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Hesse L, Oude Elberink J, van Oosterhout AJ, Nawijn MC. Allergen immunotherapy for allergic airway diseases: Use lessons from the past to design a brighter future. Pharmacol Ther 2022; 237:108115. [DOI: 10.1016/j.pharmthera.2022.108115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 12/23/2021] [Accepted: 01/11/2022] [Indexed: 10/19/2022]
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Alternatives to Subcutaneous Immunotherapy for Allergic Rhinitis. ALLERGIES 2022. [DOI: 10.3390/allergies2010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Allergic rhinitis (AR) is an important public health issue worldwide due to its increasing prevalence and impact on quality of life, school performance, and work productivity. Subcutaneous immunotherapy (SCIT) is used to treat AR and involves repeated injections of allergen extracts. SCIT is used for cases of severe AR with symptoms that are not adequately controlled by medication, when the side effects of medication limit treatment options, or where the aim is to cure rather than symptomatically treat. Although SCIT is effective, it is not necessarily curative. Furthermore, there is also a low but present risk of systemic allergic reactions, with systemic side effects occurring in less than 0–1% of treated patients. Sublingual immunotherapy (SLIT) has emerged as an effective and safe alternative to SCIT. SCIT and SLIT are the only immunotherapies currently available for AR. In addition to sublingual administration as an alternative to SCIT, other routes of antigen administration have been attempted with the goal of increasing safety while maintaining efficacy. This review discusses the efficacies of SCIT and SLIT, their mechanisms, the utility of intralymphatic immunotherapy (ILIT) as an alternative route of antigen administration, and the potential for immunotherapy using other routes of antigen administration.
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Walker SM, Durham SR, Till SJ, Roberts G, Corrigan CJ, Leech SC, Krishna MT, Rajakulasingham RK, Williams A, Chantrell J, Dixon L, Frew AJ, Nasser SM. Immunotherapy for allergic rhinitis. Clin Exp Allergy 2011; 41:1177-200. [DOI: 10.1111/j.1365-2222.2011.03794.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
Incidences of allergic disease have recently increased worldwide. Allergen-specific immunotherapy (SIT) has long been a controversial treatment for allergic diseases. Although beneficial effects on clinically relevant outcomes have been demonstrated in clinical trials by subcutaneous immunotherapy (SCIT), there remains a risk of severe and sometimes fatal anaphylaxis. Mucosal immunotherapy is one advantageous choice because of its non-injection routes of administration and lower side-effect profile. This study reviews recent progress in mucosal immunotherapy for allergic diseases. Administration routes, antigen quality and quantity, and adjuvants used are major considerations in this field. Also, direct uses of unique probiotics, or specific cytokines, have been discussed. Furthermore, some researchers have reported new therapeutic ideas that combine two or more strategies. The most important strategy for development of mucosal therapies for allergic diseases is the improvement of antigen formulation, which includes continuous searching for efficient adjuvants, collecting more information about dominant T-cell epitopes of allergens, and having the proper combination of each. In clinics, when compared to other mucosal routes, sublingual immunotherapy (SLIT) is a preferred choice for therapeutic administration, although local and systemic side effects have been reported. Additionally, not every allergen has the same beneficial effect. Further studies are needed to determine the benefits of mucosal immunotherapy for different allergic diseases after comparison of the different administration routes in children and adults. Data collected from large, well-designed, double-blind, placebo-controlled, and randomized trials, with post-treatment follow-up, can provide robust substantiation of current evidence.
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Abstract
BACKGROUND Allergen specific immunotherapy has long been a controversial treatment for asthma. Although beneficial effects upon clinically relevant outcomes have been demonstrated in randomised controlled trials, there remains a risk of severe and sometimes fatal anaphylaxis. The recommendations of professional bodies have ranged from cautious acceptance to outright dismissal. With increasing interest in new allergen preparations and methods of delivery, we updated the systematic review of allergen specific immunotherapy for asthma. OBJECTIVES The objective of this review was to assess the effects of allergen specific immunotherapy for asthma. SEARCH STRATEGY We searched the Cochrane Airways Group Trials Register up to 2005, Dissertation Abstracts and Current Contents. SELECTION CRITERIA Randomised controlled trials using various forms of allergen specific immunotherapy to treat asthma and reporting at least one clinical outcome. DATA COLLECTION AND ANALYSIS Three authors independently assessed eligibility of studies for inclusion. Two authors independently performed quality assessment of studies. MAIN RESULTS Eighty-eight trials were included (13 new trials). There were 42 trials of immunotherapy for house mite allergy; 27 pollen allergy trials; 10 animal dander allergy trials; two Cladosporium mould allergy, two latex and six trials looking at multiple allergens. Concealment of allocation was assessed as clearly adequate in only 16 of these trials. Significant heterogeneity was present in a number of comparisons. Overall, there was a significant reduction in asthma symptoms and medication, and improvement in bronchial hyper-reactivity following immunotherapy. There was a significant improvement in asthma symptom scores (standardised mean difference -0.59, 95% confidence interval -0.83 to -0.35) and it would have been necessary to treat three patients (95% CI 3 to 5) with immunotherapy to avoid one deterioration in asthma symptoms. Overall it would have been necessary to treat four patients (95% CI 3 to 6) with immunotherapy to avoid one requiring increased medication. Allergen immunotherapy significantly reduced allergen specific bronchial hyper-reactivity, with some reduction in non-specific bronchial hyper-reactivity as well. There was no consistent effect on lung function. If 16 patients were treated with immunotherapy, one would be expected to develop a local adverse reaction. If nine patients were treated with immunotherapy, one would be expected to develop a systemic reaction (of any severity). AUTHORS' CONCLUSIONS Immunotherapy reduces asthma symptoms and use of asthma medications and improves bronchial hyper-reactivity. One trial found that the size of the benefit is possibly comparable to inhaled steroids. The possibility of local or systemic adverse effects (such as anaphylaxis) must be considered.
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Affiliation(s)
- Michael J Abramson
- Epidemiology & Preventive Medicine, Monash University, School of Public Health & Preventive Medicine, The Alfred, Melbourne, Victoria, Australia, 3004
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Noninjective immunotherapy. Allergy 2006. [DOI: 10.1111/j.1398-9995.2006.01219_4.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Calamita Z, Saconato H, Pelá AB, Atallah AN. Efficacy of sublingual immunotherapy in asthma: systematic review of randomized-clinical trials using the Cochrane Collaboration method. Allergy 2006; 61:1162-72. [PMID: 16942563 DOI: 10.1111/j.1398-9995.2006.01205.x] [Citation(s) in RCA: 248] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Sublingual immunotherapy (SLIT) is effective and safe in the treatment of allergic rhinitis. However, there is no meta-analysis in asthma treatment. METHODS The clinical efficacy of SLIT for asthma was evaluated through a systematic review with meta-analysis. MEDLINE (1966-2005), EMBASE (1974-2005), LILACS (1982-2005), and the Cochrane Library were searched for related literature in any language. Randomized-controlled clinical trials (RCT) on SLIT in asthma treatment for adults and children were selected. From 119 citations, 25 studies with 1706 patients were included in this meta-analysis. For each report, quality scores were assigned and data were extracted in relation to the outcomes analyzed: asthmatic symptoms, use of asthma medications, lung function, and bronchial provocation. RESULTS According to the Jadad quality method, 64% of the studies were assigned scores of 4 or 5. Immunotherapy was seen to significantly reduce asthma severity when parameter compositions were all analyzed by categorical outcomes. There was a nonsignificant reduction in asthma symptoms when analyzed using standardized mean differences. No severe reactions were observed. CONCLUSIONS This meta-analysis found that SLIT is beneficial for asthma treatment albeit the magnitude of the effect is not very large. Moreover, it is a safe alternative to the subcutaneous route. More RCT with standardization of symptom scores and medications are needed in order to contribute further to this subject.
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Affiliation(s)
- Z Calamita
- Division of Internal Medicine and Allergy and Immunology, Medical School of Marília, Marília, São Paulo, Brazil
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Abstract
The only disease-modifying treatment that is available for allergic patients is allergen-specific immunotherapy. Two competing application forms are used: subcutaneous immunotherapy, which has been used for > 90 years, and a relatively new immunotherapy where the allergen is applied sublingually. Numerous studies have shown efficacy for subcutaneous immunotherapy and have identified possible mechanisms that are responsible for the observed reduction in allergic responses. In contrast, the efficacy of sublingual immunotherapy has not been documented to the same degree and the responsible immunological mechanisms have not yet been clearly defined. This review focuses on the published clinical and experimental data on sublingual immunotherapy and points at possible mechanisms of how sublingual immunotherapy may differ from subcutaneous immunotherapy in its mode of action, and also discusses the potential advantages and pit falls of both therapies.
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Affiliation(s)
- Melanie Werner-Klein
- Department of Pulmonary Research, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riss, Germany
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Verhagen J, Taylor A, Akdis CA, Akdis M. Advances in allergen-specific immunotherapy. Expert Opin Biol Ther 2006; 5:537-44. [PMID: 15934831 DOI: 10.1517/14712598.5.4.537] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Atopic disease affects approximately 30% of the population in western society. Allergen-specific immunotherapy (SIT) is the only treatment with a long-term effect available at the present time, and has been used successfully in the treatment of a number of allergies for almost 100 years. Despite this success, there is great demand for safer, faster and more effective approaches. At present, many studies are being conducted aiming to comply with this demand. The approaches used include conventional immunotherapy, using allergen extracts, as well as novel methods such as peptide immunotherapy, allergen DNA vaccines and non-injection routes of SIT. The clinical success of various treatments, new technical developments and a better understanding of the immunological mechanisms behind immunotherapy hold great potential for the broad application of allergen-SIT in the foreseeable future.
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Affiliation(s)
- Johan Verhagen
- Swiss Institute of Allergy and Asthma Research (SIAF), CH-7270 Davos, Switzerland
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[Past and future of allergen immunotherapy]. Arch Pediatr 2005; 11 Suppl 2:74s-79s. [PMID: 15301801 DOI: 10.1016/s0929-693x(04)90004-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Specific immunotherapy involves the administration of allergen extracts to achieve clinical tolerance of the allergens which cause symptoms in patients with allergic conditions. Immunotherapy has been shown to be effective in patients with mild forms of allergic diseases, specially in upper airway diseases. Recent studies suggest that specific immunotherapy may also modify the course of allergic disease, by reducing the risk of developing new allergic sensitizations, and also inhibiting the development of clinical asthma in children treated for allergic rhinitis. The traditional subcutaneous route is burdened with the risk of severe adverse events, therefore, local routes have been investigated and developed. The sublingual route is supported by numerous controlled trials showing its efficacy in rhinitis. The safety profile, assessed in clinical trials studies, is satisfactory. Several points still need to be elucidated, including mechanisms of action, optimal dosage, cost-effectiveness, and adherence. New approaches using mimic bacterial DNA vaccines alone or associated to modified allergen, which enhances immunogenicity in terms of eliciting a Th1-type response vaccines, are also undergoing serious consideration.
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Abstract
Allergen specific immunotherapy, together with drugs and allergen avoidance, is a cornerstone in the management of respiratory allergy. The traditional subcutaneous route is burdened with the risk of severe adverse events; therefore, safer routes of administration (noninjection or local routes) have been investigated and developed. Controlled trials failed to demonstrate the clinical efficacy and the safety of oral and bronchial administration, and these routes have been abandoned. Local nasal immunotherapy proved effective and safe in 17 of 18 controlled trials; thus it is considered a viable route of immunotherapy. Nevertheless, nasal immunotherapy is effective in rhinitis only and requires a particular administration technique; therefore its use is slowly declining. The sublingual route is supported by numerous controlled trials showing its efficacy in asthma and rhinitis in adults and children. The safety profile, assessed in clinical trials and postmarketing surveillance studies, is satisfactory; the most frequent side effects are gastrointestinal complaints, which can be easily managed by proper dose adjusting. Sublingual immunotherapy is now accepted by the World Health Organization as a valid alternative to the subcutaneous route also in children. Although the long-lasting efficacy has been recently documented for the sublingual route, several points still need to be elucidated, including mechanisms of action, optimal dosage, cost-effectiveness, and adherence.
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Affiliation(s)
- Giorgio Walter Canonica
- Division of Allergy and Respiratory Diseases, Department of Internal Medicine, University of Genoa, Italy
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Abstract
BACKGROUND Allergen specific immunotherapy has long been a controversial treatment for asthma. Although beneficial effects upon clinically relevant outcomes have been demonstrated in randomised controlled trials, there remains a risk of severe and sometimes fatal anaphylaxis. The recommendations of professional bodies have ranged from cautious acceptance to outright dismissal. With increasing interest in new allergen preparations and new methods of delivery, it was time to conduct another systematic review of allergen specific immunotherapy for asthma. OBJECTIVES The objective of this review was to assess the effects of allergen specific immunotherapy for asthma. SEARCH STRATEGY We searched the Cochrane Airways Group trials register up to June 2001, MEDLINE, Dissertation Abstracts, Current Contents and reference lists of articles. SELECTION CRITERIA Randomised controlled trials using various forms of allergen specific immunotherapy to treat asthma and reporting at least one clinical outcome. DATA COLLECTION AND ANALYSIS Three reviewers independently assessed eligibility of studies for inclusion. Two reviewers independently performed quality assessment of studies. MAIN RESULTS Seventy-five trials were included (52 of 54 previously included trials and 23 new trials). A total of 3,506 participants (3,188 with asthma) were involved. There were 36 trials of immunotherapy for house mite allergy; 20 pollen allergy trials; ten animal dander allergy trials; two Cladosporium mould allergy, one latex and six trials looking at multiple allergens. Concealment of allocation was assessed as clearly adequate in only 15 of these trials. Significant heterogeneity was present in a number of comparisons. Overall, there was a significant reduction in asthma symptoms and medication and improvement in bronchial hyper-reactivity following immunotherapy. There was a significant improvement in asthma symptom scores (standardised mean difference -0.72, 95% confidence interval -0.99 to -0.33) and it would have been necessary to treat 4 (95%CI 3 to 5) patients with immunotherapy to avoid one deterioration in asthma symptoms. Overall it would have been necessary to treat 5 (95%CI 4 to 6) patients with immunotherapy to avoid one requiring increased medication. Allergen immunotherapy significantly reduced allergen specific bronchial hyper-reactivity, with some reduction in non-specific bronchial hyper-reactivity as well. There was no consistent effect on lung function. REVIEWER'S CONCLUSIONS Immunotherapy reduces asthma symptoms and use of asthma medications and improves bronchial hyper-reactivity. One trial found that the size of the benefit is possibly comparable to inhaled steroids. The possibility of adverse effects (such as anaphylaxis) must be considered.
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Affiliation(s)
- M J Abramson
- Epidemiology & Preventive Medicine, Monash University, Central & Eastern Clinical School, The Alfred, Melbourne, Vic, Australia, 3004
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Affiliation(s)
- M K Kägi
- Dermatology and Allergy FMH, Schaffhausetstrasse 355, 8050 Zurich, Switzerland
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Fearby S, Frew AJ. Hunting the magic bullet in immunotherapy: new forms of old treatment or something completely different? Clin Exp Allergy 2001; 31:969-74. [PMID: 11467985 DOI: 10.1046/j.1365-2222.2001.01149.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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ADVERSE EFFECTS OF ALLERGEN IMMUNOTHERAPY. Radiol Clin North Am 2000. [DOI: 10.1016/s0033-8389(22)00108-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Rolland JM, Douglass J, O'Hehir RE. Allergen immunotherapy: current and new therapeutic strategies. Expert Opin Investig Drugs 2000; 9:515-27. [PMID: 11060692 DOI: 10.1517/13543784.9.3.515] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Allergic individuals respond to an environmental allergen encounter by producing T-cell cytokines, predominantly IL-4 and IL-5, which in turn drive the production of allergen-specific IgE antibodies and recruitment of an eosinophil-rich inflammatory infiltrate. Allergen-specific immunotherapy (SIT) involves the repeated injection of the allergen to specifically downregulate this predominantly Th2-type immune response. SIT is a clinically proven effective treatment for allergic diseases, including rhinoconjunctivitis and asthma. However, despite having been in clinical practice since early this century, its use remains empirical. Best practice protocols are based on clinical experience and include recommendations for selecting patients for treatment, SIT regimes and avoidance of adverse events. More rational and safer SIT regimes will result from new insights into the underlying immune mechanisms for allergic disease, in particular the critical role of helper T-cells in orchestrating this response. The development of recombinant techniques for producing purified allergens and allergen derivatives has led to a dramatic improvement in the ability to standardise allergen preparations and to develop novel vaccines for allergy treatment. Potential vaccines include short peptides based on dominant T-cell epitopes of allergens, allergen fragments and mutant allergens. All of these preparations are designed to target T-cells without binding IgE and inducing local and systemic side effects. Additional strategies under consideration include DNA vaccines and fusion protein constructs incorporating immunomodulatory elements such as bacterial cell proteins, cytokines and immunostimulatory sequences of DNA. Different forms of allergens are being evaluated for the more practical mucosal administration of allergy vaccines. The identification of recombinant allergens suitable for diagnostic use and the development of reliable laboratory assays, based on T-cell function to monitor clinical efficacy of SIT, are important practical outcomes from this research.
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Affiliation(s)
- J M Rolland
- Department of Pathology and Immunology, Monash University Medical School, Commercial Road, Prahran, Victoria 3181, Australia.
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Affiliation(s)
- M Abramson
- Department of Epidemiology and Preventive Medicine, Monash Medical School, Alfred Hospital, Melbourne, Prahan Vic, Australia
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Malling HJ, Abreu-Nogueira J, Alvarez-Cuesta E, Björkstén B, Bousquet J, Caillot D, Canonica GW, Passalacqua G, Saxonis-Papageorgiou P, Valovirta E. Local immunotherapy. Allergy 1998; 53:933-44. [PMID: 9821472 DOI: 10.1111/j.1398-9995.1998.tb03793.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- H J Malling
- National University Hospital, Copenhagen N, Denmark
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Passalacqua G, Bagnasco M, Mariani G, Falagiani P, Canonica GW. Local immunotherapy: pharmacokinetics and efficacy. Allergy 1998; 53:477-84. [PMID: 9636806 DOI: 10.1111/j.1398-9995.1998.tb04084.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- G Passalacqua
- Department of Internal Medicine, University of Genoa, Italy
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Hirokawa Y, Kondo T, Kobayashi I, Ohta Y. Rush immunotherapy with house dust extract in patients with mild extrinsic asthma. TOHOKU J EXP MED 1996; 178:371-80. [PMID: 8804154 DOI: 10.1620/tjem.178.371] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Rush immunotherapy (RIT) with house dust extract was given to 15 patients with mild extrinsic or mixed asthma. Every patient was strongly positive for IgE on the radioimmunosorbent test and sensitive to house dust extract on the scratch skin test. Nine patients were positive on the bronchial provocation test to house dust extract and 6 could not be examined. All patients did not drop out and got to house dust extract solution 10(-1) within 1 week. The symptom-medication scores decreased significantly after RIT. During RIT 1 patient developed a mild asthmatic attack and 3 patients developed generalized skin reaction. Eight weeks later, the threshold for house dust-provoked bronchoconstriction increased in 9 patients, but did not in 3 patients. The blood eosinophil count and blood histamine level significantly decreased. We conclude that RIT is able to raise antigen concentrations for a short periods and effective but not risky for mild asthma.
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Affiliation(s)
- Y Hirokawa
- Department of Pulmonology, Tokai University School of Medicine, Isehara, Japan
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Bousquet J, Des Roches A, Paradis L, Dhivert H, Michel FB. Specific immunotherapy in house dust mite allergy. Clin Rev Allergy Immunol 1995; 13:151-9. [PMID: 7489261 DOI: 10.1007/bf02758099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- J Bousquet
- Arnaud de Villeneuve Hospital, Montpellier, France
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Affiliation(s)
- J Bousquet
- Allergy Unit, Hôpital Arnaud de Villeneuve, Montpellier, France
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ARIANO R, PANZANI R, CHIAPELLA M, AUGERI G, FALAGIANI P. Local Immunotherapy of Seasonal Allergic Rhinitis in Children Due toParietaria officinalisPollen: A Preliminary Report. ACTA ACUST UNITED AC 1993. [DOI: 10.1089/pai.1993.7.227] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Dykewicz MS. ALLERGEN IMMUNOTHERAPY FOR THE PATIENT WITH ASTHMA. Immunol Allergy Clin North Am 1992. [DOI: 10.1016/s0889-8561(22)00096-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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