The safety of allergenic immunotherapy

Risks of allergy vial contamination: comparison of mixing in-office versus under ventilation hood

OBJECTIVE

Compare the risk of bacterial contamination of allergy immunotherapy vials prepared in-office versus those mixed under a ventilation hood.

STUDY DESIGN

Prospective single-blinded study.

SETTING

Tertiary otolaryngology outpatient clinic.

RESULTS

Five hundred thirty-seven vials were prepared and cultured for aerobes and anaerobes over an 11-month period. Three hundred twenty vials were arbitrarily assigned to in-office preparation and 217 to under-hood preparation. A total of two positive cultures occurred in vials prepared in-office and one from under-hood preparation. Follow-up cultures of these three vials were all negative. No patients receiving injections had signs or symptoms of skin or systemic infections from the injections.

CONCLUSION

Our results suggest that the risk of bacterial contamination in immunotherapy vials in both groups is rare.

Allergen vial mixing and immunotherapy: Risks of infections and vial contamination

OBJECTIVE

To study the risks of vial contamination and infection associated with immunotherapy vial mixing and injection.

STUDY DESIGN

Retrospective review of patient immunotherapy records from January 2000-June 2006.

SETTING

Tertiary care outpatient otolaryngology clinic.

RESULTS

Two hundred seventy-two patients were given 26,795 injections (average of 98.5 injections per patient). Three hundred ninety-nine total local reactions were reported by the subjects (1.49%; 95% CI 1.34%-1.63%). The majority (82%) of the local reactions occurred during escalation dosing. There were 23 episodes of wheezing or shortness of breath after injections (9.6 of 10,000). No patients experienced anaphylaxis. There was no documented skin or systemic infections as a result of the allergy injections. None of the patients experienced fever, discharge from the injection site, cellulitis, or required antibiotics.

CONCLUSION

This review of immunotherapy records revealed no complications of infection from the preparation and administration of immunotherapy performed in an outpatient clinic.

Allergen injection immunotherapy for seasonal allergic rhinitis

BACKGROUND

Allergic rhinitis is the most common of the allergic diseases. Despite improved understanding of the pathophysiology of allergic rhinitis and advances in its pharmacological treatment, its prevalence has increased worldwide. For patients whose symptoms remain uncontrolled despite medical treatment, allergen injection immunotherapy is advised. An allergen-based treatment may reduce symptoms, the need for medication and modify the natural course of this disease.

OBJECTIVES

To evaluate the efficacy and safety of subcutaneous specific allergen immunotherapy, compared with placebo, for reducing symptoms and medication requirements in seasonal allergic rhinitis patients.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1 2006), MEDLINE (1950 to 2006), EMBASE (1974 to 2006), Pre-MEDLINE, KOREAMED, INDMED, LILACS, PAKMEDINET, Scisearch, mRCT and the National Research Register. The date of the last search was February 2006.

SELECTION CRITERIA

All studies identified by the searches were assessed to identify randomised controlled trials involving participants with symptoms of seasonal allergic rhinitis and proven allergen sensitivity, treated with subcutaneous allergen specific immunotherapy or corresponding placebo.

DATA COLLECTION AND ANALYSIS

Two independent authors identified all studies reporting double-blind, placebo controlled randomised trials of specific immunotherapy in patients with seasonal allergic rhinitis due to tree, grass or weed pollens. Two authors independently performed quality assessment of studies. Data from identified studies were abstracted onto a standard extraction sheet and subsequently entered into RevMan 4.2.8. Analysis was performed using the Standardised Mean Difference (SMD) method and a random-effects model; P values < 0.05 were considered statistically significant. The primary outcome measures were symptom scores, medication use, quality of life and adverse events.

MAIN RESULTS

We retrieved 1111 publications of which 51 satisfied our inclusion criteria. In total there were 2871 participants (1645 active, 1226 placebo), each receiving on average 18 injections. Duration of immunotherapy varied from three days to three years. Symptom score data from 15 trials were suitable for meta-analysis and showed an overall reduction in the immunotherapy group (SMD -0.73 (95% CI -0.97 to -0.50, P < 0.00001)). Medication score data from 13 trials showed an overall reduction in the immunotherapy group (SMD of -0.57 (95% CI -0.82 to -0.33, p<0.00001)). Clinical interpretation of the effect size is difficult. Adrenaline was given in 0.13% (19 of 14085 injections) of those on active treatment and in 0.01% (1 of 8278 injections) of the placebo group for treatment of adverse events. There were no fatalities.

AUTHORS' CONCLUSIONS

This review has shown that specific allergen injection immunotherapy in suitably selected patients with seasonal allergic rhinitis results in a significant reduction in symptom scores and medication use. Injection immunotherapy has a known and relatively low risk of severe adverse events. We found no long-term consequences from adverse events.

The Safety of Immunotherapy in Patients with Allergic Asthma and Allergic Rhinitis

We studied systemic reactions associated with immunotherapy in a group of 50 patients with mean age 31.4 years. The group consisted of 36 women and 14 men who followed a three-year immunotherapy treatment with pollen and mite allergen extracts (HAL-Holland Corporation). A total number of 2550 injections were administered. Eight patients developed systemic reactions; 6 had allergic rhinitis and 2 allergic asthma. None developed severe anaphylaxis. Seven of the systemic reactions occurred immediately after injection while one was a late reaction manifested as generalized urticaria, local edema and rubor at the site of the injection. From the 7 patients who showed an immediate reaction, 5 developed generalized urticaria with local edema and rubor at the site of the injection, while 2 presented with bronchial spasm. We did not observe any reaction when the quantity of the extract injection was reduced by 50%. Our study points out that, in the vast majority of cases, immunotherapy is free of severe systemic reactions. Those that occur are associated with the injection of high-density extracts and none of them is severe.

[Immunotherapy with an oral Alternaria extract in childhood asthma. Clinical safety and efficacy and effects on in vivo and in vitro parameters]

Studies of immunotherapy with oral Alternaria extracts are scarce. We decided to perform a clinical trial of the clinical safety and efficacy of this extract as well as of its effects on in vivo and in vitro parameters in 39 patients with Alternaria allergy, aged between 7 and 17 years, who are also sensitized extract was used. Allergic activity was determined through RAST inhibition and skin prick test. Quantification of the principal allerten (Alt a 1) was performed through the 2-site binding assay, with a mean content of 34.2 ng Alt a 1/micro g protein. The parameters analyzed were the symptom-medication score, skin prick using the end-point technique, specific bronchial challenge test, peak flow, total and specific IgE and IgG4. Nineteen patiens received active treatment with oral immunotherapy and another 19 received symptomatic treatment. The initial phase of immunotherapy lasted 3 months until the maximum dose was reached. This was maintained for 12 months; the mean accumulated dos was 280,000 PNU. Significant differences were found in reduction in the symptom-medication score in the treated group after 12 months of immunotherapy. No differences were found in the control group. Immunotherapy was well tolerated with 0.42 adverse reactions per 100 doses administered. All adverse reactions were mild-to-moderate. In the treated group, papule size was significantly reduced. Values for the specific bronchial challenge test, expressed through PD20, were significantly higher in the immunotherapy group. Peak flow showed no changes in either group. Values of IgG4 were significantly higher in the immunotherapy group. Total and specific IgE levels showed no significant changes in either group. In conclusion, oral immunotherapy with Alternaria extract is clinically effective in pediatric patients. In general, the therapy was well tolerated. It modified specific cutaneous and bronchial reactivity in our sample and increased levels of specific IgG4, wich are implicated in humoral response.

Utilization and cost of immunotherapy for allergic asthma and rhinitis

BACKGROUND

Allergic rhinitis and asthma are important sources of morbidity among adults and children. Although immunotherapy is sometimes used to treat these conditions, there is little information on its use, adherence, or cost in the general population.

OBJECTIVE

We sought to characterize the recipients of immunotherapy for allergic rhinitis and/or asthma with respect to their immunotherapy and utilization of health care services.

METHODS

A combination of automated and manually extracted data was used to identify HMO members with diagnoses of allergic rhinitis or asthma who were treated with immunotherapy. Costs associated with immunotherapy and related care were examined by linear regression. Proportional hazards and Kaplan-Meier plots were used to evaluate duration of therapy.

RESULTS

Of the 122,196 persons with a diagnosis of asthma or rhinitis, 2,667 were also treated with immunotherapy. Eligibility criteria were satisfied by 603 individuals who had 28,266 encounters for immunotherapy (median 48). Most patients (>80) were treated with multiple allergens; ragweed was the most common single allergen administered. Thirty-three percent of patients with sufficient observation time completed the intended course of 61 immunotherapy treatments. Females and younger patients had shorter durations of immunotherapy. The most common reason for discontinuation of therapy was patient's decision (54%). Immunotherapy costs were related most strongly to costs for care of rhinitis and asthma. Prescription drugs accounted for more than 50% of the non-immunotherapy costs; hospitalizations accounted for less than 20%.

CONCLUSIONS

Approximately 2% of HMO members with an asthma or rhinitis diagnosis received immunotherapy. Although screened to optimize compliance, most patients did not complete immunotherapy. Costs of non-immunotherapy care were higher for individuals who completed immunotherapy which is consistent with more severe disease in this group.

Patient dropouts before completion of optimal dose, multiple allergen immunotherapy

BACKGROUND

Many patients don't complete the recommended 3 to 5-year course of immunotherapy. Why?

OBJECTIVE

Determine the percentage of our patients receiving optimal dose, multiple-allergen immunotherapy from 1982 to 1996 who discontinued their immunotherapy prior to completion of the recommended 3 to 5-year immunotherapy protocol. Second, assess the reasons for these premature dropouts. Third, determine any differences related to the clinic location where injections are given.

DESIGN AND METHODS

The medical records of patients who dropped out of our immunotherapy program before 3 years were analyzed by the author.

SUMMARY OF RESULTS

Our dropout rate before 3 years was 12%. The five commonest reasons for early dropout were concurrent medical problems, noncompliance, change of residence, inconvenience, and allergic reactions. The systemic reaction rate for the 3-year dropout group was 1.00% compared with 0.9% for our overall study group. Eighty-eight percent of the systemic reactions were mild. About 1% of our immunotherapy patients quit early due to allergic reactions secondary to immunotherapy.

CONCLUSIONS

The dropout rate for our optimal-dose patients is similar to/that reported previously by Tinkelman who apparently used a lower than optimal maintenance dose. (2) Many of our dropouts were predictable and avoidable. Few patients quit early due to allergic reactions secondary to our immunotherapy program.

Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology

This document contains complete guidelines for diagnosis and management of rhinitis developed by the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology, representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology and the Joint Council on Allergy, Asthma and Immunology. The guidelines are comprehensive and begin with statements on clinical characteristics and diagnosis of different forms of rhinitis (allergic, non-allergic, occupational rhinitis, hormonal rhinitis [pregnancy and hypothyroidism], drug-induced rhinitis, rhinitis from food ingestion), and other conditions that may be confused with rhinitis. Recommendations on patient evaluation discuss appropriate use of history, physical examination, and diagnostic testing, as well as unproven or inappropriate techniques that should not be used. Parameters on management include use of environmental control measures, pharmacologic therapy including recently introduced therapies and allergen immunotherapy. Because of the risks to patients and society from sedation and performance impairment caused by first generation antihistamines, second generation antihistamines that reduce or eliminate these side effects should usually be considered before first generation antihistamines for the treatment of allergic rhinitis. The document emphasizes the importance of rhinitis management for comorbid conditions (asthma, sinusitis, otitis media). Guidelines are also presented on special considerations in patients subsets (children, the elderly, pregnancy, athletes and patients with rhinitis medicamentosa); and when consultation with an allergist-immunologist should be considered.

A controlled trial of immunotherapy for asthma in allergic children

BACKGROUND

Injections of allergens are widely prescribed for patients with asthma, but little is known about the effectiveness of immunotherapy.

METHODS

We conducted a double-blind, placebo-controlled trial of multiple-allergen immunotherapy in 121 allergic children with moderate-to-severe, perennial asthma. The children, who required daily medication for their asthma, were randomly assigned to receive subcutaneous injections of either a mixture of up to seven aeroallergen extracts or a placebo. Maintenance injections were continued for 18 months or longer. Medications were adjusted every two to three weeks on the basis of peak flow rates and symptoms. The principal outcome was the daily medication score. Bronchial sensitivity to methacholine (the concentration provoking a 20 percent decrease in the forced expiratory volume in one second [PC20]) was measured twice yearly.

RESULTS

The median medication score declined from 5.4 to 4.9 in the immunotherapy group (P<0.001) and from 5.2 to 5.0 in the placebo group (P<0.001), but there was no significant difference between the groups (P>0.6). The number of days on which oral corticosteroids were used was similar in the two groups. Partial or complete remission of asthma occurred in 31 percent of the immunotherapy group and in 28 percent of the placebo group (P>0.5). There was no difference between the groups in the use of medical care, symptoms, or peak flow rates. The median PC20 increased significantly in both groups, but again with no difference between the two groups.

CONCLUSIONS

Immunotherapy with injections of allergens for over two years was of no discernible benefit in allergic children with perennial asthma who were receiving appropriate medical treatment.

Clinical efficacy and safety of local nasal immunotherapy

Local nasal immunotherapy represents an alternative route of allergen administration. It was proposed to overcome the risk of systemic reactions rarely reported during the traditional subcutaneous immunotherapy. Some studies carried out in the past generally showed good efficacy but poor tolerability. The aqueous extracts mostly used in these studies carry some drawbacks such as the volume effect, self-digestion and the difficulty of administering reproducible dosages. The recent availability of allergen extracts in powder form has led to better stability and standardization. The studies carried out with these freeze-dried allergens showed clinical efficacy and good tolerability in perennial (mite, cat) and seasonal (grass, birch, Parietaria) allergic rhinitis. According to these findings this new local nasal immunotherapy with extract in powder form represents a suitable alternative to the traditional immunotherapy in the treatment of allergic rhinitis.

Future immunotherapy: what lies ahead?

There is currently great interest in developing improved methods of immunotherapy and new techniques of immune system manipulation to ameliorate allergic diseases. This article reviews current research trends in the immunologic treatment of allergy, including the use of chemically modified allergens, nonparenteral allergen exposure, sustained-release allergen delivery, anti-immunoglobulin E antibodies, gamma-globulin, immune complexes, cytokines, and T-cell-tolerogenic peptides.

Injection immunotherapy. British Society for Allergy and Clinical Immunology Working Party

A working party of the British Society for Allergy and Clinical Immunology has reviewed the role of specific allergen immunotherapy in the treatment of allergic disease and produced a position statement summarising the available evidence for efficacy and safety. The working party recommends specific allergen immunotherapy for treating summer hay fever uncontrolled by conventional medication and for wasp and bee venom hypersensitivity. It is not recommended for asthma or for allergic rhinitis due to other allergens. For the recommended indications the risk:benefit ratio is acceptable provided patients are carefully selected; in particular, patients with asthma should be excluded as they are especially vulnerable to adverse reactions. Injections should be given only by doctors experiences in this form of treatment in a clinic where full resuscitative facilities are immediately available. Provided patients remain symptom free a 60 minute observation period after injection is sufficient to detect all serious adverse reactions.

Childhood asthma: diagnosis and treatment

This discussion of asthma management should be regarded as providing guidelines, not dogma. The underlying principles of asthma management include recognition of the variability of the disease and the importance of the underlying inflammatory condition. Clinical assessment is not enough and objective monitoring with PEFR or spirometry provides important data. The treatment protocols require individualization. It is important that the patient and family are team members working together with the medical staff toward a goal of good asthma management. In the discussion of the management of asthma, much emphasis was placed on spirometry and home measurement of PEFR. Office use of spirometry is now the norm for asthma management. Providing asthmatic patients with peak flow meters and instructions in their use is part of the routine care of asthma. Instruction of the patient and family in the proper use of medications is paramount. The MDI devices need to be prescribed with careful instructions regarding their use. When the patient comes in for follow-up, part of the examination should include the patient's demonstration of how he uses this device. Discussion of the proper and safe use of bronchodilators is important. Overuse of inhaled bronchodilators may be a reflection of increasing asthma or, at the very least, evidence that the patient does not understand appropriate treatment of asthma. If a patient is dependent on regular use of an inhaled beta agent, it is likely that he would benefit from therapy directed at the underlying inflammation of asthma. The patient and the family should understand the purpose of each medication, the side effects, and the risks and benefits of their use. In particular, if steroid medications are necessary, the reasons for their use should be explained. Carefully matching the severity of the asthma with the therapeutic protocols provides an organized approach to asthma treatment. Avoiding triggers of asthma and controlling the environmental exposure to potential triggers leads to lower medication requirements and less lability. Offering the family written instructions to cope with changes in the child's condition, based on assessment of clinical and PEFR observations, allows them more autonomy and comfort in the day-to-day care of the asthmatic child.

Allergen immunotherapy. Review of efficacy and current practice

The modern use of allergen immunotherapy is described. Evidence for efficacy in inhalant allergy and insect sting allergy is reviewed. Current indications for allergen immunotherapy are discussed.