Comparative analysis of sublingual immunotherapy medicines for adherence and clinical outcomes

IR (index of reactivity)-house dust mite sublingual immunotherapy liquid formulation for allergic rhinoconjunctivitis: Systematic review and meta-analysis of randomized and nonrandomized studies

Background

Although randomized controlled trials (RCT) are the reference standard of evidence in allergen immunotherapy (AIT), nonrandomized studies (NRS) are needed to confirm their results in more representative populations, particularly for treatment duration and persistence. However, when discrepancies are observed between RCT and NRS, NRS reliability decreases because these discrepant results are generally attributed to the methodologic flaws of NRS.

Objective

We compared the benefit of sublingual AIT (SLIT) for allergic rhinoconjunctivitis in NRS versus RCT focusing on a single product/allergen to reduce heterogeneity.

Methods

For meta-analysis, house dust mite (HDM) SLIT liquid formulation studies were sourced from computerized (Medline, Web of Science, and LILACS databases, to January 2023) and manual literature searches. Populations, treatments, and outcome data were combined (DerSimonian-Laird method). Noncomparative NRS were compared to RCT' SLIT arm before and after treatment. Efficacy was determined as the standardized mean difference (SMD) in symptom score (SS) and medication score (MS).

Results

Data from 12 NRS (682 patients) and 8 RCT (176 patients) were analyzed. The benefit with index of reactivity (IR)-HDM SLIT liquid formulation was found significant for, first, SS in both NRS (SMD = -1.27; 95% confidence interval [CI], -1.64, -0.90) and RCT (SMD = -0.56; 95% CI, -0.90, -0.21), and second, MS with SMD equal to -1.35 (95% CI, -1.77, -0.93) and -0.46 (95% CI, -0.67, -0.25), respectively. Metaregression showed that symptom improvement was correlated with treatment duration with consistent results in NRS and RCT with 12-month SS data: -0.87 (interquartile range, -1.02, -0.77) and -0.75 (interquartile range, -0.93, -0.41), respectively.

Conclusion

This meta-analysis showed comparable clinical benefit of IR-HDM SLIT liquid formulation increasing over time in both NRS and RCT, suggesting that NRS may reliably integrate RCT results and be considered for guidelines.

[Demographic features and compliance of children with allergic diseases receiving sublingual immunotherapy]

OBJECTIVES

To study the demographic features of children with allergic diseases receiving standardized sublingual immunotherapy (SLIT) and the influencing factors for the compliance with SLIT.

METHODS

A retrospective analysis was performed on the demographic features and follow-up data of 1 789 children with allergic diseases who received SLIT in Children's Hospital of Jiangxi Province from January 1, 2018 to December 31, 2020. The compliance with SLIT and its influencing factors were analyzed.

RESULTS

A total of 1 789 children received SLIT, among whom there were 1 271 boys (71.05%) and 518 girls (28.95%), with an age range of 4-14 years. Among these children, 777 (43.43%) had complete compliance with SLIT and 1 012 (56.57%) withdrew from the treatment within one year. Among the 1 012 children, 354 (34.98%) withdrew from the treatment due to self-conscious inconvenient use, 346 (34.19%) withdrew due to unsatisfactory treatment outcome, 253 (25.00%) stopped the treatment due to the improvement in symptoms, and 59 (5.83%) terminated the treatment due to adverse reactions. Withdrawal was mainly observed within 1-4 months after treatment (74.31%, 752/1 012). Girls tended to have a lower compliance rate than boys, and the children with a single disease had a lower compliance rate than those with multiple diseases (P<0.05). The multivariate analysis showed that compared with boys, girls had an increased risk of withdrawal (OR=0.811, 95%CI: 0.658-0.998, P<0.05), and compared with the children with multiple diseases, the children with a single disease were more likely to withdraw from the treatment (OR=1.313, 95%CI: 1.005-1.715, P<0.05).

CONCLUSIONS

Children with allergic diseases tend to have poor compliance with SLIT, which is associated with sex and the number of diseases, and the main reasons for withdrawal are self-conscious inconvenient use and unsatisfactory treatment outcome.

Dropouts From Sublingual Immunotherapy and the Transition to Subcutaneous Immunotherapy in House Dust Mite-Sensitized Allergic Rhinitis Patients

Purpose: Both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) are effective in reducing symptoms and medication scores and inducing long-term efficacy in patients with allergic rhinitis (AR). However, SLIT has been associated with poor patient adherence. This study investigates the factors impacting dropout rates from SLIT in house dust mite (HDM)-sensitized AR patients. Methods: A retrospective study was performed to analyze dropout rates and reasons in AR patients receiving Dermatophagoides farinae (Der f) SLIT with a follow-up period of 2 years. Results: A total of 719 HDM-sensitized AR patients received Der f-SLIT. Dropout rates increased with time and most occurred after 1 year of SLIT. By month 24, 654 (91%) patients had discontinued SLIT. The dropout rates by month 24 were 100, 90.1, and 91.1% in children <5 years old, children aged 5-18 years old, and adults ≥ 18 years old, respectively. Combination with allergic asthma and mono- or multi-sensitization to other aeroallergens did not affect the dropout rates. The most common self-reported reasons for dropouts were refusal of continuation, dissatisfaction with the efficacy, transition to SCIT, and adverse effects. Refusal of continuation increased with age, whereas transition to SCIT decreased with age. Ninety-seven cases transitioned from SLIT to SCIT, and the transition rates increased with time. Comorbid allergic asthma did not affect the transition rates. However, multi-sensitization was associated with a slightly higher rate of transition to SCIT. The most common reason for the transition was dissatisfaction with the efficacy (54.6%), which was only reported by patients older than 5 years. For children who began SLIT at younger than 5 years old, the most common reason (81.2%) for transition was age reaching 5 years. Conclusions: HDM-SLIT has a very high dropout rate, which is mainly due to refusal of continuation and dissatisfaction with the efficacy. Transitioning from SLIT to SCIT may help keep these patients on AIT and thus increase adherence and long-term efficacy.

Consensus on the treatment of allergic asthma with sublingual house dust mite immunotherapy in the field of Pneumology

INTRODUCTION

: Many patients sensitized to mites remain symptomatic and uncontrolled despite traditional treatment. Sublingual immunotherapy (SLIT) has demonstrated to reduce the symptoms of allergic rhinitis, the need for additional drug treatments, and to reduce the number of moderate and severe exacerbations in patients with allergic asthma caused by mites that had not been adequately controlled.

AREAS COVERED

: After reviewing the most recent literature, a scientific committee composed by 5 pneumologists experts in asthma proposed 41 items that addressed the diagnosis of allergic asthma caused by mites, the role of house dust mite (HDM) SLIT tablet in the therapeutic plan and in the control of the disease, and the profile of patients with asthma candidates for this therapy. Through a modified Delphi method, the items were send to 106 pneumologists involved in asthma to be agreed.

EXPERT OPINION

: The high degree of consensus reached by the panel of pneumologists shows the importance of HDM SLIT tablet in the treatment of allergic asthma caused by mites, particularly taking into account that they barely use this therapy because until now they did not have a registered treatment with solid evidence of efficacy and safety.