Nucleic acid vaccines and CpG oligodeoxynucleotides for allergen immunotherapy

PURPOSE OF REVIEW

Molecular forms of allergen-specific immunotherapy (AIT) are continuously emerging to improve the efficacy of the treatment, to shorten the duration of protocols and to prevent any side effects. The present review covers the recent progress in the development of AIT based on nucleic acid encoding allergens or CpG oligodeoxynucleotides (CpG-ODN).

RECENT FINDINGS

Therapeutic vaccinations with plasmid deoxyribonucleic acid (DNA) encoding major shrimp Met e 1 or insect For t 2 allergen were effective for the treatment of food or insect bite allergy in respective animal models. DNA expressing hypoallergenic shrimp tropomyosin activated Foxp3+ T regulatory (Treg) cells whereas DNA encoding For t 2 down-regulated the expression of pruritus-inducing IL-31. Co-administrations of major cat allergen Fel d 1 with high doses of CpG-ODN reduced Th2 airway inflammation through tolerance induction mediated by GATA3+ Foxp3hi Treg cells as well as early anti-inflammatory TNF/TNFR2 signaling cascade. Non-canonical CpG-ODN derived from Cryptococcus neoformans as well as methylated CpG sites present in the genomic DNA from Bifidobacterium infantis mediated Th1 or Treg cell differentiation respectively.

SUMMARY

Recent studies on plasmid DNA encoding allergens evidenced their therapeutic potential for the treatment of food allergy and atopic dermatitis. Unmethylated or methylated CpG-ODNs were shown to activate dose-dependent Treg/Th1 responses. Large clinical trials need to be conducted to confirm these promising preclinical data. Moreover, tremendous success of messenger ribonucleic acid (mRNA) vaccines against severe acute respiratory syndrome coronavirus 2 must encourage as well the re-exploration of mRNA vaccine platform for innovative AIT.

Desensitisation overcomes rituximab- and tocilizumab-related immediate hypersensitivity in childhood

OBJECTIVES

Biologic drugs (BD) have been game-changers in rheumatic diseases; however, severe hypersensitivity reactions concerning anaphylaxis may limit their use. Desensitisation is a crucial option that is safe and effective to maintain patients on the preferred drug. Herein we report 84 Rapid Drug Desensitisation (RDD) procedures with rituximab and tocilizumab in children with rheumatic diseases.

METHODS

The study was conducted as a retrospective chart review of patients who received tocilizumab or rituximab therapy between January 2010 and December 2018. The results of RDD with tocilizumab and rituximab were documented.

RESULTS

The study group consisted of 53 patients (11.6±4.5 years, 67.9% female) with rheumatic disease who had used tocilizumab (64.1%, 1007 infusions) or rituximab (35.8%, 73 infusions). Five patients (14.7%) had experienced anaphylaxis with tocilizumab and two patients (10.5%) with rituximab. Anaphylaxis was grade II in four cases whereas it was grade III in the remaining three children. Skin testing with the culprit BD performed in five children yielded positive results. We performed 65 RDDs with tocilizumab in 3 patients and 19 RDDs with rituximab in two patients. No reactions were recorded in 97.6% of the procedures. We observed one anaphylaxis during the 5th RDD of tocilizumab. After modifying the protocol, this patient continued tocilizumab RDD uneventfully.

CONCLUSIONS

RDD is a groundbreaking innovation which ensures giving the full target doses while protecting the patient against severe hypersensitivity reactions (HSRs) and anaphylaxis. As BD use increases in childhood, management of HSRs to BD will become more complicated, necessitating an increased need for RDD in clinical practice.

Allergen immunotherapy: definition, indications, and reactions

Specific allergen immunotherapy is the administration of increasing amounts of specific allergens to which the patient has type I immediate hypersensitivity. It is a disease-modifying therapy, indicated for the treatment of allergic rhinitis, allergic conjunctivitis, allergic asthma, and Hymenoptera hypersensitivity. Specific immunoglobulin E (IgE) antibodies for appropriate allergens for immunotherapy must be documented. Indications for allergen immunotherapy include (1) inadequate symptom control despite pharmacotherapy and avoidance measures; (2) a desire to reduce the morbidity from allergic rhinitis and/or asthma, or reduce the risk of anaphylaxis from a future insect sting; (3) when the patient experiences undesirable adverse effects from pharmacotherapy; and (4) when avoidance is not possible. Several studies reported that immunotherapy in allergic rhinitis seems to prevent the development of new allergic sensitizations and/or new onset asthma. Humoral-, cellular-, and tissue-level changes occur with allergen immunotherapy, including induction of allergen-specific regulatory T and B cells, interleukin 10, and transforming growth factor β production; suppression of T-helper type 2 cell proliferation; large increases in anti-allergen IgG4 antibodies; and reduction in basophil, mast cell, and eosinophil mediator release. Allergen immunotherapy can be administered either subcutaneously in the physician's office or sublingually by the patient at home. The use of immunotherapy in food allergy is still under investigation.

Association of pediatric obesity and asthma, pulmonary physiology, metabolic dysregulation, and atopy; and the role of weight management

Introduction: Obesity affects about 40% of US adults and 18% of children. Its impact on the pulmonary system is best described for asthma. Areas covered: We reviewed the literature on PubMed and Google Scholar databases and summarize the effect of obesity, its associated metabolic dysregulation and altered systemic immune responses, and that of weight gain and loss on pulmonary mechanics, asthma inception, and disease burden. We include a distinct approach for diagnosing and managing the disease, including pulmonary function deficits inherent to obesity-related asthma, in light of its poor response to current asthma medications. Expert opinion: Given the projected increase in obesity, obesity-related asthma needs to be addressed now. Research on the contribution of metabolic abnormalities and systemic immune responses, intricately linked with truncal adiposity, and that of lack of atopy, to asthma disease burden, and pulmonary function deficits among obese children is fairly consistent. Since current asthma medications are more effective for atopic asthma, investigation for atopy will guide management by distinguishing asthma responsive to current medications from the non-responsive disease. Future research is needed to elucidate mechanisms by which obesity-mediated metabolic abnormalities and immune responses cause medication non-responsive asthma, which will inform repurposing of medications and drug discovery.

Wilderness Dermatology: Bugs, Plants, and Other Nuisances That May Ruin Your Hike

Spending time outdoors can be rewarding. However, exposure to the sun, insect bites, and plant exposures may result in a wide range of dermatologic manifestations. In this article, we describe potential cutaneous manifestations of common wilderness exposures in New England including photodermatoses from prolonged sun exposure, phytodermatoses from plant exposures, and arthropod-bite reactions from common insects (mosquitos, spiders, ticks, hymenoptera, mites and chiggers). The article will also address preventive and treatment strategies which may help physicians and their patients better prepare for spending time in the wilderness. [Full article available at http://rimed.org/rimedicaljournal-2019-02.asp].

Investigation of the interaction of allergens of Glycine max with IgE-antibody for designing of peptidomimetics based anti-allergen

Allergen induced IgE dependent type I hypersensitivity is the main cause of the allergy, which would be a burden on medical setup in coming years. Allergens of Glycine max have been isolated, and their disease relationships are documented. Therefore, it becomes important to investigate the interaction of different allergens of Glycine max with IgE and also screen suitable therapeutics to prevent this interaction. The amino acid sequences of all allergens of Glycine max and their isoallergens have been taken, and 3D structure of allergens (Gly m 3, Gly m 4, Gly m 5, Gly m 6 and Gly m 8) and their isoallergens were generated using Modeller v9.17. The modeled structures were further validated using PSVS, ProSA, RAMPAGE, and PDBsum. HL domain of Fab region of human IgE (PDBID: 2R56) was generated using UCSFchimera. The HL domain was minimized by Schrodinger software using the OPLS_2005 force field. SiteMap identified epitope binding site of the minimized domain. All the predicted epitopes of different allergens were docked to the binding site of HL domain using the Patchdock server. We have also designed a peptidomimetics based inhibitor targeted at interaction interface of Gly m8 and IgE, using in-silico virtual screening, molecular mechanics, and molecular dynamics simulation studies. These studies identified BDE32166344 ((N-(1-{[1-(1-aminocyclopentanecarbonyl)-3-hydroxypyrrolidin-3-yl]methyl}piperidin-4-yl)acetamide) as a peptidomimetics based lead with binding energy of -72.77 kcal/mol. Therefore, the present study investigates the interaction between different Gly m allergens and IgE antibody and identifies peptidomimetics based lead that might be developed as a suitable therapeutics against allergy caused by allergen of Glycine max.

Allergen-specific immunotherapy of Hymenoptera venom allergy - also a matter of diagnosis

Stings of hymenoptera can induce IgE-mediated hypersensitivity reactions in venom-allergic patients, ranging from local up to severe systemic reactions and even fatal anaphylaxis. Allergic patients' quality of life can be mainly improved by altering their immune response to tolerate the venoms by injecting increasing venom doses over years. This venom-specific immunotherapy is highly effective and well tolerated. However, component-resolved information about the venoms has increased in the last years. This knowledge is not only able to improve diagnostics as basis for an accurate therapy, but was additionally used to create tools which enable the analysis of therapeutic venom extracts on a molecular level. Therefore, during the last decade the detailed knowledge of the allergen composition of hymenoptera venoms has substantially improved diagnosis and therapy of venom allergy. This review focuses on state of the art diagnostic and therapeutic options as well as on novel directions trying to improve therapy.

Which immunotherapy product is better for patients allergic to Polistes venom? A laboratory and clinical study

BACKGROUND

Venom immunotherapy (VIT) is highly effective in preventing allergic reactions to insect stings, but the appropriate venom must be used to achieve clinical protection. In patients with multiple positive results to venoms, molecular allergy diagnostics or CAP-inhibition may identify the causative venom. Concerning allergy to venom from Polistes spp. it has been proposed that only the European species P. dominulus should be used for VIT. However, this recommendation is not present in any international guideline. Using both laboratory and clinical data, we aimed to evaluate the reliability of this proposal.

METHODS

We performed an in vitro study using CAP-inhibition to determine sensitization of 19 patients allergic to Polistes venom. The clinical study included 191 patients with positive tests to Polistes treated with VIT, 102 were treated with P. dominulus and 89 were treated with a mix of American Polistes (mAP).

RESULTS

The difference in % of inhibition was significant concerning inhibition of P. dominulus sIgE by P. dominulus venom (79.8%) compared with inhibition by mAP venom (64.2%) and not significant concerning the inhibition of mAP sIgE by P. dominulus venom (80.1%) and by mAP venom (73.6%). Instead, the clinical protection from stings was not statistically different between the two kinds of venom.

CONCLUSION

The data from CAP inhibition would suggest that the choice of either P. dominulus venom or mAP venom for VIT is appropriate in patients with CAP inhibition higher than 70%, but the clinical data show the same odds of protection from stings using for VIT P. dominulus or mAP venom.

EAACI Molecular Allergology User's Guide

The availability of allergen molecules ('components') from several protein families has advanced our understanding of immunoglobulin E (IgE)-mediated responses and enabled 'component-resolved diagnosis' (CRD). The European Academy of Allergy and Clinical Immunology (EAACI) Molecular Allergology User's Guide (MAUG) provides comprehensive information on important allergens and describes the diagnostic options using CRD. Part A of the EAACI MAUG introduces allergen molecules, families, composition of extracts, databases, and diagnostic IgE, skin, and basophil tests. Singleplex and multiplex IgE assays with components improve both sensitivity for low-abundance allergens and analytical specificity; IgE to individual allergens can yield information on clinical risks and distinguish cross-reactivity from true primary sensitization. Part B discusses the clinical and molecular aspects of IgE-mediated allergies to foods (including nuts, seeds, legumes, fruits, vegetables, cereal grains, milk, egg, meat, fish, and shellfish), inhalants (pollen, mold spores, mites, and animal dander), and Hymenoptera venom. Diagnostic algorithms and short case histories provide useful information for the clinical workup of allergic individuals targeted for CRD. Part C covers protein families containing ubiquitous, highly cross-reactive panallergens from plant (lipid transfer proteins, polcalcins, PR-10, profilins) and animal sources (lipocalins, parvalbumins, serum albumins, tropomyosins) and explains their diagnostic and clinical utility. Part D lists 100 important allergen molecules. In conclusion, IgE-mediated reactions and allergic diseases, including allergic rhinoconjunctivitis, asthma, food reactions, and insect sting reactions, are discussed from a novel molecular perspective. The EAACI MAUG documents the rapid progression of molecular allergology from basic research to its integration into clinical practice, a quantum leap in the management of allergic patients.

[Allergen-specific immunotherapy provides long-lasting symptom relief]

Allergen immunotherapy (AIT) to patients with allergy towards pollens, cats or house dust mite provides longstanding improvement of symptoms of rhinoconjunctivitis and allergic asthma and reduces the need for symptomatic medication. In addition, some studies suggest that AIT can protect from the development of asthma in children with allergic rhinitis. The clinical effects of AIT are explained by a shift from a Th2 to a Th1-mediated immune response upon allergen exposure. In Sweden the treatment is given as sublingual tablets (grass) or subcutaneous injections, and a treatment period of 3-4 years is necessary to ensure longstanding effect of the treatment. Serious side-effects such as asthma attacks or anaphylaxis are uncommon, if the treatment is provided by staff specifically trained to administer AIT. Intralymphatic administration of the allergen extract is a novel and promising approach that might shorten the treatment period with similar clinical effects.

Natural rubber latex allergy: implications for the orthodontist

Natural rubber latex (NRL) allergy can have potentially serious consequences, and reports of orthodontic patients reacting to NRL have increased significantly over recent years. It is therefore important for the orthodontist to know how to manage patients with an NRL allergy and how to deal with possible reactions to NRL. Safe and effective practice depends on recognizing patients who are at risk of NRL allergy, and an awareness of materials and equipment that contain NRL and the availability of suitable NRL-free alternatives.

Effect of an ACE inhibitor on allergic reaction to a bee sting

An 83-year-old man being treated with combination product containing perindopril and indapamide had a systemic reaction after being stung by a bee. An angiotensin-converting enzyme inhibitor may significantly increase the severity of allergic reactions after being stung by bees, ants, or wasps. Clinicians should be aware of the potential for this phenomenon if assisting people who have been stung.

Omalizumab increases the intrinsic sensitivity of human basophils to IgE-mediated stimulation

BACKGROUND

Treatment of allergic patients with omalizumab results in a paradoxical increase in their basophil histamine release (HR) response ex vivo to cross-linking anti-IgE antibody. It is not known whether this change in response is associated with an increase in intrinsic cellular sensitivity, which would be a paradoxical response.

OBJECTIVE

We sought to determine whether the increase in response to anti-IgE antibody is a reflection of an increased cellular sensitivity expressed as molecules of antigen-specific IgE per basophil required to produce 50% of the maximal response.

METHODS

Patients were treated with omalizumab or placebo for 12 weeks (NCT01003301 at ClinicalTrials.gov), and the metric of basophil sensitivity was assessed at 4 time points: baseline, 6 to 8 weeks, 12 weeks (after which treatment stopped), and 24 weeks (12 weeks after the end of treatment).

RESULTS

As observed previously, treatment with omalizumab resulted in a marked increase in the maximal HR induced by cross-linking anti-IgE antibody. This change was accompanied by a marked shift in intrinsic basophil sensitivity, ranging from 2.5- to 125-fold, with an average of 6-fold at the midpoint of the treatment to 12-fold after 12 weeks. The magnitude of the increase in cellular sensitivity was inversely related to the starting sensitivity or the starting maximum HR. The increased cellular sensitivity also occurred when using leukotriene C4 secretion as a metric of the basophil response. Twelve weeks after the end of treatment, cellular sensitivity was found to shift toward the baseline value, although the return to baseline was not yet complete at this time point.

CONCLUSIONS

Treatment with omalizumab results in a markedly increased sensitivity of basophils to IgE-mediated stimulation in terms of the number of IgE molecules required to produce a given response. These results provide a better quantitative sense of the phenotypic change that occurs in basophils during omalizumab treatment, which has both mechanistic and clinical implications.

A 1-day imported fire ant rush immunotherapy schedule with and without premedication

BACKGROUND

Rush immunotherapy (RIT) schedules can expedite protection in individuals sensitive to imported fire ant (IFA) stings.

OBJECTIVE

To evaluate the safety and efficacy of 1-day RIT with IFA whole body extract (WBE) and determine the benefit of premedication with antihistamines and prednisone.

METHODS

Patients with systemic reactions to IFAs and evidence of specific IgE by skin test or serologic test started a 1-day RIT protocol without premedication. The 1-day RIT protocol consisted of a total of 10 injections every 30 to 60 minutes to achieve a 0.3-mL 1:100 (wt/vol) dose. A higher systemic reaction rate (SRR) prompted protocol revision to include a 3-day course of oral 20 mg of prednisone twice daily, 150 mg of ranitidine, and 10 mg of loratadine started 2 days before the 1-day RIT. Patients returned on days 8 and 15 to receive a 0.5 mL 1:100 (wt/vol) maintenance injection. The effectiveness of the RIT was evaluated with a sting challenge on approximately day 22.

RESULTS

Eighty of the 96 patients enrolled initiated the 1-day RIT. The first nonpremedicated group exhibited a SRR of 24.3% (9 of 37 patients), whereas the revised premedicated group had a SRR of 9.5% (4 of 42 patients; P = .07). The most severe reaction during RIT included dizziness, angioedema, and urticaria. Sting challenges on 53 patients resulted in 1 mild rhinitis reaction (efficacy, 98.1%).

CONCLUSION

One-day RIT with IFA WBE for IFA hypersensitivity is efficacious. Although there was a trend with premedications to reduce SRRs during the RIT, safety data with premedication require confirmation in a larger trial.

[Allergies to betalactam-antibiotics: when and how to evaluate?]

When there is the suspicion of an allergic reaction to betalactam-antibiotics, the allergological evaluation is an important tool to confirm the allergy and to test alternative medicaments. As all the testing methods for the allergologic evaluation (cutaneous tests and in-vitro tests) don't have a high sensitivity, a broad case report and the former documentation of the symptoms and diagnostic findings are essential, to enable a high significance of the examination and to assess the indication for the provocation test which is the gold standard in many cases. The documentation of the time flow is basic, to differentiate between immediate reactions (hours after intake) and nonimmediate reactions (several days after intake). The diagnostic evaluation not later than after six months increases the prospects for a successful allergic evaluation.

Allergen-specific immunotherapy: update on immunological mechanisms

Immunotherapy selectively modulates the allergen-specific immune response. It involves the gradual administration of increasing amounts of allergen for the purpose of inducing protective immunological changes and it is the only curative approach for specific type I allergy.

AIM

Description of the allergic inflammation.- Comprehension of the early cellular changes after specific immunotherapy has been initiated. Exposure of the mechanisms involved in tolerance induction by regulatory T cells (Treg) with the inhibition of the Th2 responses. Comprehension of IL-10 and transforming growth factor (TGF- ) roles. Explanation of specific IgE, IgG and IgA changes. Description of the suppression of inflammatory responses during immunotherapy.

Allergic fungal sinusitis causing nasolacrimal duct obstruction

INTRODUCTION

Allergic fungal sinusitis is thought to represent a chronic autoimmune reaction directed against fungal elements within the sinuses, and is commonly seen in individuals with a history of chronic sinusitis that is refractory to medical therapy. The authors present a case of allergic fungal sinusitis involving the lacrimal drainage system.

CASE

A 54-year-old woman initially presented with recurrent erythema and induration of the left nasolacrimal sac due to dacryocystitis, which was unresponsive to treatment with topical and systemic antibiotics. Radiological evaluation demonstrated the presence of multiple soft tissue masses along the medial canthi. During subsequent endoscopic dacryocystorhinostomy, significant amounts of allergic mucin were found within the sinuses and marked eosinophilia was present within tissue obtained from the lacrimal sac, findings highly suggestive of allergic fungal sinusitis.

CONCLUSION

A diagnosis of allergic fungal sinusitis should be considered in patients presenting with epiphora in the appropriate clinical context. However, involvement of the lacrimal drainage system is an exceedingly unusual presentation.

[Analysis of adverse reactions induced by subcutaneous immunotherapy against dust mite allergy in 234 cases with allergic rhinitis and asthma]

OBJECTIVE

To investigate the incidence of local reactions (LRs) and systemic reactions (SRs) of subcutaneous immunotherapy (SCIT) and to analyze the potential risk factors of such reactions in Chinese population.

METHOD

This is a retrospective study on 234 dust mite sensitized patients with allergic rhinitis and asthma who received allergen immunotherapy in our hospital from 2003 to 2010. Chart review was conducted to capture clinical data of reactions to immunotherapy. Parameters included signs and symptoms, the onset of reaction, and interventions in treating such reactions, particularly, the administration of epinephrine (EPI) and adjustment of vaccine dosage due to LRs and SRs.

RESULT

The 234 patients received a total of 7679 injections. Among them, 4973 LRs (64.8%) and 235 SRs (3.1%) were observed in 67 patients (28.6% of all patients). SRs included respiratory symptoms (205 events, 88.4%) and cutaneous symptoms (31.5%). Of the total of 235 SR events, 212 (90.2%) were presented as mild SRs and 23 (9.8%) were in severe SR category (grade III and grade IV, EAACI grading system). Overall, severe SRs accounted for 0.3% of total injections. Seventeen of the 23 SR events required epinephrine treatment (0.2% of total injections). Of the 67 patients, 61 completed the course of treatment after dose adjustment; 36 patients had their doses decreased prior to further advancing to target dose. Nineteen subjects tolerated splitting two injections at 30 minutes interval. Six patients advanced the dose based on protocol and another 6 had to stop immunotherapy. Most of the SRs (77.4%) occurred during the maintenance phase of immunotherapy. The levels of TIgE, SIgE D1 and SIgE D2 were found to be significantly higher in patients with SRs comparing to patients without SRs (P < 0.05). SRs more commonly occurred in patients with age less than 14 years than their older counterparts (95.5% vs. 85.6%, OR = 3.58, 95%CI = 1.040 - 12.322, P < 0.01). The incidence of SRs were significantly higher in asthma patients who received SCIT than non-asthma patients (OR = 2, 95%CI = 1.136 - 4.624).

CONCLUSION

Our study suggests that risk factors of SRs include maintenance phase (higher allergen vaccine doses), patients with asthma, age of less than 14 years, higher levels of TIgE, and SIgE D1 and SIgE D2. Effective management includes proper dose adjustment, splitting doses into 2 injections at 30 min apart, and strictly following immunotherapy indications.

[House dust mite allergy--how to win?]

Manifestations of house dust mite allergy include perennial allergic rhinitis often accompanied by ocular symptoms, allergic asthma, and somewhat rarer atopic dermatitis. Sensitization to mite tropomyosin may lead to hypersensitivity to certain foodstuffs. Allergic sensitization and development of the disease are connected to the level of allergen exposure, indicating that the patients' home exposure to mite allergens is a useful indicator of their risk. Since the possibility of allergen avoidance is limited, and available pharmacological treatments have just symptomatic effects, the only causative treatment for mite allergy is specific immunotherapy. Its well-documented clinical effects include reduction of symptoms, prevention of the disease severity progression, and prevention of sensitization to new allergens. Immunological parameters show characteristic dynamics during treatment, which is also reflected in gradual reduction of the skin reactivity towards the allergen. Despite ample evidence and a hundred-year use in clinical practice, the efficacy of specific immunotherapy is sometimes still questioned. The aim of this paper is to show that, when properly indicated with due consideration of the person's sensitization profile, it is a very successful treatment method.

[Allergen specific immunotherapy celebrated 100 years in 2011!]

Allergen specific immunotherapy begun 100 years ago, when Leonard Noon published his works. Important progress have been made ever since and numerous studies published. The indications enlarged with the time and thus, more allergen based treatments became available. The purpose of this article is to give a quick review of specific immunotherapy history on occasion of its centenary, and summarize the most important clinical developments reached in 2011 in this field.

Direct medical costs associated with atopic diseases among young children in Thailand

OBJECTIVE

Allergic diseases are the most common childhood illness in Thailand. Their prevalence has been rising over time, with several studies having revealed substantial economic burden. However, no such study had yet been conducted for Thailand. The aim of this study was to estimate direct medical costs associated with atopic diseases among children aged 0-5 years in Thailand.

RESEARCH DESIGN AND METHODS

A cost-of-illness model was constructed to estimate the total direct medical costs of atopic diseases comprising atopic dermatitis, chronic rhinitis, asthma (i.e., recurrent wheeze), and cow's milk allergy. The model employed a prevalence-based approach, considering a total number of atopic cases in 2010. Direct medical costs were estimated using a bottom-up analysis with the estimation of the quantity of healthcare resource use and the unit costs. Epidemiological data were obtained from literature and Thai surveys, whereas treatment unit costs were from either a hospital database or Thai standard cost list. Expert opinion informed type, frequency, and quantity of medical resources utilized. Key limitations included lack of data-driven evidences on severity distribution for this particular age group, indirect costs, and medical resource use associated with each condition.

RESULTS

Total direct cost was estimated to be THB 27.8 billion (US$899 million). Treatments contributed largest to the total costs (46%), followed by inpatient care (37%), outpatient care (12%), and monitoring and labs (5%). Costs per treated patient were highest in cow's milk allergy (THB 64,383; US$2077), followed by rhinitis (THB 12,669; US$409), asthma (THB 9633; US$312), and atopic dermatitis (THB 5432; US$175).

CONCLUSION

Atopic diseases in young children are associated with substantial burden in direct medical costs to Thailand. These costs can be diminished through nutritional intervention recognized to effectively decrease the incidence of atopic diseases.

Oral desensitisation with food is food-specific and protein-specific

The avoidance of food(s) is the main therapeutic approach to food allergy. Nevertheless, orally- or sublingually-administered food allergens have gained attention and a number of food-allergic children can tolerate gradually increasing amounts of cow&#x0027;s milk and hen&#x0027;s egg. Our purpose is to show that oral desensitisation with food is an allergen-specific therapeutic approach and for this, we describe 4 illustrative children with IgE-mediated food allergy. The first was allergic to cow&#x0027;s milk and hen&#x0027;s egg, the second to cow&#x0027;s milk, hen&#x0027;s egg and fish. Both underwent oral desensitisation to both cow&#x0027;s milk and hen&#x0027;s egg. The third child was allergic to cow&#x0027;s milk, hen&#x0027;s egg and fish and underwent oral desensitisation with cow&#x0027;s milk. The last child was allergic to raw but not to cooked/boiled hen&#x0027;s egg and underwent the oral desensitisation with hen&#x0027;s egg. The first 2 children reached the clinical tolerance to cow&#x0027;s milk after the cow&#x0027;s milk oral desensitisation, but reached the hen&#x0027;s egg tolerance only after the hen&#x0027;s egg oral desensitisation. Moreover, the second child did not tolerate fish after being desensitised to both cow&#x0027;s milk and hen&#x0027;s egg. The third child tolerated cow&#x0027;s milk, but not hen&#x0027;s egg and fish, at the end of the cow&#x0027;s milk oral desensitisation. The fourth child could tolerate the previously not tolerated raw hen&#x0027;s egg after the oral desensitisation with raw hen&#x0027;s egg. In conclusion, we indicate that oral desensitisation with food is allergen specific. The induction of the clinical tolerance to one food is not followed by the tolerance to the other food(s) that the patient is allergic to. To obtain a double or multiple food tolerance, separate desensitisation protocols, one for each food, have to be carried out. Oral desensitisation with food discriminates between raw and cooked proteins.

Recombinant allergens for allergen-specific immunotherapy: 10 years anniversary of immunotherapy with recombinant allergens

The broad applicability of allergen-specific immunotherapy for the treatment and eventually prevention of IgE-mediated allergy is limited by the poor quality and allergenic activity of natural allergen extracts that are used for the production of current allergy vaccines. Today, the genetic code of the most important allergens has been deciphered; recombinant allergens equalling their natural counterparts have been produced for diagnosis and immunotherapy, and a large panel of genetically modified allergens with reduced allergenic activity has been characterized to improve safety of immunotherapy and explore allergen-specific prevention strategies. Successful immunotherapy studies have been performed with recombinant allergens and hypoallergenic allergen derivatives and will lead to the registration of the first recombinant allergen-based vaccines in the near future. There is no doubt that recombinant allergen-based vaccination strategies will be generally applicable to most allergen sources, including respiratory, food and venom allergens and allow to produce safe allergy vaccines for the treatment of the most common forms of IgE-mediated allergies.

Immunological mechanisms of allergen-specific immunotherapy

The studies on the mechanisms of specific immunotherapy (SIT) point out its targets that decide on the efficacy of SIT and hence might be used for its further improvement. Several mechanisms have been proposed to explain the beneficial effects of immunotherapy. The knowledge of the mechanisms underlying allergic diseases and curative treatment possibilities has experienced exciting advances over the last three decades. Studies in several clinical trials in allergen-SIT have demonstrated that the induction of a tolerant state against allergens in many ways represents a key step in the development of a healthy immune response against allergens. Several cellular and molecular mechanisms have been demonstrated: allergen-specific suppressive capacities of both inducible subsets of CD4(+) CD25(+) forkhead box P3(+) T-regulatory and IL-10-secreting type 1 T-regulatory cells increase in peripheral blood; suppression of eosinophils, mast cells, and basophils; Ab isotype change from IgE to IgG4. This review aims at the better understanding of the observed immunological changes associated with allergen SIT.

100 years of hyposensitization: history of allergen-specific immunotherapy (ASIT)

Hundred years ago, Leonhard Noon and John Freeman published their pioneering works on allergen-specific immunotherapy (ASIT) using grass pollen extracts. To honor their contribution to the development of ASIT as the only causal treatment of IgE-mediated allergies, we review the history of ASIT that started with the anecdotal descriptions of ASIT performed by the ancient king Mithridates (132-63 B.C.) and Jenner's development of a cowpox vaccine. Following Noon's and Freeman's first controlled human trials, ASIT was performed by a large number of modalities and with a myriad of pharmacologic preparations. These developments range from early aqueous pollen extracts and whole bee extracts to chemically modified allergens (allergoids) and various recombinant allergens. In addition to allergen-specific immunotherapy, non-specific immune response modifiers have been used in the past or are in the developmental stage. Also, currently many innovative experimental approaches of ASIT are studied in animal models and human in vitro systems and will hopefully further broaden the range of allergies that can be treated by ASIT, with enhanced efficacy and further reduced side-effects.

Immunological mechanisms of sublingual allergen-specific immunotherapy

Within the last 100 years of allergen-specific immunotherapy, many clinical and scientific efforts have been made to establish alternative noninvasive allergen application strategies. Thus, intra-oral allergen delivery to the sublingual mucosa has been proven to be safe and effective. As a consequence, to date, sublingual immunotherapy (SLIT) is widely accepted by most allergists as an alternative to conventional subcutaneous immunotherapy. Although immunological mechanisms remain to be elucidated in detail, several studies in mice and humans within recent years provided deeper insights into local as well as systemic immunological features in response to SLIT. First of all, it was shown that the target organ, the oral mucosa, harbours a sophisticated immunological network as an important prerequisite for SLIT, which contains among other cells, local antigen-presenting cells (APC), such as dendritic cells (DCs), with a constitutive disposition to enforce tolerogenic mechanisms. Further on, basic research on local DCs within the oral mucosa gave rise to possible alternative strategies to deliver the allergens to other mucosal regions than sublingual tissue, such as the vestibulum oris. Moreover, characterization of oral DCs led to the identification of target structures for both allergens as well as adjuvants, which could be applied during SLIT. Altogether, SLIT came a long way since its very beginning in the last century and some, but not all questions about SLIT could be answered so far. However, recent research efforts as well as clinical approaches paved the way for another exciting 100 years of SLIT.

Immunotherapy with peptides

Specific allergen immunotherapy is clinically effective and disease modifying. It has a duration of effect that exceeds the treatment period and prevents both the progression of allergic rhinitis to asthma and the acquisition of new allergic sensitizations. However, immunotherapy is associated with a high frequency of adverse events related to the allergenicity of vaccines. Allergenicity is conferred by the presence of intact B-cell epitopes that crosslink allergen-specific IgE on effector cells. The use of linear peptide sequences representing fragments of the native allergen is one approach to reduce allergenicity. Preclinical models of peptide immunotherapy have demonstrated efficacy in both autoimmunity and allergy. Translation of this technology into the clinic has gained momentum in recent years based on encouraging results from early clinical trials. To date, efforts have focused on two major allergens, but vaccines to a broader range of molecules are currently in clinical development. Mechanistically, peptide immunotherapy appears to work through the induction of adaptive, allergen-specific regulatory T cells that secrete the immunoregulatory cytokine IL-10. There is also evidence that peptide immunotherapy targeting allergen-specific T cells can indirectly modulate allergen-specific B-cell responses. Peptide immunotherapy may provide a safe and efficacious alternative to conventional subcutaneous and/or sublingual approaches using native allergen preparations.

[Signal receptors of congenital immunity: a new molecular target for diagnostics and treatment of inflammatory diseases]

The discovery of signal receptors of congenital immunity (signal PRR) not only provided a novel view of basic aspects of pathogenesis of chronic inflammatory diseases but also created a basis for the development of additional diagnostic criteria for these pathologies and new pharmaceuticals for their treatment. Reduced expression and function of PRR due to mutations/polymorphisms or epigenetic disturbances of regulation can be regarded as immunodeficient conditions manifest as severe infectious inflammatory diseases. In contrast, excessive expression and activation of PRR as a rule leads to chronic autoinflammatory, autoimmune, and atopic diseases involving adaptive immunity and aggression against own tissues and cells. Assessment of certain mutations in PRR genes, their expression and activation provides a powerful tool for in-depth diagnostics of inflammatory diseases. Simultaneously, new lines of immunostimulating and anti-inflammatory therapy are developed based on the knowledge of molecular physiology of PRR with the use of synthetic agonists and antagonists of signal PRR.

[Pathophysiology of asthma: data concerning regulation of IGE and Th2 responses in the lung]

Asthma is one of the most common chronic diseases, affecting 5-10% of the population worldwide. It is closely associated with the "atopic" hypersensitivity to environmental antigens ('allergens'), which is mediated by specific IgE driven by a T helper 2-type immune response, also promoting recruitment of eosinophils and mast cells and mucus overproduction. Our first research axis showed that allergen immunotherapy in patients with allergic rhinitis and asthma to grass pollen induces inhibition of the IL-9/ mast cells axis and a selective induction of allergen-specific IgA2 antibodies in serum, which correlated to nasal tissue expression of TGF-beta. We further showed that these IgA antibodies, whilst unable to inhibit IgE-facilitated allergen presentation by B cells as achieved by IgG4 antibodies, could trigger IL-10 expression in monocytes and dendritic cells through activation of p38 MAP-kinase and recruitment of sp1 and NFkappaB transcription factors. In addition, results in a murine model of asthma suggested a protective role of secretory IgA. A second research axis, exploring local immune responses to lung allergen exposure, identified the CCR4 pathway as critically mediating the recruitment of Th2 cells into the lung of atopic asthmatics. In patients with non-atopic (intrinsic) asthma, we recently reported on the local production of specific IgE to mite allergens (Der p), able to activate basophils in vitro, while lung challenge to Der p in vivo did not result into asthmatic responses. Altogether, we showed (1) that allergen immunotherapy triggers production of IgA2, which could be protective through induction of IL-10 in monocytes/dendritic cells and/ or by scavenging allergens within secretions, and (2) that allergen exposure, which triggers the recruitment of Th2 cells through the CCR4 pathway, induces locally the production of specific IgE, irrespectively of systemic atopic features, supporting the concept according which "second signals" condition in vivo the inception and exacerbations of asthma.

Passive immunization with allergen-specific antibodies

The induction of allergen-specific IgG antibodies has been identified as a major mechanism responsible for the reduction of allergic inflammation in allergic patients treated by allergen-specific immunotherapy. Several studies suggest that allergen-specific IgG antibodies induced by vaccination with allergens block mast cell and basophil degranulation, IgE-facilitated allergen presentation to T cells and IgE production. The availability of recombinant allergens and technologies for the production of recombinant human antibodies allows engineering of allergen-specific antibodies which can be used for passive immunization (i.e., therapy) and eventually for the prevention of allergy (i.e., prophylaxis). This chapter summarizes data supporting the possible use of allergen-specific antibodies for treatment and prophylaxis. Finally, concrete approaches for the treatment and prevention of allergy based on blocking antibodies are envisioned.

[Allergologic emergencies in dermatology--diagnostic and therapeutic procedures]

Emergencies in allergology and clinical immunology are quite common and pose a public health problem in Croatia and worldwide. Allergic reactions ranging from mild symptoms such as pruritus to generalized skin eruptions, gastrointestinal and respiratory symptoms to anaphylaxis with cardiovascular emergencies are very common. Reaction develops to inhalant substances, food and food ingredients, various foreign substances (blood, latex, etc.) and many other well known antigens and drugs which are frequent causes of anaphylactic reactions, asthma, generalized urticaria, angioedema. There are 35 different skin reactions induced by drugs through immune complexes, complement mediated reactions and direct histamine liberation (by opiates or dextran) and modulators of arachidonic acid metabolism (such as NSAID). Along with painful infiltrates, insect venom allergy manifests with disseminated exanthema and angioedema. Current diagnostic methods, especially therapeutic procedures for emergencies in concordance with the international consensus of the European Allergy White Paper, require the same procedure in clinical practice. Many patients with different allergic skin diseases are treated inappropriately, some are tested in active phase of the disease, during anti-allergic therapy, and some are administered corticosteroids and antihistamines longer than necessary. Sometimes, the treatment of emergencies requires a person experienced in intensive care medicine. However, any physician might be responsible for the treatment of acute symptoms in his office, and thus has to know the modalities and relevant drugs and treatment essentials. Anaphylactic reactions are rare, but every physician should be prepared for the worst. Due knowledge of the correct management should be a must for all of us. The most common emergencies require emergency treatment and diagnostic procedures upon disease regression.

[Secondary and tertiary prevention of allergic asthma in children]

Asthma is a disease of the lung epithelial barrier, most often associated with allergy in children. Asthma and allergy are two distinct diseases, but the phenotypic expression of asthma depends on atopic status. A better definition of phenotypes of asthma would result in better targeting of prevention and treatment modalities. Secondary prevention aims to prevent the onset of asthma and the acquisition of new sensitizations in sensitized children. Studies concerning allergen avoidance are insufficient to reach a definitive conclusion and antihistamines have not been shown to be effective. The results for specific immunotherapy suggest a benefit to prevent transition from allergic rhinitis to asthma and the onset of new sensitizations. Tertiary prevention aims to reduce symptoms in children with an existing allergic asthma diagnosis. The avoidance of known respiratory allergens will only be effective in combination with management of the whole environment. Specific immunotherapy has a real place, in combination with background therapy. It should be used according to guidelines in appropriately treated patients.

Specific immunotherapy suppresses Th2 responses via modulating TIM1/TIM4 interaction on dendritic cells

BACKGROUND

Specific immunotherapy (SIT) is the only curable remedy for allergic disorders currently; however, the underlying mechanism is not fully understood yet. This study aimed to elucidate the mechanism of SIT on suppressing TIM4 (T cell immunoglobulin mucin domain molecule 4) expression in dendritic cells (DCs) and modulating the skewed T helper 2 (Th2) responses in patients with airway allergy.

METHODS

Twenty patients with allergic rhinitis (AR) were treated with SIT for 3 months. Before and after SIT, the expression of TIM4 in peripheral DC and TIM1 in Th2 cells was examined. The role of Fc gamma receptor (FcgammaR) I and II in modulating the expression of TIM4 in DCs was investigated.

RESULTS

The interaction of TIM1/TIM4 played a critical role in sustaining the polarization status of Th2 cells in AR patients. Cross-linking FcgammaRI by antigen/IgG complexes increased the production of TIM4 by dendritic cells via upregulating tumor necrosis factor-alpha in DCs. Exposure to microbial products promoted the expression of FcgammaRI in DCs that further increased the expression of TIM4. Exposure to specific antigens alone upregulated the expression of FcgammaRII in DCs, that suppressed the expression of TIM4.

CONCLUSIONS

We conclude that SIT suppresses the skewed Th2 responses via disrupting the interaction of TIM1/TIM4 in antigen-specific Th2 cells.

Approach to the patient with drug allergy

Clinicians commonly encounter patients who report to have drug allergy. In a large part, such allergy corresponds to adverse drug reactions, which are not immune mediated. The incriminated drug need not always be avoided for further therapy. On the other hand, drug allergy may manifest in many unexpected clinical pictures and thus not be recognized. There is no single standardized diagnostic test to confirm the immune-mediated mechanism and to identify the causative drug. Therefore, immune-mediated drug hypersensitivity reactions and their causative drugs have to be considered by the constellation of exposure, timing, and clinical features, including the pattern of organ manifestation. Prior experience with the drug is also an important feature. An allergologic workup with additional investigation may provide some help. Patients should be informed carefully about their drug allergy, whereby symptoms, drug that elicits reaction, modes of diagnosis of drug allergy, and possibly alternatives should be indicated in their allergy passport.

Influence of acupuncture on type I hypersensitivity itch and the wheal and flare response in adults with atopic eczema - a blinded, randomized, placebo-controlled, crossover trial

BACKGROUND

Itch is a major symptom of allergic skin disease. Acupuncture has been shown to exhibit a significant effect on histamine-induced itch in healthy volunteers. We investigated the effect of acupuncture on type I hypersensitivity itch and skin reaction in a double-blind, randomized, placebo-controlled, crossover trial.

METHODS

An allergen stimulus (house dust mite or grass pollen skin prick) was applied to 30 patients with atopic eczema before (direct effect) and after (preventive effect) two experimental approaches or control observation: acupuncture at points Quchi and Xuehai [verum acupuncture (VA), dominant side], 'placebo-point' acupuncture (PA, dominant side), no acupuncture (NA). Itch intensity was recorded on a visual analogue scale. After 10 min, wheal and flare size and skin perfusion (via LASER-Doppler) were measured at the stimulus site, and the validated Eppendorf Itch Questionnaire (EIQ) was answered.

RESULTS

Mean itch intensity was significantly lower in VA (35.7 +/- 6.4) compared to NA (45.9 +/- 7.8) and PA (40.4 +/- 5.8) regarding the direct effect; and significantly lower in VA (34.3 +/- 7.1) and PA (37.8 +/- 5.6) compared to NA (44.6 +/- 6.2) regarding the preventive effect. In the preventive approach, mean wheal and flare size were significantly smaller in VA (0.38 +/- 0.12 cm(2)/8.1 +/- 2.0 cm(2)) compared to PA (0.54 +/- 0.13 cm(2)/13.5 +/- 2.8 cm(2)) and NA (0.73 +/- 0.28 cm(2)/15.1 +/- 4.1 cm(2)), and mean perfusion in VA (72.4 +/- 10.7) compared to NA (84.1 +/- 10.7). Mean EIQ ratings were significantly lower in VA compared to NA and PA in the treatment approach; and significantly lower in VA and PA compared to NA in the preventive approach.

CONCLUSIONS

Acupuncture at the correct points showed a significant reduction in type I hypersensitivity itch in patients with atopic eczema. With time the preventive point-specific effect diminished with regard to subjective itch sensation, whereas it increased in suppressing skin-prick reactions.

Food allergy

Adverse immune responses to foods affect approximately 5% of young children and 3% to 4% of adults in westernized countries and appear to have increased in prevalence. Food-induced allergic reactions are responsible for a variety of symptoms and disorders involving the skin and gastrointestinal and respiratory tracts and can be attributed to IgE-mediated and non-IgE-mediated (cellular) mechanisms. Genetic disposition and environmental factors might abrogate oral tolerance, leading to food allergy. Disease outcomes are influenced by the characteristics of the immune response and of the triggering allergen. Diagnosis is complicated by the observation that detection of food-specific IgE (sensitization) does not necessarily indicate clinical allergy. Therefore diagnosis requires a careful medical history, laboratory studies, and, in many cases, an oral food challenge to confirm a diagnosis. Novel diagnostic methods, including ones that focus on immune responses to specific food proteins or epitopes of specific proteins, are under study. Currently, management of food allergies consists of educating the patient to avoid ingesting the responsible allergen and to initiate therapy (eg, with injected epinephrine for anaphylaxis) in case of an unintended ingestion. Improved therapeutic strategies under study include oral and sublingual immunotherapy, Chinese herbal medicine, anti-IgE antibodies, and modified vaccines.

Immediate type hypersensitivity to chemotherapeutic agents in pediatric patients

Nine patients (3 boys and 6 girls) with a median age of 9.5 years, with immediate type hypersensitivity reactions to chemotherapeutic agents were reviewed. The presenting symptoms were urticaria (4/9) and anaphylaxis (5/9). The causative agents were vincristine (2/9), L-asparaginase (2/9), mesna (1/9), cyclosporine (1/9), carboplatin (2/9) and cyclophosphamide (1/9). Three of the five patients with anaphylaxis were changed to alternative chemotherapeutic agents. In two cases alternative drugs were not available and the patients underwent safe and successful desensitization. Three of the 4 patients with urticaria were successfully exposed to graded challenges with cyclosporine, carboplatin and cyclophosphamide, respectively. In the other case with generalized urticaria, mesna was withdrawn due to a positive intradermal test. In patients with immediate type hypersensitivity reactions to chemotherapeutic drugs, if effective alternative chemotherapeutic agents are not available and/or the skin test is negative, a careful drug challenge and/or desensitization should be performed.

Immunotherapy with wasp venom is accompanied by wide-ranging immune responses that need further exploration

Immunotherapy with wasp allergen leads to a variety of specific immunological changes. It is unknown, however, whether unspecific effects also occur, and which parameter shifts might indicate treatment success. Therefore, data of patients who had completed immunotherapy with wasp venom were analysed retrospectively for a change in the following parameters after therapy: threshold of skin tests with wasp venom, total and specific serum IgE, specific serum IgG and IgG4, and binding of IgE and IgG4 to major wasp venom allergens. Reactions to field stings were explored. A significant increase in the skin test threshold and a significant decrease in total serum IgE, specific serum IgE and major wasp allergens binding IgE were found. Concentrations of specific serum IgG and IgG4 increased. Patients with corresponding changes in at least three specific parameters did not report severe reactions to verified field stings after therapy. The marked decrease in total serum IgE indicates that wasp immunotherapy has wide-ranging immunological effects, and it appears reasonable to check combinations of several parameters for treatment control.

Food protein-induced enterocolitis syndrome

PURPOSE OF REVIEW

To review current knowledge and recent advances in food protein-induced enterocolitis syndrome (FPIES).

RECENT FINDINGS

Rice is the most common solid food causing FPIES. Rice FPIES is associated with more severe reactions than other foods. Infants presenting acutely may be hypothermic (<36 degrees C) and have thrombocytosis. Finding of hypoalbuminemia and weight gain less than 10 g/day helps to differentiate chronic infantile cow's milk FPIES from infectious causes. Gastric juice leukocytes more than 10 cells per high-power field are found in infants with positive oral food challenge to cow's milk.

SUMMARY

FPIES is a non-IgE-mediated gastrointestinal food hypersensitivity disorder. Food protein-activated intestinal lymphocytes elaborate inflammatory cytokines that result in increased intestinal permeability, malabsorption, dysmotility, emesis, diarrhea, pain, and failure to thrive. Decreased intestinal transforming growth factor beta and increased TNFalpha may be important in FPIES. Cow's milk and soy are the most common causes of FPIES, but cereal grains (rice, oat, and barley), fish, poultry, and vegetables may also cause FPIES. The majority of FPIES resolve by age of 3 years.

A new protocol for specific oral tolerance induction in children with IgE-mediated cow's milk allergy

IgE-mediated cow's milk allergy (CMA) is a heavy burden for patients, particularly for children and their families. Allergen avoidance represents the only therapeutic option, but oral desensitization protocols have been suggested. Because of the long duration and complexity of these protocols we examined the feasibility of an oral tolerance induction protocol using a weekly up-dosing schedule. Children with IgE-mediated food allergy to milk, confirmed by a double-blind placebo-controlled food challenge, were recruited. Six of them were randomized to double-blind desensitization with milk or soy formula as placebo. Seven patients underwent the protocol in open fashion. The desensitization schedule started with one drop of whole CM diluted 1:25 every week. The dose was doubled weekly until the 18th week to achieve an intake of 200 mL in approximately 4 months. Of the 13 children enrolled, 10 children received CM and 3 control children received soy formula. Full tolerance (200 mL of milk) was achieved in 7 children; in 2 children this therapeutic approach failed, because severe reactions occurred during the procedure. One patient achieved a partial tolerance (64 mL of milk). The three control children receiving placebo still showed a positive food challenge at the end of the study. A weekly up-dosing oral tolerance induction could be a viable alternative to traditional protocols for children with IgE-mediated CMA.

Treatment with a combination of anti-IgE and specific immunotherapy for allergic rhinitis and asthma

Novel therapies that interfere specifically with immunological mechanisms underlying allergen-induced pathology are currently in clinical evaluation. Among these is anti-IgE, which directly targets IgE serum antibodies, thus inhibiting the central mechanism of immediate type hypersensitivity reactions. Application of anti-IgE antibodies effectively reduces IgE serum levels regardless of allergen specificity. It has been successfully tested in patients with allergic rhinitis, asthma and food allergy, showing significant efficacy in reducing symptom scores and use of rescue medications. Anti-IgE therapy is limited by high costs and the requirements for permanent or every-season treatment. The advantage of specific immune therapy (SIT) is the potential to alter the course of the disease, which has been demonstrated in patients with allergic rhinitis, insect venom allergy and, to a lesser degree, with asthma. The broader application of SIT is restricted by sometimes life-threatening side-effects. Here, we summarize the results of clinical trials investigating the effects of combination therapy with anti-IgE and SIT in patients with rhinitis and asthma. These studies show that combination of anti-IgE plus SIT may be beneficial for the treatment of allergic diseases by improving efficacy and limiting side effects.