than 0.0001) in the PRW group. There was a statistically significant difference in symptom score mean between untreated patients (1007 +/- 174) and previously treated patients whether they received supplemental injections (554 +/- 180) (p less than 0.01) or whether they did not (650 +/- 168) (p less than 0.03). In summary the efficacy of 15 injections of PRW immunotherapy persists at least several years without need for supplemental immunotherapy.

A double-blind histamine placebo-controlled trial of polymerized whole grass for immunotherapy of grass allergy

Twenty-six patients were recruited for a study of the safety and efficacy of immunotherapy with IPG. They were randomly assigned to two groups based on skin test titrations to grass allergens. One group was treated in a double-blind fashion before the 1982 grass season with 12 weekly injections totaling approximately 48,000 PNU, and the other group was treated with 12 weekly injections of caramelized glucose histamine placebo. Daily symptom and medication score sheets were completed by all patients each day of the grass season. Blocking antibody rose ninefold in the IPG group (p less than 0.007) but was unchanged in the placebo group. There was no significant change in IgE against rye grass group I in either the IPG or the placebo group. Symptom-score mean in the IPG group was 217 +/- 71 (S.E.M.), statistically lower (p less than 0.02) than the mean in the placebo group 496 +/- 117 (S.E.M.). There were no systemic reactions and only minor local reactions. There was no change in routine laboratory tests in either group. Although two prior studies with grass allergen immunotherapy reported efficacy, these studies did not use symptom-score analysis. This is the first double-blind, histamine placebo-controlled study of grass immunotherapy that demonstrates efficacy by symptom-score index evaluation. IPG is a safe, clinically effective, and potentially cost-effective therapy for grass pollinosis.