Allergen specific sublingual immunotherapy in children with asthma and allergic rhinitis

Standardization of clinical outcomes used in allergen immunotherapy in allergic asthma: An EAACI position paper

INTRODUCTION

In allergic asthma patients, one of the more common phenotypes might benefit from allergen immunotherapy (AIT) as add-on intervention to pharmacological treatment. AIT is a treatment with disease-modifying modalities, the evidence for efficacy is based on controlled clinical trials following standardized endpoint measures. However, so far there is a lack of a consensus for asthma endpoints in AIT trials. The aim of a task force (TF) of the European Academy of Allergy and Clinical Immunology (EAACI) is evaluating several outcome measures for AIT in allergic asthma.

METHODS

The following domains of outcome measures in asthmatic patients have been evaluated for this position paper (PP): (i) exacerbation rate, (ii) lung function, (iii) ICS withdrawal, (iv) symptoms and rescue medication use, (v) questionnaires (PROMS), (vi) bronchial/nasal provocation, (vii) allergen exposure chambers (AEC) and (viii) biomarkers.

RESULTS

Exacerbation rate can be used as a reliable objective primary outcome; however, there is limited evidence due to different definitions of exacerbation. The time after ICS withdrawal to first exacerbation is considered a primary outcome measure. Besides, the advantages and disadvantages and clinical implications of further domains of asthma endpoints in AIT trials are elaborated in this PP.

CONCLUSION

This EAACI-PP aims to highlight important aspects of current asthma measures by critically evaluating their applicability for controlled trials of AIT.

Diagnosis and Management of Allergic Rhinitis in Asthmatic Children

Allergic rhinitis (AR) is a common upper airways inflammatory condition especially in paediatric population; its burden potentially impacts on quality of life, quality of sleep and daily performance, which can be difficult to perceive but not less relevant in the middle-long term. The present review aims to provide an updated overview on AR epidemiology, diagnosis and with a special focus on its connections with bronchial asthma. In fact, when considering asthmatic pediatric population, AR is probably the most important risk factor for asthma onset and the most impactful extra-bronchial determinant of asthma control. Under this perspective, allergen immunotherapy (AIT) should always be considered in the light of a precision medicine approach. In fact, AIT does represent a unique opportunity to specifically interfere with AR immunological background, improve both AR and bronchial asthma control and prevent allergic disease evolution. Verifying the patient's eligibility to that option should be considered as a priority for every physician managing children suffering from AR, especially when associated with bronchial asthma.

Immunotherapy in the Treatment of Allergic Rhinitis in Children

Allergic rhinitis (AR) is an inflammation of the nasal membranes characterized by multiple allergic symptoms. It is a widespread health problem that affects patients' ability to engage in social and physical activity, which lowers their quality of life. The pathophysiology of AR is complex and requires sensitization and the development of a specific immune response to the allergen. Allergen-specific immunotherapy (AIT) is a therapeutic method that induces specific immune tolerance to allergens. The objectives of this review are to demonstrate the mechanism of action of immunotherapy, explain how it alleviates clinical symptoms of allergic rhinitis, list the indications and contraindications of immunotherapy in the treatment of allergic rhinitis, and identify different modalities of allergen immunotherapy, their disease-modifying effects, as well as their potential risks and benefits. The review of the literature highlights that T-cell and B-cell responses to inhaled allergens are altered by AIT, which decreases both early and late reactions to allergen exposure. To induce clinical and immunologic tolerance, especially in the pediatric age, escalating dosages of the causing allergen are administered subcutaneously or sublingually. AIT is indicated for severe persistent AR when avoidance measures and medications are inadequate to control the symptoms. To conclude, AIT is a disease-modifying therapy that is safe and effective for the treatment of allergic rhinitis. It is indicated when the symptoms are uncontrolled or when there are undesirable effects from pharmacotherapy.

Do not forget asthma comorbidities in pediatric severe asthma!

Asthma is the most common chronic respiratory disease in childhood. The long-term goals in managing asthma aim to control symptoms and prevent exacerbations, as well as to reduce side effects of therapy and mortality disease-related. Most of patients have mild to moderate asthma and respond well to standard therapies. However, a minor proportion of children with asthma has severe disease that remains uncontrolled despite optimal adherence to prescribed therapy and treatment of contributory factors, including trigger exposures and comorbidities, which can mimic or worsen asthma and contribute to exacerbations and poor quality of life. Evaluation of comorbidities is fundamental to optimize the management of the disease in a subgroup of patients with poor responder asthma. The overall aim of this article is to describe characteristics of main pediatric severe asthma comorbidities reported in literature, giving clinicians tools to recognize and manage properly these conditions.

Effect of Traditional Chinese Medicine on Allergic Rhinitis in Children under Data Mining

The data mining analysis of the medication rule and the curative effect of traditional Chinese medicine in treating allergic rhinitis in children was performed by using the association rule Apriori algorithm. The model of interest degree was introduced to improve the Apriori algorithm, and the performance difference of the algorithm before and after improvement was analyzed. Traditional Chinese medicine prescriptions for the treatment of allergic rhinitis in children were selected from the dictionary of Chinese medicine formulations. The frequency, frequent itemsets, and the improved Apriori algorithm of each prescription were analyzed comprehensively. The results showed that both the execution time of the improved Apriori algorithm and the number of mining association rules were signally lower. 102 Chinese herbal compounds were selected, in which the occurrence frequency of Flos magnoliae was the highest (67 times, 5.33%). The occurrence frequency of diaphoretic drugs was the highest (412 times, 32.78%) in drug types. The occurrence frequency of Yu Ping Feng powder was the highest (21 times, 20.59%) in the Chinese herbal compound. After the association rule analysis of the improved Apriori algorithm, Perilla frutescens, Saposhnikovia divaricata, ginseng, Notopterygium root, and Astragalus propinquus Schischkin were often mixed with liquorice, and Flos magnoliae were usually mixed with Fructus xanthii and black plum. Compared with the conditions before treatment, the sign scores of children with allergic rhinitis were remarkably decreased after treatment with traditional Chinese medicine compounds (P < 0.05). The mining performance of the Apriori algorithm was improved by introducing an interest-based model. The treatment of traditional Chinese medicine on allergic rhinitis in children was combined with children's physiological and pathological characteristics of children, which used mild medicines.

Recent Advances in Allergen-Specific Immunotherapy as Treatment for Allergic Asthma: A Practical Overview

The Global Initiative for Asthma Report updated in 2019 stated that potential benefits of allergen immunotherapy (AIT), compared to pharmacological and avoidance options, must be weighed against the risk of adverse effects and the inconvenience and cost of the prolonged course of therapy in asthma. Thus, with the aim of clarifying some aspects with regard to the possible use of AIT in allergic asthma treatment armamentarium, a group of expert allergists from the Spanish Allergy and Clinical Immunology Scientific Society (SEAIC), particularly from the Immunotherapy and Asthma Interest Groups developed a frequently asked questions in clinical practice. This document updates relevant topics on the use of AIT in asthma and could facilitate physician clinical decisions and improve health outcomes for individual patients.

Use of Sublingual Immunotherapy for Aeroallergens in Children with Asthma

Asthma is a heterogeneous disease that in children is often allergen-driven with a type 2 inflammation. Sublingual immunotherapy represents an important progress in the use of personalized medicine in children with allergic asthma. It is a viable option for house dust mite-driven asthma and in subjects with the asthma associated with allergic rhinitis. The use and indications for isolated asthma caused by other allergens are still controversial owing to heterogeneity of commercially available products and methodological limitations of studies in children. Nevertheless, most studies and meta-analyses found the efficacy of sublingual immunotherapy. Sublingual immunotherapy is safe but cannot be recommended in children with uncontrolled asthma.

Allergen immunotherapy in children and adolescents with respiratory diseases

To date, the only disease-modifying treatment strategy for allergic rhinitis and asthma is allergen immunotherapy (AIT). There is evidence that AIT improves allergic rhinitis and asthma, such as reducing symptom severity and medication use and improving of quality of life, with a long-lasting effect after the end of the course. The recent clinical trials evidenced AIT effectiveness and safety in allergic asthma. Consequently, the current version of the GINA (Global Initiative for Asthma) guidelines recommend AIT as an add-on therapy for asthma. There is also evidence that AIT may exert preventive activity on the possible progression from allergic rhinitis to asthma in children and the onset of new sensitizations.

[Allergic immunotherapy in children and adolescents]

L’immunothérapie spécifique allergénique nécessite l’administration répétée d’allergènes dans le but de provoquer une tolérance clinique et immunologique. C’est la seule thérapeutique à visée étiologique qui permet de modifier l’évolution de la maladie en assurant une rémission après l’interruption de la procédure. La prévention de nouvelles sensibilisations par l’immunothérapie reste discutée. Nous envisagerons dans cette revue les principaux mécanismes immunologiques et les indications de l’immunothérapie chez l’enfant et l’adolescent.

Allergen Immunotherapy in Pediatric Asthma: A Pragmatic Point of View

To date, the only disease-modifying treatment strategy for allergic rhinitis and asthma is allergen immunotherapy (AIT). There is evidence that AIT improves allergic rhinitis and asthma, such as reducing symptom severity and medication use and improving of quality of life, with a long-lasting effect after the end of the course. The recent clinical trials evidenced AIT effectiveness and safety in allergic asthma. Consequently, the current version of the GINA (Global Initiative for Asthma) guidelines recommend AIT as an add-on therapy for asthma. There is also evidence that AIT may exert preventive activity on the possible progression from allergic rhinitis to asthma in children and the onset of new sensitizations. The present review provides a pragmatic summary of the clinical indications of AIT in pediatric asthma, including the immunological mechanisms, the predictive biomarkers, and the safety issues in clinical practice.

Effects of specific allergen immunotherapy on biological markers and clinical parameters in asthmatic children: a controlled-real life study

BACKGROUND

Allergen-specific immunotherapy (AIT) is the only treatment able to change the natural course of allergic diseases. We aimed at investigating the clinical efficacy of SLITOR (Serbian registered vaccine for sublingual allergen specific immunotherapy).

METHODS

7-18 years old children with allergic asthma and rhinitis were enrolled and addressed to the active (AIT plus pharmacological treatment) or control (standard pharmacological treatment only) group. Clinical and medications scores, lung function and exhaled FeNO were measured at baseline and at every follow-up.

RESULTS

There was a significant improvement in both nasal and asthma symptom scores as well as in medication score in SLIT group. SLIT showed an important influence on lung function and airway inflammation.

CONCLUSIONS

Our data showed that SLITOR was effective not only in terms of patient reported outcomes but an improvement of pulmonary function and decrease of lower airway inflammation were also observed.

Subcutaneous and Sublingual Immunotherapy in Allergic Asthma in Children

This review presents up-to-date understanding of immunotherapy in the treatment of children with allergic asthma. The principal types of allergen immunotherapy (AIT) are subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT). Both of them are indicated for patients with allergic rhinitis and/or asthma, who have evidence of clinically relevant allergen-specific IgE, and significant symptoms despite reasonable avoidance measures and/or maximal medical therapy. Studies have shown a significant decrease in asthma symptom scores and in the use of rescue medication, and a preventive effect on asthma onset. Although the safety profile of SLIT appears to be better than SCIT, the results of some studies and meta-analyses suggest that the efficacy of SCIT is better and that SCIT has an earlier onset than SLIT in children with allergic asthma. Severe, not controlled asthma, and medical error were the most frequent causes of SCIT-induced adverse events.