Inflammation in Respiratory Allergy Treated by Sublingual Immunotherapy

The most common allergic diseases, such as rhinitis, asthma and atopic dermatitis, are sustained by allergic inflammation, the treatment of which requires anti-inflammatory activity. Among the available treatments, allergen immunotherapy (IT) has a documented impact on allergic inflammation which persists after its discontinuation and modifies the natural course of allergy. The anti-inflammatory effects of IT, and particularly of sublingual IT (SLIT), are based on the ability to modify the phenotype of T cells which, in allergic subjects, are characterized by a prevalence of the Th2 type, with production of IL-4, IL-5, IL-13, IL-17, and IL-32 cytokines. IT-induced changes result in a Th1-type response (immune deviation) related to an increased IFN-gamma and IL-2 production or in a Th2 reduced activity, through a mechanism of anergy or tolerance. It is now known that T cell tolerance is characterized by the generation of allergen-specific Treg cells, which produce cytokines such as IL-10 and TGF-beta with immunosuppressant and/or immunoregulatory activity. Recent studies suggest that the anti-inflammatory mechanism of SLIT is similar to classical, subcutaneous IT, with a prominent role in SLIT for mucosal dendritic cells. The tolerance pattern induced by Treg accounts for the suppressed or reduced activity of inflammatory cells and for the isotypic switch of antibody synthesis from IgE to IgG, and especially to IgG4. Data obtained from biopsies clearly indicate that the pathophysiology of the oral mucosa plays a pivotal role in inducing tolerance to the sublingually administered allergen.

Prevalence and incidence of reactions to insect stings in children: a reappraisal

AIM

The prevalence of systemic reactions (SR) to Hymenoptera stings in children was estimated in values lower than 1% in early studies but much higher in recent surveys. We evaluated the current prevalence and the incidence of SR and large local reactions (LLR) to Hymenoptera stings in children in Italy.

METHODS

The data on children were collected from the database of the population study on the city of Cotignola, analyzing the answers to the part of the questionnaire about Hymenoptera stings, that concerned if the subject was ever stung by apids or vespids, if there has been a SR or a LLR, and if subjects with reactions received a diagnostic evaluation and a medical treatment.

RESULTS

Of the population of 1035 children, 173 (16.7%) were stung at least one time by Hymenoptera. Of them, 5 had had a SR and 9 had had a LLR. This defines a prevalence of SR of 0.5% and of LLR of 0.9%. Only one reaction was severe. Of the 14 subjects with SR or LLR, 5 (35.7%) underwent a diagnostic evaluation and one (7.1%) was treated with venom immunotherapy. The incidence of SR in the subsequent 2 years was 0.09% in the first year and 0.08% in the second year.

CONCLUSIONS

These findings do not confirm the recent reports of an increased prevalence of Hymenoptera venom allergy in children. The incidence of SR to stings, thus far unreported for children, was very low both in the first and in the second year.

Evaluation of house dust mite allergy in real life: patients' characteristics and satisfaction with treatment

BACKGROUND

HDMs are a ubiquitous allergen source, with a very well defined biology, but their role in clinical settings and in everyday clinical practice is not well characterized. Aim of this cross-sectional, questionnaire-based study was to assess the clinical characteristics of HDM-related respiratory allergy in a large population of Italian patients.

METHODS

A structured questionnaire was sent to allergists randomly chosen among those of the Italian Federation of Immunology, Allergy and Clinical Immunology (IFIACI). They were asked to fill it with the clinical data of 10-12 consecutive patients referred for respiratory allergy, positive to HDM skin prick test. The questionnaire assessed type and severity of allergy, demographics, yearly distribution of symptoms, treatment, and satisfaction with the therapy.

RESULTS

45 allergists collected data from 499 patients. Within the evaluated population, 42% had rhinitis only, 45% asthma + rhinitis and 13% asthma alone. Rhinitis was moderate/severe in 51% of patients. Asthma was intermittent in 36% of patients, mild in 37% and moderate in 27%. Conjunctivitis was the most frequent comorbidity (36%), followed by rhinosinusitis (16%), adenoid hypertrophy (6%) and polyposis (5%). Out of the population, 56.2% of patients were not at all or partially not satisfied of their treatment for rhinitis, whereas the percentage of dissatisfied patients was about 53% for asthma therapy. 34% patients (n = 170) were monosensitized to HDM. It is confirmed that patients have more symptoms during the fall-winter periods.

CONCLUSION

Patients with HDM allergy have frequently moderate-severe rhinitis, and about 50% of them are not satisfied with their treatment.

Evaluation of stability of allergen extracts for sublingual immunotherapy during transport under unfavourable temperature conditions with an innovative thermal insulating packaging

Many pharmaceutical and biotechnological products are temperature-sensitive and should normally be kept at a controlled temperature, particularly during transport, in order to prevent the loss of their stability and activity. Therefore, stability studies should be performed for temperature-sensitive products, considering product characteristics, typical environmental conditions, and anticipating environmental extremes that may occur during product transport in a specific country. Staloral products for sublingual immunotherapy are temperature sensitive and are labelled for maintenance under refrigerated conditions (2-8°C). Given the peculiar climatic context of Italy and the great temperature fluctuations that may occur during transport, this study was aimed at evaluating the impact of a new engineered thermal insulating packaging for Staloral. In particular, the purpose was to assess whether the new packaging could create a container condition able to preserve the stability and immunological activity of the product during the transport phase throughout Italy. The results showed that the range of temperatures that can affect the product, in the area surrounding the product packaging, may reach a peak of 63°C during transport under the most unfavourable climatic conditions, i.e. in a non-refrigerated van during the summer season, from the site of production in France to the patient's house in Catania, the city with the highest temperatures in Italy. However, the highest temperature reached inside the vaccine did not exceed 45°C over a period of about 2 h. The ELISA inhibition test on samples subjected to the extreme temperature conditions previously defined (45°C) showed an immunological activity higher than 75% of that initially measured and was comparable to those obtained with samples stored at controlled temperature (5°C). This means that, even in the worst case scenario, the structure of the allergen extracts is not influenced and the vaccine potency is preserved.

Allergen immunotherapy may exert an extra-anti-allergic activity in children

Allergic patients frequently suffer from infections. Allergen immunotherapy (AIT) usually improves respiratory symptoms, mainly in allergic rhinitis (AR). This study was aimed at evaluating the possible impact of AIT on extra-allergic outcomes in a cohort of Italian children with respiratory allergy patients. The study was performed on 77 children (43 males, mean age 10.5 years) with AR. The kind and the number of prescribed allergen extracts, type of diagnosis, severity of symptoms, and use of drugs were evaluated at baseline and after 2 year AIT. Globally 40 patients were treated with AIT, the remaining 37 children served as control. AIT-treated children had lower symptoms, drug use, and less severe extra-allergic surrogate markers of infection in comparison with children untreated with AIT. In conclusion, this study provides the first evidence that 2-year SLIT is able of exerting an adjunctive anti-allergic activity in AR children.

A survey on features of allergic rhinitis in children

OBJECTIVE

A number of epidemiologic studies evaluated the prevalence of allergic rhinitis (AR), but few data are available on its different clinical presentations. We addressed this survey to assess the features of AR in children and adolescents.

METHODS

Thirty-five centers in Italy included 2623 pediatric patients with rhinitis, of whom 2319 suffered from AR, while 304 had other kinds of rhinitis. For each patient a standardized questionnaire was filled in, including ARIA classification, the duration of symptoms, the allergen identified as clinically relevant, the co-morbidities, the kind of treatment, the response to treatment, the satisfaction with the treatment, and the feasibility of allergen immunotherapy (AIT).

RESULTS

Of the 2319 patients, 597 (25.7%) had mild intermittent, 701 (30.2%) mild persistent, 174 (7.5%) moderate-severe intermittent, and 773 (33.3%) moderate-severe persistent AR. The allergens most relevant were grass pollen and dust mites. The most frequently used drugs were oral antihistamines (83.1%) and topical corticosteroids (63.5%). The response to treatment was judged as excellent in 13.5%, good in 45.1%, fair in 30.8%, poor in 10%, and very bad in 0.6% of cases. The satisfaction with treatment was judged as very satisfactory in 15.2%, satisfactory in 61.8%, unsatisfactory in 22.4%, and very unsatisfactory in 0.5% of cases. AIT was considered indicated in 53.1% of patients with mild intermittent, 79.2% of moderate-severe intermittent, 72.6% of mild persistent, and 82.7% of moderate-severe persistent AR.

CONCLUSIONS

The limitation of this study is that the population was not unselected and this prevents epidemiological significance. These results offer confirmation of the adequacy of ARIA guidelines in classifying patients with AR and of the association of severe phenotype with lack of success of drug treatment.

Satisfaction with allergy treatments depends on symptom severity but not on allergen specificity in patients with allergic rhinitis

Allergic rhinitis is characterized by troublesome symptoms that may be particularly severe. Most of rhinitics are dissatisfied with drug treatments. The dissatisfaction level depends on symptoms severity, but not on the type of causal allergen.

Prevalence of allergic disorders in Italy: the Cotignola population study

BACKGROUND

The worldwide prevalence of allergic diseases such as rhinitis, asthma, and atopic dermatitis is continuously increasing, while other allergic disorders such as urticaria and angioedema are less investigated. We performed a population study evaluating the prevalence of any kind of allergic disorders.

METHODS

The entire population of 7,201 inhabitants of Cotignola (Ravenna, Italy) was surveyed by a questionnaire assessing symptoms related to rhinitis, asthma, anaphylaxis, skin symptoms and insect sting allergy as well as the features of clinical presentations, diagnosis, and treatment received.

RESULTS

Valid questionnaires were obtained by 6,676 inhabitants (92.7%). The sample was formed by 3,266 males and 3,495 females, the mean age was 45.6 years; 1,035 subjects (15.5%) were aged less than 18 years; 404 subjects (6%) had at least one episode of wheezing/breathlessness in their lifetime, and 243 of them (60.1%) had a diagnosis of asthma; 1,002 subjects (14.8%) had nose symptoms in their lifetime, and 375 of them (37.4%) had a diagnosis of allergic rhinitis or rhinoconjunctivitis. For other allergic manifestations, data were obtained from 5,730 subjects; of them, 178 (3.1%) had skin symptoms, 59 (1.1%) had oral symptoms, and 37 (0.6%) had anaphylaxis; 207 (3.6%) had reactions to insect stings. There were no significant differences in prevalence between Italians and immigrants. Only 51.7% of subjects with asthma, 46.5% of those with rhinitis, 22.7% of those with other allergies, but 97.1% of those with insect allergy, received treatment.

CONCLUSIONS

These findings confirm recent data on epidemiology of allergic diseases in Europe, particularly in Italy, and add some details on how such diseases are managed.

Which allergen extract for grass pollen immunotherapy? An in vitro study

BACKGROUND

Grass pollen is a major cause of allergy throughout the world. The only treatment targeting the causes and not only the symptoms of allergy is specific immunotherapy (IT). A number of controlled trials demonstrated the efficacy of IT in grass pollen allergic subjects, most using extracts of multiple grasses but some using extracts of a single grass. The optimal grass extract for IT has not yet been established.

METHODS

This study is aimed at investigating the IgE-binding pattern in sera from IT-naïve patients from central Italy with allergic rhinitis and/or asthma caused by grass pollen. A 5-grass extract was used (containing Dactylis glomerata, Poa pratensis, Lolium perenne, Antoxanthum odoratum and Phleum pratense) and compared to Phleum pratense alone, which is the most frequently used single grass extract, by the RAST-inhibition technique.

RESULTS

The 5-grass extract showed, by RAST-inhibition, a significantly higher binding compared to the Phleum pratense extract for Antoxanthum odoratum and Poa pratensis, while the two extracts for immunotherapy showed similar binding affinity for Phleum pratense and the non-Pooideae grass, Cynodon dactylon.

CONCLUSIONS

The use of a mixed-grass pollen extract seems to be the optimal choice when applying specific IT in grass pollen-allergic subjects from the Mediterranean area.

The POLISMAIL lesson: sublingual immunotherapy may be prescribed also in polysensitized patients

Polysensitization is a feature of allergic rhinitis (AR) that significantly impairs the quality of life (QoL) of AR patients. Allergen-specific immunotherapy is the only causal therapy for AR. However, the polysensitization phenomenon may represent a crucial obstacle as far as it concerns the choice of the allergen extract which should be used for immunotherapy. Therefore, a real-life based multi-centre study, named POLISMAIL, has been designed which aims at evaluating the behaviour of some allergists managing polysensitized AR patients. The effect of two-year SLIT treatment in those patients was also evaluated. A single allergen extract was used for two-thirds of patients, whereas a mix of two allergens was chosen for the remaining patients. The severity grade of AR and the type of diagnosis were significantly improved by 2-year SLIT. In addition, SLIT significantly improved QoL. Both outcomes confirm that SLIT with one or two allergen extracts achieves a significant improvement in polysensitized patients. In conclusion, the POLISMAIL study demonstrates that polysensitization should not represent a counter-indication for prescribing immunotherapy. The choice to limit SLIT to 1-2 allergen extracts was sufficient and effective in improving symptoms and QoL.

Sublingual immunotherapy in polysensitized patients: effect on quality of life

BACKGROUND

Quality of life (QOL) is an important issue in allergic rhinitis and has been evaluated in a number of studies that have shown how it is impaired in untreated patients and improved by effective treatment. However, there are no data concerning QOL after sublingual immunotherapy (SLIT) in polysensitized patients.

OBJECTIVE

To evaluate the effect, in real-life clinical practice, of SLIT on QOL in a population of polysensitized patients with allergic rhinitis.

METHODS

We prospectively evaluated 167 consecutively enrolled polysensitized patients with allergic rhinitis. QOL was measured in all cases with the Rhinoconjunctivitis Quality of Life Questionnaire at baseline and after 1 year of SLIT (performed in approximately 70% of cases using single allergen extracts provided by the same manufacturer).

RESULTS

The most frequent causes of sensitization were grass pollen, Parietaria, and house dust mites. The mean number of sensitizations per patient was 3.65. SLIT was performed with 1 extract in 123 patients (73.6%), with 2 extracts in 31 patients (18.6%), and with more than 2 extracts in 13 patients (7.8%). The mean values of all the QOL items improved significantly (P < .01 in all cases), with the following reductions noted: activities, 3.96 to 2.89; sleep, 2.07 to 1.56; general problems, 2.16 to 1.5; practical problems, 3.69 to 2.58; nasal symptoms, 3.57 to 2.50; eye symptoms, 2.92 to 1.83; and emotional aspects, 2.2 to 1.44.

CONCLUSIONS

This study provides evidence that QOL can be improved in polysensitized patients treated with SLIT, and that the use of just 1 or 2 allergen extracts seems to be sufficient and effective in terms of improving QOL.

Phase II trial of single-agent oral vinorelbine in elderly (> or =70 years) patients with advanced non-small-cell lung cancer and poor performance status

BACKGROUND

Elderly patients with advanced non-small-cell lung cancer (NSCLC) with poor performance status (PS) are a special population requiring particular attention. Single-agent oral vinorelbine could be an attractive option.

PATIENTS AND METHODS

A total of 43 patients with stage IIIB-IV NSCLC and Eastern Cooperative Oncology Group (ECOG) PS of two or more with good functional status were prospectively recruited. Oral vinorelbine was administered at the dose of 60 mg/m(2) on days 1-8 every 3 weeks. Primary end points were response rate and safety.

RESULTS

Overall response rate was 18.6% with 8 partial responses; 18 of 43 (41.8%) experienced stable disease lasting >12 weeks and 17 of 43 (39.6%) disease progression for an overall clinical benefit of 60.4%. Median time to progression was 4.0 (range 2-22) months and median overall survival 8.0 (range 3-35) months. Treatment was well tolerated. Of 187 cycles, we did not observe any grade 3/4 toxicity with the exception of a single not-febrile G3 neutropenia. Regardless of severity, main toxic effects observed were nausea in 48.1% and vomiting in 22.9% of patients, anemia in 43.2%, fatigue in 32.6% and leukopenia in 23.2%.

CONCLUSION

Single-agent oral vinorelbine is extremely safe in elderly patients with advanced NSCLC and ECOG PS of two or more and may represent a valid option in this very special population.

Sublingual immunotherapy: administration, dosages, use

Allergen extracts for sublingual immunotherapy (SLIT) are currently marketed by several manufacturers, with administration schedules and amount of allergen(s) quite variable in the different products, although almost all are standardized biologically or immunologically. The allergen extracts for SLIT are available in two main pharmaceutical forms: solution to be delivered by drop-counters, pre-dosed actuators (mini-pumps) or disposable single-dose vials; tablets with appropriate composition that allows a slow (1-2 minutes) dissolution in the mouth in contact with saliva. In Europe, SLIT is prescribed in general for one or a few allergens, and mixtures are less used, though there is no immunological contraindication to give multiple allergens. SLIT traditionally involves a build-up phase and a maintenance phase with the top dose. The build-up phase has usually the duration of 4 - 6 weeks. The patient must start with the lowest concentration and gradually increase, using the different dosage preparations, until the maintenance dose is reached. Rush and ultra-rush inductions have been introduced, based on the safety profile of SLIT that is very favorable. For these reasons it has been suggested that an updosing phase maybe even not necessary. The no-updosing approach would result in a treatment that is more patient-friendly and convenient to manage. Indeed, the most recent randomized trials were performed with the no-updosing regimen and their results in term of safety were as favorable as the studies performed with the traditional updosing approach. The currently recommended duration of SLIT is comprised between 3 and 4 years depending on the clinical response in single patients.

Sublingual immunotherapy in polysensitized allergic patients with rhinitis and/or asthma: allergist choices and treatment efficacy

Polysensitization is very common in allergic patients and was previously reported to be associated with more severe symptoms and impaired quality of life. Polysensitization is often considered as a contraindication for specific immunotherapy (SIT). This study is aimed at evaluating the allergist attitude for decision making in choosing SIT in a cohort of Italian polysensitized patients. Moreover, the 1-year effectiveness of the prescribed sublingual immunotherapy (SLIT) in this cohort was evaluated. The study was performed on 244 patients (109 males, 135 females, mean age 28.7 years, S.D. 12.0) with allergic rhinitis (assessed by ARIA criteria) and/or mild to moderate asthma (assessed by GINA criteria) treated with SLIT for 1 year. The kind and the number of prescribed allergen extracts, type of diagnosis, severity of symptoms, use of drugs, and adverse events were evaluated at baseline and after 1 year. A total of 230 patients were treated with SLIT: 165 with a single extract, and 65 with two different extracts (mix). SLIT treatment significantly improved disease staging, and reduced symptom severity and drug use. No systemic reaction was reported. In conclusion, these findings provide preliminary evidence that SIT is effective and safe in polysensitized patients after 1 year of treatment also using single extracts, and thus does not represent an obstacle for prescribing SIT.

Lack of inflammatory cells in the oral mucosa of subjects undergoing sublingual immunotherapy

The cells involved in allergic inflammation, such as mast cells, basophils, and eosinophils, have been thoroughly studied in the nose, the lungs and the skin, demonstrating an evident increase in response to the introduction of the specific allergen, while little is known in the mucosal system and particularly in the oral mucosa. We investigated such tissue by using the model of sublingual immunotherapy (SLIT), by which high doses of the specific allergen enter the mouth. Oral biopsies were carried out on seven subjects allergic to grass pollen and treated with SLIT by a grass extract. In biopsies carried out before SLIT there was a very low number of mast cells and eosinophils both in the epithelium and subepithelium layers, and insignificant changes were detected after SLIT. These findings show the lack of allergic inflammation in the oral mucosa upon contact with the specific allergen and confirm the role of the mouth as a tolerogenic site, which is conceivable considering the different attitude of the mouth, where the antigens transit to undergo digestion, in respect to the airways or the skin, where the antigen absorption is potentially dangerous.

Characteristics of patients with allergic polysensitization: the POLISMAIL study

BACKGROUND

The natural history of respiratory allergy is commonly characterized by a worsening of symptom severity, frequent comorbidity of rhinitis and asthma, and polysensitization to aeroallergens. The polysensitization phenomenon starts since childhood and is rare to find monosensitized adult patients. However, there are few studies investigating the characteristics of polysensitized patients.

METHODS

This study was performed on a large cohort of patients with allergic rhinitis (assessed by ARIA criteria) and/or mild to moderate asthma (assessed by GINA). The kind and the number of sensitizations, their patterns, and the relation with quality of life (QoL) measured by the Juniper's RQLQ guestionnaire, were evaluated.

RESULTS

Globally 418 patients (50.2% males, 49.8% females, mean age 26.4 years, range 3.5-65 years, 64 smokers, 371 non-smokers) were enrolled: 220 had allergic rhinitis alone, and 198 allergic rhinitis and asthma. The mean number ofsensitizations was 2.6. Three hundred-five patients (73%) had persistent rhinitis (PER), 220 of them with moderate-severe form. There was no significant derence in rate of rhinitis and asthma in monosensitized or polysensitized patients. Most patients were sensitized to pollens, whereas only 24.2% of them were sensitized to perennial allergens. Polysensitization was significantly associated with some issues of QoL, confirming previous findings, but not with number ofsensitizations.

CONCLUSIONS

This study provides data confirming for poly-sensitized patients the relevance of ARIA classification of AR. PER is the most common form of AR in this cohort, symptoms are frequently moderate-severe, and asthma is present in about the half of patients with AR.

Comparison between continuous or intermittent schedules of sublingual immunotherapy for house dust mites: effects on compliance, patients satisfaction, quality of life and safety

Sublingual immunotherapy (SLIT) is indicated in the treatment of allergic rhinitis and asthma. However, an issue scantly investigated is the patients satisfaction and the consequent compliance. This study is aimed at evaluating the possible differences of SLIT administered continuously or intermittently on several parameters: clinical efficacy, Quality of Life (QoL), satisfaction, compliance and safety. Forty allergic patients were treated for 12 months. The treatment was carried out by sublingual administration of an allergen extract of a 50% mixture of Dermatophagoides pteronyssinus and Dermatophagoides farinae at 10 and 300 IR/ml concentrations. Patients were randomly treated continuously or intermittently (i.e. 2 month treatment alternate to 2 month suspension). Both schedules were significantly effective in reducing allergic symptoms and improving QoL. Compliance and satisfaction were good in both groups. Local and systemic reactions were few, self-resolving, and mild in both schedules. Intergroup analysis did not reveal any difference between the two groups regarding these parameters. In conclusion, this preliminary study provides the evidence that also intermittent SLIT is as effective and safe as traditional continuous treatment. In addition, compliance and satisfaction are super-imposable in the two groups.

Intermittent and Persistent Allergic Rhinitis and Association with Asthma in Children

The natural history of allergic rhinitis (AR) is commonly characterized by worsening of symptom severity, frequent comorbidity with asthma, and polysensitization to aeroallergens. The polysensitization phenomenon starts in early childhood. AR classification has been recently revised, and some studies investigated the new types: intermittent (IAR) and persistent (PER) AR. However, no study has been carried out on children regarding this issue. This preliminary study was performed on a large cohort of children with allergic rhinitis to evaluate the type and severity of rhinitis and its possible association with asthma, including severity grade. One hundred and thirty-nine children (86 males, 53 females, mean age 11.8 years, range 3.5–17.7 years) with allergic rhinitis were prospectively and consecutively evaluated. Seventy-one children had rhinitis alone and 68 had rhinitis associated with asthma. Forty children had IAR, 30 of whom with moderate-severe grade. Ninety-nine children had PER, 65 of whom had moderate-severe grade. The severity of AR was not associated with asthma presence (Fisher χ2 = 0.5765; Prob.=0.9018). Regarding asthma severity, 30 children had the intermittent form, whereas 38 had the persistent form: 15 mild, 22 moderate, and 1 severe. This study provides the first evidence concerning the ARIA classification in children, partially confirming findings obtained in adulthood.

Sublingual immunotherapy: from safety to mechanism of action

Allergen specific immunotherapy is an important option for the treatment of respiratory allergy and its clinical efficacy has been clearly demonstrated by several studies. However, the injective route of administration and the possibility of severe side effects has limited its use in children and led to the introduction of new forms of administration. Sublingual immunotherapy (SLIT) has proven to be an effective and safe treatment for respiratory allergy. However, its mechanism of action is still debated. Pharmacokinetic studies showed that, differently from nasal mucosa, allergen extracts administered by SLIT are not immediately adsorbed but are long retained before being drained to local lymph nodes. This difference may be responsible of the absence of severe side effects and instead of short-lasting local symptoms. Studies by biopsies of the oral mucosa should greatly help in defining the presence and the role of cells involved in the mechanisms of oral tolerance.

Economic evaluation of sublingual immunotherapy: an analysis of literature

Allergic rhinitis and asthma constitute a global health problem because of their very high prevalence and the consequent burden of disease, concerning medical and economical issues. Among the treatments of allergy, specific immunotherapy has the capacity to favourably alter the natural history of the disease both during and after its performance and thus to reduce the direct and indirect costs of allergic rhinitis and asthma. A number of studies reported such cost reduction for traditional, subcutaneous immunotherapy and recent data demonstrate that also sublingual immunotherapy (SLIT) is associated to economic advantages and/or monetary savings, specifically in terms of reduction of disease economic burden. Only few formal economic assessments of SLIT have been carried out so far, this article will present and discuss the published studies addressed to this issue. The data obtained, although the number of studies is still limited, provide preliminary evidence supporting a SLIT effect on sparing costs for respiratory allergy.

Pharmacoeconomics of subcutaneous allergen immunotherapy

The current burden of allergic diseases, estimated by both direct and indirect costs, is very relevant. In fact the cost estimation for rhinitis amount globally to 4-10 billion dollars/year in the U.S. and to an average annual cost of 1089 euros per child/adolescent and 1543 euros per adult in Europe. The estimated annual costs in Northern America for asthma amounted to 14 billion dollars. Consequently, preventive strategies aimed at reducing the clinical severity of allergy are potentially able to reduce its costs. Among them, specific immunotherapy (SIT) joins to the preventive capacity the carryover effect once treatment is discontinued. A number of studies, mainly conducted in the US and Germany demonstrated a favourable cost-benefit balance. In the nineties, most surveys on patients with allergic rhinitis and asthma reported significant reductions of the direct and indirect costs in subjects treated with SIT compared to those treated with symptomatic drugs. This is fully confirmed in recent studies conducted in European countries: in Denmark the direct cost per patient/year of the standard care was more than halved following SIT; in Italy a study on Parietaria allergic patients demonstrated a significant difference in favor of SIT plus drug treatment for three years versus drug treatment alone, with a cost reduction starting from the 2nd year and increasing to 48% at the 3rd year, with a highly statistical significance which was maintained up to the 6th year, i.e. 3 years after stopping immunotherapy, corresponding to a net saving for each patient at the final evaluation of 623 euros per year; in France a cost/efficacy analysis comparing SIT and current symptomatic treatment in adults and children with dust mite and pollen allergy showed remarkable savings with SIT for both allergies in adults and children.

Dose dependence of efficacy and safety of subcutaneous immunotherapy

A number of experimental and clinical evidence has shown that exposure to high amounts of allergen molecules favours the development of tolerance. This is true also for subcutaneous immunotherapy (SCIT), for which a dose dependence of clinical efficacy was clearly demonstrated. The effective doses, measured as microg of major allergens, to be administered during maintenance treatment were established for the main allergens. Regarding pollens, the range of effectiveness corresponds to 25-41 and 13-20 microg of major allergens Phl p 5 and Phl p 6 for grasses, to 10-47 microg of Amb a 1 for ragweed, to 12 microg of Bet v 1 for birch, and to 6.2 microg of Par j 1 for Parietaria. With house dust mites, a maintenance dose of 5-11.5 microg of the major allergen from Dermatophagoides pteronyssinus Der p 1 is associated to clinically relevant effects, and with cat epithelium the clinical success is observed using a dose of 13-15 microg of Fel d 1. Nevertheless, there are adverse reactions facing SCIT, which are related to the amount of injected allergen. In fact, the safety decreases when the administered doses increase. This has led to "optimal doses" being defined which show a good balance between efficacy and safety (corresponding for example to a dose of 7 microg for Der p 1 and of 13 microg for Fel d 1). The dose dependency with respect to both efficacy and safety makes essential to accurately consider the risk/benefit ratio in each patient eligible for SCIT.

Dose dependence of efficacy but not of safety in sublingual immunotherapy

Sublingual immunotherapy (SLIT) currently represents, as indicated by meta-analysis of its efficacy and safety, a valid option to the generally used traditional subcutaneous immunotherapy (SCIT) for treating respiratory allergy. Regarding efficacy, recent studies demonstrated that, similar to what has already been observed in SCIT as well as in experimental and clinical studies about the magnitudo of allergen exposure, the effectiveness on both clinical symptoms and immunologic changes depends on the amount of allergen administered during treatment. In addition, in vitro studies addressed with the role of dendritic cells, currently considered to be of pivotal importance in orienting toward tolerance the immune response to allergens, showed that the internalisation of allergen molecules, which is followed by tolerogenic presentation to T cells, depends on the amount of allergen. However, such dose dependence is not apparent concerning the safety. In fact, the comparison of studies respectively conducted with high and low allergen doses did not show differences in the rate of systemic reactions, which in any case never had the presentation of anaphylaxis, and instead a significant difference in the rate of local reactions, following the oral and gastrointestinal contact with the allergen extract, in favour of high dose studies.

Cost effectiveness of sublingual immunotherapy in children with allergic rhinitis and asthma

BACKGROUND

Economic evaluations are increasingly relevant in order to provide support for decision makers when judging about alternative ways to allocate public funds. Aim of this study was to evaluate the economic effect of treatment with high dose sublingual immunotherapy (SLIT) in children.

METHODS

The study involved one allergy center, located in the north of Milan, Italy. From the existing records of patients seen for allergic disease, we extracted all children and adolescents with allergic disease, who had 1-year data prior to receiving SLIT and 3-year data on SLIT. Outcome measures (number of exacerbations, visits, absence from nursery or school), direct costs (euros spent on drugs, specialist visits, SLIT) and indirect costs (costs resulting from children school and parental work loss) were analysed. A second analysis compared a sub-group of allergic asthmatic children with a control group for costs, based on records of patients not SLIT-treated, extracted from a network-database of paediatricians.

RESULTS

135 patients were extracted, of which 46 had perennial, and 89 had seasonal allergy with comparable gender and age distribution. A substantial reduction was found in all outcome measures during SLIT compared with the before period. The average annual cost/patient was 2672 before SLIT initiation and _629/year during SLIT. Similar results were found for allergen subgroups. The asthma sub-analysis involved 41 children with SLIT and 35 controls. Again, SLIT patients showed a substantial reduction in outcome measures; the direct cost/patient over the whole follow-up (4 years) was _1182 for SLIT patients and _1100 for controls.

CONCLUSION

High dose SLIT may be effective in reducing the cost of allergic rhinitis and asthma and comparably expensive to conventional treatment in children with allergic asthma over a 4 years follow-up.

The efficacy of sublingual immunotherapy for respiratory allergy is not affected by different dosage regimens in the induction phase

BACKGROUND

Sublingual administration of allergens is a safe and effective alternative to subcutaneous immunotherapy in patients with respiratory allergies. A drawback to this therapeutic approach is the relatively long and complex management of the induction phase.

AIM OF THE STUDY

To determine whether different induction regimens affect the outcome of sublingual immunotherapy.

METHODS AND RESULTS

Adult and pediatric patients with allergic rhinoconjunctivitis and/or asthma were included in the study. Ten subjects served as controls and received symptomatic treatments. Forty-three subjects were allocated to sublingual immunotherapy, with three different induction protocols (8-, 15- and 20-day, respectively). Symptom and medication scores, skin test results and (in asthmatic patients) FEV1 values were monitored for two years. Adverse effects were recorded. All induction regimens produced a significant improvement in symptom and medication usage (p < 0.0001); skin test scores decreased (p < 0.0001) and FEV1 improved (p < 0.05). In contrast, symptom and skin test scores did not significantly change in controls. No relevant adverse effects were observed with any of the induction regimens.

CONCLUSIONS

For patients with respiratory allergies, sublingual immunotherapy with an 8-day induction protocol is safe and effective. Our results encourage the usage of shorter induction regimens, which produce better compliance with this therapy.

Higher frequency of early local side effects with aqueous versus depot immunotherapy for hymenoptera venom allergy

Venom immunotherapy has proven a very effective method for the treatment of allergy to Hymenoptera venom. Aqueous instead of depot extracts are prevalently used for this immunotherapy. The advantage of using aqueous extracts has not been fully investigated. We made an open, non-controlled study on 45 subjects sensitized to either Apis mellifera or Vespula spp. Patients were assigned to either a depot (N=27) or an aqueous (N=18) immunotherapy regimen, and side effects were monitored during the induction and the 3-year maintenance phase. The effect of naturally occurring stings during the treatment and after its interruption was recorded as well. Side effects were less frequent with the depot extract both on a "per patient" (22.2% versus 50.0%) and on a "per dose" (2.9% versus 10,2%) basis (p=0.026 and p<0.000, respectively). Better tolerance was mainly due to the lower frequency of local side effects occurring at early times after vaccination. The efficacy of vaccination was comparable in the 2 cohorts, as expected. We conclude that depot immunotherapy to Hymenoptera venom should be preferred to aqueous immunotherapy for the lower occurrence of local side effects. This might influence a better compliance with this potentially life-saving treatment.

Long-lasting effect of sublingual immunotherapy in children with asthma due to house dust mite: a 10-year prospective study

BACKGROUND

Subcutaneous immunotherapy for respiratory allergy has shown a long-lasting efficacy after its discontinuation, whereas this evidence is still lacking for sublingual immunotherapy, despite the fact that it is widely used.

OBJECTIVE

We aimed to evaluate whether a long-lasting effect of SLIT occurs, in a prospective parallel group controlled study.

METHODS

Sixty children (mean age 8.5 years) suffering from allergic asthma/rhinitis due to mites were subdivided into two matched groups: 35 underwent a 4- to 5-year course of SLIT with standardized extract and 25 received only drug therapy. The patients were evaluated at three time points (baseline, end of SLIT and 4 to 5 years after SLIT discontinuation) regarding presence of asthma, use of anti-asthma drugs, skin prick tests and specific IgE.

RESULTS

We found that in the SLIT group there was a significant difference vs. baseline for the presence of asthma (P </= 0.001) and the use of asthma medications (P </= 0.01), whereas no difference was observed in the control group. The mean peak expiratory flow result was significantly higher in the active group than in the control group after 10 years. No change was seen as far as new sensitizations were concerned. Specific IgE showed a near-significant increase (baseline vs. 10 years, P = 0.06) only in the control group.

CONCLUSION

Our study demonstrates that sublingual immunotherapy is effective in children and that it maintains the clinical efficacy for 4 to 5 years after discontinuation.

The safety of cluster immunotherapy with aluminium hydroxide-adsorbed honey bee venom extract

Venom immunotherapy (VIT) with aqueous extracts is considered a life-saving treatment in insect allergy, but systemic side effects are quite common, especially in patients sensitized to Apis mellifera venom. Only a few studies are available regarding depot VIT administered according to the standard weekly schedule, while no data are available for cluster VIT with depot preparations. This study was designed to compare the tolerance of aqueous cluster or rush VIT versus cluster depot VIT in patients sensitized to Apis mellifera. Fifty-five patients with a history of systemic reaction (grade II to IV according to Müller) after an Apis mellifera sting were divided at random into 3 groups. Forty patients were treated with aqueous VIT (20 according to a cluster schedule and 20 according to a rush schedule) and 15 with Depot VIT according to a cluster schedule. All local and systemic side effects were recorded. Four patients belonging to the aqueous-cluster, 4 belonging to the aqueous-rush, and 1 belonging to the depot-cluster schedule had large local reactions after VIT (p < 0.009). Systemic side effects were recorded in 1, 7 and 0 patients (p < 0.003) respectively. No statistically significant difference was found between the two cluster regimens in the frequency of side effects. Depot VIT administered according to a cluster schedule was well tolerated, and its tolerance is better than aqueous-rush VIT for Apis mellifera.

Prevention of new sensitizations in monosensitized subjects submitted to specific immunotherapy or not. A retrospective study

BACKGROUND

Specific immunotherapy is the only currently available allergen-orientated treatment able to modify the natural history of respiratory allergic diseases. Safety and clinical efficacy of this treatment are well documented, but evidence about the ability to reduce new sensitizations is still poor.

OBJECTIVE

We report a retrospective study conducted in order to assess the prevention of new sensitizations in monosensitized subjects treated with specific immunotherapy vs. monosensitized patients treated with anti-allergic drugs.

METHODS

8396 monosensitized patients with respiratory symptoms were selected according to an open, retrospective design. Group A included 7182 patients submitted to specific immunotherapy (and anti-allergic drugs when needed) for 4 years and then treated with drugs for at least 3 years. Group B included 1214 patients treated only with drugs for at least 7 years. All patients underwent prick test with a standard panel of allergens and total and specific IgE determination before and after 4 years of treatment and again 3 years later.

RESULTS

Groups were well balanced. Polysensitized subjects were 23.75% in Group A and 68.03% in Group B after 4 years (P < 0.0001) and 26.95% and 76.77%, respectively, after 7 years (P < 0.0001). Asthmatic subjects were more prone to develop polysensitization in comparison to subjects suffering only from rhinitis (32.14% instead of 27.29% after 4 years, 36.5% instead of 31.33% after 7 years; P < 0.0001). Specific IgE decreased by 24.11% in Group A and increased by 23.87% in Group B (P < 0.0001). Total IgE decreased by 17.53% in Group A and increased by 13.71% in Group B (P < 0.0001).

CONCLUSIONS

Specific immunotherapy was observed retrospectively to reduce new sensitizations in monosensitized subjects suffering from respiratory allergic diseases.

Prevention of new sensitizations in monosensitized subjects submitted to specific immunotherapy or not. A retrospective study

BACKGROUND

Specific immunotherapy is the only currently available allergen-orientated treatment able to modify the natural history of respiratory allergic diseases. Safety and clinical efficacy of this treatment are well documented, but evidence about the ability to reduce new sensitizations is still poor.

OBJECTIVE

We report a retrospective study conducted in order to assess the prevention of new sensitizations in monosensitized subjects treated with specific immunotherapy vs. monosensitized patients treated with anti-allergic drugs.

METHODS

8396 monosensitized patients with respiratory symptoms were selected according to an open, retrospective design. Group A included 7182 patients submitted to specific immunotherapy (and anti-allergic drugs when needed) for 4 years and then treated with drugs for at least 3 years. Group B included 1214 patients treated only with drugs for at least 7 years. All patients underwent prick test with a standard panel of allergens and total and specific IgE determination before and after 4 years of treatment and again 3 years later.

RESULTS

Groups were well balanced. Polysensitized subjects were 23.75% in Group A and 68.03% in Group B after 4 years (P < 0.0001) and 26.95% and 76.77%, respectively, after 7 years (P < 0.0001). Asthmatic subjects were more prone to develop polysensitization in comparison to subjects suffering only from rhinitis (32.14% instead of 27.29% after 4 years, 36.5% instead of 31.33% after 7 years; P < 0.0001). Specific IgE decreased by 24.11% in Group A and increased by 23.87% in Group B (P < 0.0001). Total IgE decreased by 17.53% in Group A and increased by 13.71% in Group B (P < 0.0001).

CONCLUSIONS

Specific immunotherapy was observed retrospectively to reduce new sensitizations in monosensitized subjects suffering from respiratory allergic diseases.

Sublingual immunotherapy in tree pollen allergy. Double-blind, placebo-controlled study with a biologically standardised extract of three pollens (alder, birch and hazel) administered by a rush schedule

BACKGROUND

sublingual immunotherapy has been recognised as safe and effective but it is still poorly documented in tree pollen allergy. Allergy to alder, birch and hazel is important in Northern European countries but its clinical relevance is increasing in Southern Europe.

METHODS

thirty patients, selected and observed for one pollen season, were randomised to receive placebo (15 patients) or active treatment (15 patients). Twenty-seven patients completed the first year and 24 of them were treated with active therapy during the second year of the study in comparison to a parallel group of ten patients treated only with drugs. Symptom and drug scores during each pollen season, birch-specific IgE, changes in skin test reactivity, changes in specific Nasal Provocation Test and the daily average pollen count for the relevant trees were considered for the assessment of the efficacy of the treatment.

RESULTS

both active and placebo group showed a statistically significant improvement in scores in comparison to the previous year, under a lower allergenic pressure. The improvement was higher in the active group (76.04 % reduction of drugs) but not significantly different from that registered in the placebo group (37.05 % reduction). In the open phase of the study, treated patients showed significantly better scores in comparison to the control group. No significant changes in skin reactivity, specific IgE and Nasal Provocation Test were registered. SLIT tolerance was very good.

CONCLUSIONS

our data show a better but not statistically significant clinical outcome for patients actively treated with SLIT, but the placebo effect and the year-by-year variability of the environmental allergenic load in our small-size pilot study do not allow for a conclusive statement about the efficacy of this form of therapy.

Low domestic exposure to house dust mite allergens (Der p 1) is associated with a reduced non-specific bronchial hyper-responsiveness in mite-sensitized asthmatic subjects under optimal drug treatment

BACKGROUND

Airway inflammation in asthma causes symptoms, airflow limitation and bronchial hyper-responsiveness. The strategy of asthma management is to reduce airway inflammation by drug treatment and avoidance of triggers, including allergens.

OBJECTIVE

We determined the effect of exposure to house dust mite (HDM) allergens on bronchial responsiveness in asthmatics sensitive to mites while under optimal drug treatment.

METHODS

We studied 71 mild to moderate HDM-sensitive asthmatics. Drug treatment sufficient to keep asthma under control was administered to each patient for 1 year. Subjects were divided into two groups, according to the amount of Der p 1 in their bedrooms measured after standard HDM reduction measures: low Der p 1 exposure (0.64 +/- 0.5 microg/g dust) (Group 1, n = 34) and high Der p 1 exposure (12.5 +/- 11.4 microg/g) (Group 2, n = 37). Bronchial responsiveness to methacholine (PD20FEV1) was determined at the beginning and end of the study.

RESULTS

In Group 1, PD20FEV1 increased 2.15-fold at the end of the study from 57 to 123 microg (P < 0.05), whereas in Group 2 no significant changes were observed. The subjects in Group 2 tended to increase the use of inhaled steroids and bronchodilators in the autumn months compared with subjects in Group 1, but the difference was not significant.

CONCLUSION

This long-term study shows that exposure to lower levels of mite allergens in the bedroom is associated with a decrease of bronchial hyper-responsiveness in sensitized asthmatic subjects under optimal drug treatment.

Effects of sublingual immunotherapy in patients sensitised to Ambrosia. An open controlled study

BACKGROUND

Allergy to Ambrosia is a disease of growing importance in Europe. Injective and non-injective immunotherapy have been recognised as safe and effective but no evidence is currently available for sublingual immunotherapy (SLIT) in patients sensitised to Ambrosia. This study was planned to assess the effects and the safety of SLIT in patients clinically sensitised to Ambrosia.

METHODS

19 patients clinically sensitised to Ambrosia and treated with SLIT were compared to 14 patients treated only with drugs. Diary cards with symptoms and drug consumption were filled-in by patients during the pollen season whereas specific nasal challenge and skin prick test were run two months before and after the pollen season. Patients and doctors were also asked to express their subjective assessment about symptoms and drug consumption during the season.

RESULTS

SLIT-treated patients had less symptoms and a significantly minor drug intake (p = 0.04) as compared to untreated patients. Nasal challenge test improved significantly in the SLIT group (p = 0.0001) but not in the control group (p = 0.6875) with a significant difference between groups at the end (p = 0.0413) but not at the beginning of the trial (p = 0.213). The decrease in skin reactivity was significant in the control group (p = 0.0186) and highly significant in the SLIT group (p < 0.0001), with no difference between groups (p = 0.2987). Subjective assessment from both patients and doctors was favorable to SLIT (p = 0.0005 for symptoms; p = 0.0019 for drug consumption). Only one minor local side effect was registered during SLIT.

CONCLUSIONS

According to our data, SLIT in patients allergic to Ambrosia is safe and able to improve both subjective and objective parameters.

Clinical study on Alternaria spores sensitization

BACKGROUND

sensitization to fungi spores is often associated with sensitization to other allergens and so it is difficult to estabilish the exact cause of illness.

OBJECTIVE

the aim of the study was to evaluate a group of patients monosensitized to Alternaria and to establish the prevalence, periodicity and clinical profile of this kind of sensitization.

METHODS

37 subjects who were monosensitized to Alternaria (prick-test positive), according to a previous epidemiological study were evaluated. Clinical symptoms and the period of their occurrence were taken into consideration as well as immunological parameters (RAST).

RESULTS

20 patients (over 50%) included in the study proved to be affected by asthma associated with other allergic symptoms and 22 patients (60%) presented perennial symptoms. The RAST carried out on 34 monosensitized subjects proved positive in 11 and negative in 23.

CONCLUSIONS

Alternaria sensitization is characterized by a perennial periodicity with severe respiratory symptoms (asthma) which occur primarily in children. Prick test is preferable to and more reliable than RAST as a diagnostic test.

Clinical and immunologic effects of a rush sublingual immunotherapy to Parietaria species: A double-blind, placebo-controlled trial

BACKGROUND

The local (noninjection) routes of immunotherapy are presently regarded as viable therapeutic options for respiratory allergy, and their mechanisms of action are currently undergoing investigation.

OBJECTIVE

We evaluated the clinical efficacy of a preseasonal rush sublingual-swallow immunotherapy and its effects on allergic inflammation in patients with seasonal rhinoconjunctivitis caused by Parietaria species.

METHODS

Thirty patients with Parietaria species-induced rhinoconjunctivitis (13 with mild intermittent asthma) were randomly assigned sublingual-swallow immunotherapy or placebo in a rush preseasonal course. We assessed the seasonal symptom-drug intake score by diary card and the inflammatory infiltration and the intercellular adhesion molecule 1 expression on nasal epithelium after specific allergenic challenge before and after treatment.

RESULTS

The investigated immunotherapy was well tolerated, and no side effects were recorded. A significant reduction of the symptom score (P =.016) and drug intake score (P =. 008) after immunotherapy was observed only in the active group. A decrease of the cumulative score was observed also in the placebo group (P =.046), but the significance was clearly higher (P =.006) in the active group. In the active group a reduction of neutrophils (P =.001), eosinophils (P =.01), and intercellular adhesion molecule 1 expression (P =.04) after specific nasal challenge was also detected.

CONCLUSION

The present results suggest that this sublingual-swallow immunotherapy administered through a rush schedule is clinically effective and safe and that it decreases the immune-mediated inflammatory responses to the allergen.

Sublingual immunotherapy: a double-blind, placebo-controlled trial with Parietaria judaica extract standardized in mass units in patients with rhinoconjunctivitis, asthma, or both

BACKGROUND

New routes of administering immunotherapy in respiratory allergy are being studied as an alternative to conventional injective immunotherapy. We carried out a study to evaluate the clinical efficacy and effects of sublingual immunotherapy in patients with Parietaria judaica-induced respiratory allergy.

METHODS

A double-blind, placebo-controlled design was followed. Thirty patients with P. judaica rhinoconjunctivitis, mild asthma, or both were randomly chosen for sublingual immunotherapy (14 patients) or placebo treatment (16 patients). The patients underwent preseasonal rush induction treatment followed by coseasonal maintenance treatment during the Parietaria pollen season. Symptom and drug scores, as well as specific IgE and specific IgG4, were recorded.

RESULTS

Significantly lower symptom and drug scores were found (P=0.04), especially during the Parietaria pollination period, in the immunotherapy group. No significant difference in specific IgE and specific IgG4 was detected between the active and placebo groups; a statistically significant increase of specific IgE was detected in both groups (P=0.05). No patient undergoing active sublingual immunotherapy reported local or systemic side-effects.

CONCLUSIONS

Our data suggest that sublingual immunotherapy is both clinically effective and safe in treating patients with Parietaria-induced rhinoconjunctivitis and mild asthma.

Grass pollen specific sublingual/swallow immunotherapy in children: open-controlled comparison among different treatment protocols

BACKGROUND

sublingual-swallow immunotherapy has been recognized as safe and effective in adults. Different treatment schedules have been proposed and used, but the current experience in children is insufficient. We carried out a study to evaluate the clinical efficacy and the safety in children allergic to grass pollen, following different schedules.

METHODS

an open study was performed with 3 parallel treated groups and a control group, each including 12 children suffering from rhinoconjunctivitis due to grass pollen. The patients underwent either a preseasonal treatment or a pre-coseasonal treatment during the grass pollen season. The analysis of the clinical outcome was based on the number of days with symptoms and/or drug consumption in the pollen peak month.

RESULTS

significantly less days with symptoms and/or drug intake in all of the groups submitted to SLIT in comparison to the control group were found (p < 0.0001). Among the three schedules used, the best clinical results were obtained with the two pre-coseasonal treatments (p < 0.0001), with a preference for the schedule with the lowest maintenance dose according to the drug intake (p = 0.0267). Two patients belonging to the coseasonal schedule with the highest maintenance dose interrupted the treatment because of systemic mild side effects.

CONCLUSIONS

our data suggests that in children with rhinoconjunctivitis to grass pollen, SLIT is effective and well tolerated and that the pre-coseasonal schedule should be preferred to the preseasonal treatment. According to our data, the best maintenance dose during the pollen season for children, both for tolerance and clinical outcome, corresponds to 0.4 microg of the grass major allergen Group 5 administered three times a week.

Rush sublingual immunotherapy in Parietaria allergic patients

Forty patients, monosensitized to Parietaria judaica with a clinical history of at least two years of rhinoconjunctivitis with or without asthma, were selected and randomly allocated in two groups. According to an open controlled experimental plan, twenty patients were submitted to sublingual immunotherapy (SLIT) with a solution of purified and biologically standardized extract of Parietaria judaica, following a preseasonal rush schedule. All patients, twenty belonging to the SLIT group and twenty belonging to the control group, were allowed to take authorized rescue drugs at need. At the end of the Parietaria pollen season. 15 patients for each group resulted to have complied with the criteria of the study. SLIT tolerance turned out to be excellent as no side effects were noticed in the group under treatment. No change could be detected in specific IgE and IgG4 in either group. According to the daily symptom and drug scores registered by each patient in a diary card, the SLIT group showed a statistically significant lower symptom score (p = 0.032) and lower drug plus symptom score (p = 0.037) during the peak pollen period (May-June 1994) in comparison to the group treated only with symptomatic drugs. Moreover, 13 out of 15 patients submitted to SLIT expressed a very favourable subjective opinion about the therapy and asked to continue the same treatment the following season. According to our results, the rush SLIT schedule, followed by maintenance during the pollen season, is simple, safe and effective for Parietaria pollen allergy and showed an excellent compliance.

Injective versus sublingual immunotherapy in Alternaria tenuis allergic patients

Little knowledge is available on molds either from the environmental or clinical points of view. The latter is mainly due to the lack, until recent times, of purified and standardized extracts. Injective immunotherapy, largely used for patients allergic to mites and pollens, is regarded with some concern for molds. On the other hand, mold-related allergic symptoms (i.e.,from Alternaria tenuis) have in Italy an incidence of about 5 percent, mainly in young patients. We have therefore run a pilot study comparing the efficacy and safety of injective (SIT) and sublingual (SLIT) immunotherapy by administering the same purified and standardized extract of Alternaria tenuis to a total of 23 patients for two years, according to an open experimental plan. Excellent tolerance was shown to SLIT while four (two medium-grade) side effects appeared with SIT. Clinical improvement, subjectively stated comparing symptoms (mainly rhinitis) and drug consumption before and after the therapy, confirmed by an increase in the Specific Nasal Provocation threshold, was obtained with both therapies, but with a statistically significant difference in favour of SLIT. Skin reactivity and blood Alternaria tenuis specific IgE, total IgG and IgG changed in the SIT-treated group, while no statistically significant change was shown in the SLIT-treated group. These results are in good agreement with previous reports on SIT and SLIT with other inhalant allergens (mites, grasses), and suggest the potential use of SLIT for Alternaria allergy, mainly in young patients, when there are concerns about the safety of and compliance with the traditional injective therapy.