Determinants of patient compliance with allergen immunotherapy

A novel dose-adjustment protocol for interrupted subcutaneous immunotherapy for allergic rhinitis

Background: This study aimed to develop a novel dose strategy for subcutaneous immunotherapy to reduce medical waste and financial burdens for patients who are required to restart subcutaneous immunotherapy. Patients & methods: A prospective, nonrandomized concurrent controlled trial was performed to assess the safety and advantages of the novel dose-adjustment protocol compared with the conventional one. 76 subjects were grouped to receive novel or conventional dose-adjustment protocols. Results: The injections, visits and time needed to reach the pre-established dose with the novel regimen were decreased. Furthermore, there were no differences in side reactions between the two groups. Conclusion: The novel protocol seemed safe and well tolerated, offering the advantages of time efficiency and reduced healthcare costs.

Causes of Non-Adherence to Allergen-Specific Immunotherapy: A Foundation towards a Patient-Personalized Approach

BACKGROUND

Allergen-specific immunotherapy (AIT) is the only disease-modifying therapy for allergic conditions, resulting in a long-lasting tolerance beyond the duration of the treatment. Due to the strong relationship between the effectiveness, its optimal duration (at least three years) and the observation of the correct administration protocol, appropriate adherence to the plan of treatment represents a critical factor for the therapeutical success of AIT.

METHODS

Analysis of studies about the rate of adherence in subcutaneous and sublingual immunotherapy, which are the main routes of administration of AIT.

RESULTS

There are different causes leading to a premature interruption of the therapy or to it being incorrectly carried out; the most reported include erroneous expectations of the effectiveness and the adverse effects, economic issues, inconvenience and unrelated clinical conditions.

CONCLUSIONS

An attentive analysis of the main causes of dropouts may be useful to improve the management of these patients and to develop new strategies for a personalized approach. These strategies should be dynamic, involving attentive communication between the physician and the patient about all the possible criticalities, especially in the initial phase of the therapy, and facilitating, as much as possible, access to healthcare providers over the course of the maintenance phase, including by exploiting technological tools.

Efficacy of subcutaneous immunotherapy for patients with asthma and allergic rhinitis in Korea: effect on eosinophilic inflammation

Background

Atopic asthma (AA) and allergic rhinitis (AR) are often seen as comorbidities and specific immunotherapy (SIT) is considered evidence-based treatment for them both.

Objective

The purpose of this study was to evaluate the efficacy of multiallergen subcutaneous SIT (SCIT) in reducing nasal and sputum eosinophilia, symptom scores, and impaired lung function in Korean pediatric patients with AR and AA.

Methods

Children aged 6-15 years with a documented history of bronchial asthma and seasonal/perennial AR were recruited then randomly selected to 1 of 2 groups: "immunotherapy group" (inhaled corticosteroids [ICS] and short-acting beta₂-agonist [SABA] + subcutaneous injection of standardized extracts of up to 4 allergens [n = 53]) or "drug only group" (ICS and SABA only [n = 19]). All data were collected retrospectively.

Results

Comparing the 2 treatment groups, the immunotherapy group showed a significantly (p = 0.006) greater reduction in nasal eosinophilia over the 3-year treatment period. Only the immunotherapy group exhibited a significant reduction in sputum eosinophilia over the 3-year treatment period (p = 0.003). Fifty-one point one percent of patients in the immunotherapy group showed significant improvement in the methacholine challenge test negative conversion rate compared to only 17.65% in the drug only group (p = 0.0168). There were significantly greater improvements in symptom scores in the immunotherapy group compared to the drug only group. For all allergens tested, only house dust mite reactivity changed significantly over the treatment period and only in the immunotherapy group (Dermatophagoides pteronyssinus [p < 0.0001] and Dermatophagoides farina [p = 0.035]).

Conclusion

SCIT was associated with greater improvements in lung function and bronchial hyperresponsiveness and reductions in nasal and sputum eosinophilia and allergen reactivity. Changes in symptom scores were also much greater in patients receiving SCIT when compared to those who did not receive it. Korean children with AA and AR respond well to long-term multiallergen SCIT.

Intralymphatic immunotherapy for allergic rhinitis: A systematic review and meta-analysis

Background: Only a fraction of patients with allergic rhinitis receive allergen-specific immunotherapy (AIT). AIT is most commonly delivered subcutaneously in a series of injections over 3-5 years. Common obstacles to completing this therapy include cost and inconvenience. Intralymphatic immunotherapy (ILIT) has been proposed as a faster alternative, which requires as few as three injections spaced 4 weeks apart. Objective: This systematic review and meta-analysis evaluated the current evidence that supports the use of ILIT for allergic rhinitis. Methods: Clinical trials were identified in the published literature by using an electronic search strategy and were evaluated by using a risk of bias tool. Treatment outcome (symptom scores, medication scores, and combined symptom and medication scores) and provocation testing results (nasal provocation and skin-prick testing) were included in a meta-analysis of standardized mean difference with subgrouping by using a random-effects model. Overall adverse event rates were tabulated, and overall risk ratios were calculated by using a random-effects model. Results: We identified 17 clinical trials that met eligibility criteria. The standardized mean difference of ILIT on the symptom and medication score was -0.72 (95% confidence interval [CI], -0.98 to -0.46; p < 0.0001) (n = 10). The standardized mean difference of ILIT on nasal provocation and skin-prick testing was -1.00 (95% CI, -1.38 to -0.61; p < 0.0001) (n = 7) and -0.73 (95% CI, -0.99 to -0.47; p < 0.0001) (n = 7), respectively. No statistically significant heterogeneity was detected. The overall adverse event rate was 39.5% for ILIT and 23.5% for placebo. Also, 98.4% of adverse events were mild. Conclusion: Our meta-analysis demonstrated that ILIT was safe, conferred desensitization to seasonal and nonseasonal allergens, alleviated allergic rhinitis symptoms, and reduced medication use. A larger randomized, double-blind, placebo controlled trial will be necessary for wider adaptation of this form of AIT.

Real-world evidence costs of allergic rhinitis and allergy immunotherapy in the commercially insured United States population

OBJECTIVE

To assess total and allergic rhinitis (AR)-related healthcare costs among AR patients residing in the United States with a focus on patients persisting with AIT.

METHODS

AR patients were identified in the IBM MarketScan database between 1 January 2014 to 31 March 2017. Patients receiving allergy immunotherapy (AIT) were identified with relevant billing codes (earliest AIT claim = index date); non-AIT patients were identified with claims containing a diagnosis code for AR (earliest AR claim = index date). AIT patients reaching 25+ injection claims were analyzed as a separate maintenance cohort. All patients were required to have continuous enrollment for 12 months preceding and following index.

RESULTS

A total of 2,334,530 AR patients were included; 103,207 had at least 1 AIT claim, with 45,279 (43.9%) of these patients reaching maintenance, and 24,640 AIT patients (23.9%) never presenting a single injection claim. Compared to non-AIT patients, patients initiating AIT presented higher rates of baseline comorbidities, including asthma (30.1% vs. 7.5%) and conjunctivitis (21.7% vs. 4.4%). During the follow-up period, patients reaching the maintenance phase of AIT incurred lower total costs than the overall AIT cohort ($10,431±$16,606 vs. $11,612±$24,797), and also presented lower follow-up hospitalization costs ($698±$7,248 vs. $1,281±$12,991) and total medical costs ($7950±$13,844 vs. $8989±$22,019).

CONCLUSIONS

Continued efforts are needed to increase patient awareness of available options and adherence to AIT, along with reducing wastage. Despite AIT patients presenting fairly progressed disease at the time of treatment initiation, this therapy remains an economical treatment option, as it was not accompanied by substantial increases in overall healthcare expenditure, and may promote positive societal impacts beyond the direct medical costs.What is known on this topicThe prevalence of allergic diseases has increased over the past 50 years and affects between 10-30% of the world population.Allergic rhinitis (AR) poses a significant economic burden in the form of both direct and indirect costsAllergy immunotherapy (AIT) is the only treatment option able to modify the underlying course of the disease.What this study addsSpecific all-cause and AR-related healthcare costs decreased following the initiation of AIT among patients diagnosed with AR, with the largest decreases observed among AIT patients reaching the maintenance phase of treatment, while non-AIT patients showed increases in all categories assessed over a similar follow-up period.Cost decreases among AIT patients were observed despite increased levels of comorbidities compared to non-AIT patients, as the AIT cohort presented elevated rates of atopic dermatitis (7.1% vs. 2.7%), conjunctivitis (21.7% vs. 4.4%), asthma (30.1% vs. 7.5%), and chronic sinusitis (22.6% vs. 4.9%).An analysis of patients' index subcutaneous AIT consultation revealed substantial variability in the initial treatment costs, with nearly 20% of paid amounts exceeding $1,000; given nearly 1 in 4 AIT patients who get AIT mixed never came back for their first injection, this highlights an opportunity to target frontloaded billing practices and the timing of mixing/injection as an area to minimize healthcare waste.

Subcutaneous Allergen Immunotherapy in Children: Real Life Compliance and Effect of COVID-19 Pandemic on Compliance

Background

Subcutaneous allergen immunotherapy (SCIT) is an effective treatment for allergic rhinitis, asthma, and venom allergy. Compliance is essential for SCIT to obtain maximal benefit as it is a long-term treatment.

Objectives

This study aimed to determine the level of real-life SCIT compliance in pediatric patients and the associated factors. Additional aims were to determine how SCIT compliance was affected by the COVID-19 pandemic and why some patients dropped out SCIT.

Method

Pediatric patients diagnosed with allergic rhinitis, allergic asthma, or venom allergy that received SCIT between September 2012 and July 2020 were analyzed.

Results

The study included 201 children (66.7% male) with a median (interquartile range) age of 12.8 years (9.4–15.2) at the time of the first SCIT injection. The overall compliance rate before COVID-19 pandemic was 86.1%. Short SCIT follow-up time and venom anaphylaxis were found to be risk factors for drop out. The leading causes of drop outs were moving to another city/country (32.1%), symptom improvement (17.8%), treatment ineffectiveness (14.2%), and adverse reactions (14.2%). Among the 108 patients that were still receiving SCIT during the COVID-19 pandemic, 31 (28.7%) dropped out the therapy. The most frequent reasons for drop-out were fear of being infected with COVID-19 (35.4%) and thinking that the AIT practise stopped due to COVID-19 pandemic (29%). Male gender and older age were found to be the independent risk factors for drop-out of SCIT.

Conclusions

Real life compliance in children was found 13.9% and it was higher than adults. Nearly one-third of children dropped out during the CO­VID-19 pandemic. Male gender and older age are associated with SCIT drop-out during the COVID-19 pandemic.

Real-world mapping of allergy immunotherapy in the United States: The argument for improving adherence

Background: There is a dearth of real-world evidence studies focused on allergy immunotherapy (AIT) use among patients with allergic rhinitis (AR). Objective: This study examined claims data of AR patients residing in the United States to assess patient characteristics and health outcomes. Methods: AR patients were identified in the IBM MarketScan database between January 1, 2014, and March 31, 2017. Patients receiving AIT were identified with relevant billing codes (earliest AIT claim for vaccine as the index date); patients without AIT were identified with claims that contained a diagnosis code for AR (earliest AR claim as the index date). All the patients were required to have continuous enrollment 12 months prior to and following their index date. AIT patients reaching 25+ injection claims were analyzed as a separate maintenance cohort. Patients were assessed for demographic characteristics, comorbid conditions, and health care utilization. Results: A total of 2,334,530 AR patients were included; 103,207 had at least one AIT claim, with 45,279 (43.9%) of these patients reaching maintenance. Patients who reached AIT maintenance presented higher rates of baseline comorbidities than both the full AIT cohort and the patients with no AIT claims, including asthma (34.6% versus 30.1% versus 7.5%) and upper respiratory tract infections (63.1% versus 60.3% versus 34.2%). From baseline to follow-up, maintenance AIT patients demonstrated reductions in all AR-related comorbidities assessed, along with reductions in all-cause and AR-related service utilization. Conclusion: Patients initiating AIT presented the greatest need for therapeutic intervention, as evidenced by higher allergy-related comorbidities; those who reached maintenance demonstrated improved outcomes following the initiation of therapy. Continued efforts to increase patient awareness and adherence to AIT are needed.

Compliance in subcutaneous and sublingual allergen immunotherapy: A nationwide study

INTRODUCTION

Allergic rhino-conjunctivitis is a highly prevalent condition. In moderate to severe cases, allergen immunotherapy (AIT) is a cost-effective therapeutic option. Previous data have reported a large difference in treatment compliance of subcutaneously (SCIT) and sublingually (SLIT) administered AIT.

METHODS

By use of the unique civil registration number assigned to all Danish citizens and the Danish National Health Service Prescription Database, compliance rates of all patients prescribed with grass pollen AIT from January 1998 until December 2016 were analysed annually during the three-year treatment period.

RESULTS

The male/female ratio was close to 1:1 in SCIT, while SLIT was more frequently used by men. A large proportion of users was children or adolescents (32% and 45%, SCIT and SLIT, respectively). Compliance of both subcutaneous and sublingual treatment gradually fell each year; compliance in year 3 was 57% and 53% for subcutaneous and sublingual treatment, respectively. Compliance of grass pollen sublingual treatment was also analysed each year after registration on the Danish market. Compliance significantly increased following the introduction and stabilised on a relatively high level.

CONCLUSION

Based on previous studies, we hypothesised that AIT compliance would be low, especially in SLIT. However, in Denmark, compliance in SCIT and SLIT was almost similar, and the majority of patients completed the three-year treatment period with a compliance in the last quintile.

Safety of uSCIT-MPL-4: prevalence and risk factors of systemic reactions in real life

Aim: We assessed the safety of allergoid adjuvanted by monophosphoryl lipid A (uSCIT-MPL-4) in a real-life setting. Materials & methods: Patients treated with uSCIT-MPL-4 were followed-up for 1 year. Systemic reactions (SRs) were registered and the association with potential risk factors was evaluated. Results: 2929 patients were included. Grade 0, 1, 2, 3 and 4 SR reactions were observed respectively in 3.3, 1.5, 0.31, 0.07 and 0.07% of patients. A significant association was detected between Grade ≥1 SRs and: female gender, number of administrations, previous local reactions. Conclusion: uSCIT-MPL-4 is safe. Local reactions should be accurately assessed as they may represent a risk factor for Grade ≥1 SRs, together with gender and number of doses/year.

A low inflammatory, Langerhans cell-targeted microprojection patch to deliver ovalbumin to the epidermis of mouse skin

In a low inflammatory skin environment, Langerhans cells (LCs) - but not dermal dendritic cells (dDCs) - contribute to the pivotal process of tolerance induction. Thus LCs are a target for specific-tolerance therapies. LCs reside just below the stratum corneum, within the skin's viable epidermis. One way to precisely deliver immunotherapies to LCs while remaining minimally invasive is with a skin delivery device such as a microprojection arrays (MPA). Today's MPAs currently achieve rapid delivery (e.g. within minutes of application), but are focussed primarily at delivery of therapeutics to the dermis, deeper within the skin. Indeed, no MPA currently delivers specifically to the epidermal LCs of mouse skin. Without any convenient, pre-clinical device available, advancement of LC-targeted therapies has been limited. In this study, we designed and tested a novel MPA that delivers ovalbumin to the mouse epidermis (eMPA) while maintaining a low, local inflammatory response (as defined by low erythema after 24 h). In comparison to available dermal-targeted MPAs (dMPA), only eMPAs with larger projection tip surface areas achieved shallow epidermal penetration at a low application energy. The eMPA characterised here induced significantly less erythema after 24 h (p = 0.0004), less epidermal swelling after 72 h (p < 0.0001) and 52% less epidermal cell death than the dMPA. Despite these differences in skin inflammation, the eMPA and dMPA promoted similar levels of LC migration out of the skin. However, only the eMPA promoted LCs to migrate with a low MHC II expression and in the absence of dDC migration. Implementing this more mouse-appropriate and low-inflammatory eMPA device to deliver potential immunotherapeutics could improve the practicality and cell-specific targeting of such therapeutics in the pre-clinical stage. Leading to more opportunities for LC-targeted therapeutics such as for allergy immunotherapy and asthma.

Adherence to Subcutaneous Allergen Immunotherapy in Southeast Turkey: A Real-Life Study

BACKGROUND Subcutaneous immunotherapy (SCIT) in allergic rhinitis (AR) and asthma is a very effective treatment, but adherence is still a serious problem. Studies addressing real-life adherence to SCIT are rare in the literature. The aim of this study was to evaluate the adherence to SCIT in AR and asthma. MATERIAL AND METHODS The medical records of patients prescribed SCIT for treatment of AR and/or asthma were evaluated. Patients who continued the SCIT treatment as prescribed were defined as adherent, patients who stopped the treatment before the recommended period were defined as nonpersistent, and those who never started the treatment were defined as primary poor adherence. Age, gender, residence, type of SCIT, comorbidities, occupation, income, and adverse reactions were evaluated between these groups. RESULTS Ninety-five patients prescribed SCIT for the treatment of AR and/or asthma formed our cohort (female/male: 51/44). The mean (SD) age and duration of SCIT were 32.2±10.0 (range, 17-63) years, 14.4±12.7 (1.0-58.5) months, respectively. Sixty-two (65.3%) patients were adherent, (28.4%) patients were nonpersistent, and 6 (6.3%) patients were primary poor adherent. Nineteen (21.4%) patients had local adverse reactions and one (1.1%) had anaphylaxis. There were no differences between groups for age, gender, residence, type of SCIT, comorbidities, income, or occupation. The most frequent reason of nonpersistence was the cost of treatment. CONCLUSIONS Our study found that adherence to SCIT is low in a real-life setting in southeast Turkey, similar to most previous adherence studies.

Success factors for adherence in hyposensitization

For the success of an immunotherapy regimen, adherence is a major success factor. The goal of our study was to identify the factors that positively and negatively influence patient compliance, and to create strategies to improve it. Four questionnaires were designed for different patient groups: A – after immunotherapy; B – during immunotherapy; C – before immunotherapy; D – no experience with immunotherapy. From March to October 2008, 790 questionnaires were collected. For the first group, questionnaire A was answered by 272 patients. Of these, 15.8% had dropped out of immunotherapy. Women had higher dropout rates than men (16.8% vs. 12.3%). The following aspects of immunotherapy were viewed by the patients as negative: time consuming (69.5%), adverse reactions (62.5%), insufficient patient information (53.7%), no change in use of symptomatic medication (33.8%) and no change in symptoms (60.7%). Despite the mentioned drawbacks, 74% of all patients would still recommend allergen immunotherapy. Questionnaire B was completed by 281 patients. In this group, 8.7% had already considered dropping out. The following unfavourable aspects were identified: time consuming (66.2%), adverse reactions (61.9%), insufficient patient information (54.8%), no change in symptoms (51.2%) and use of symptomatic medication (47.0%). Despite this, up to 95.4% of all patients would recommend immunotherapy. Questionnaire C was filled-out by 55 patients. The following reasons were rated by the patients as “important” or “very important” for the decision to start hyposensitization: long-lasting symptom alleviation (100%), few adverse reactions (98.2%), comprehensive patient information (96.3%), easy integration into daily routine (89.1%), re-assessment of therapy by doctor (83.3%) and reduced need for symptomatic medication (81.8%). Questionnaire D was filled in by 182 participants. 89% had already heard the term hyposensitization before. Their general knowledge regarding this therapy was average (3.23 on a scale of 1 – 6; where 1 = optimum). Long-lasting symptom alleviation (99.5%), comprehensive patient information (97.8%), easy integration into daily routine (96.1%), reduced symptomatic medication use (92.6%) and re-assessment by doctor (88.8%) were considered “very important” or “important” characters in the desired immunotherapy regime. Adherence to the hyposensitization schedule is essential for its success. The treating doctor should aim at choosing the right therapy and working out an individualized patient treatment plan. Equally important is providing information to the patient throughout the duration of the treatment. The doctor should assist the patient to create an optimized time schedule to help make the therapy less time-consuming.

The global development and clinical efficacy of sublingual tablet immunotherapy for allergic diseases

Allergy immunotherapy (AIT) is a treatment option for respiratory allergy that is complementary to pharmacotherapy, with a distinct mechanism of action. Alternative methods to subcutaneous administration of AIT that enable patients to safely self-administer AIT is considered an unmet clinical need. The sublingual immunotherapy tablet (SLIT-tablet) is an orally disintegrating pharmaceutical formulation (oral lyophilisate) containing standardized allergens. SLIT-tablets have been developed for sublingual immunotherapy (SLIT) of cedar-pollen, grass-pollen, ragweed-pollen, tree-pollen, and house dust mite allergies. It is a once-daily tablet treatment to be self-administered after the first dose has been provided under the supervision of a physician with experience in the diagnosis and treatment of allergic diseases. Once the first dose is adequately tolerated, subsequent doses may be self-administered. SLIT-tablets have proven efficacy for allergic rhinitis (AR) with and without conjunctivitis (C) and allergic asthma (AA) in adults, children, and poly-sensitized allergic patients. Meta-analyses indicate that SLIT-tablets have superior or similar efficacy compared with anti-allergic pharmacotherapies for seasonal AR and superior efficacy for perennial AR. SLIT-tablets have also demonstrated clinically relevant improvements of asthma, with significant reductions in the following: daily inhaled corticosteroid use, risk of asthma exacerbations, and asthma symptoms. SLIT-tablets are generally well tolerated, with a low risk of systemic allergic reactions. The most common treatment-related adverse events are mild-moderate oral reactions. Current evidence supports SLIT-tablets to be considered as an alternative or add-on treatment to pharmacotherapy for AR/C and asthma. Future SLIT developments may include early intervention to prevent the development or progression of allergic disease in children.

Healthcare costs for allergic rhinitis patients on allergy immunotherapy: a retrospective observational study

OBJECTIVE

Subcutaneous immunotherapy (SCIT) for allergic rhinitis (AR) has been shown to control symptoms for up to several years following treatment discontinuation, but the effect of SCIT on healthcare costs for commercially insured patients is unknown. The objective of this study was to compare healthcare costs and resource utilization for patients with AR who received SCIT compared with those who discontinued SCIT shortly after initiation.

METHODS

This retrospective cohort study evaluated medical and pharmacy claims from the Optum Research Database from January 2009 through February 2014 for adults and pediatric patients with >7 (continuers) vs. ≤7 (discontinuers) injection visits for SCIT within 60 days of initiation.

RESULTS

After 1:1 propensity score matching, each cohort included 6710 patients. Continuers were less likely than discontinuers to use oral corticosteroids (27.7% vs. 29.6%, p = .018), or to have ≥1 respiratory-related emergency room visit (5.4% vs. 6.5%, p = .008) and ≥1 inpatient stay (1.1% vs. 1.7%; p = .002). Continuers were more likely than discontinuers to have ≥1 AR-related office (98.8% vs. 94.6%, p < .001) or outpatient visit (2.4% vs. 1.7%, p = .002). Continuers had greater mean total AR-related costs than discontinuers ($1918 vs. $646, p < .001). Unadjusted mean total respiratory-related costs were lower for continuers than discontinuers, although the difference was not statistically significant ($1589 vs. $1785, p = .077); when adjusted with a generalized linear model, these costs were significantly lower among continuers (p < .001).

CONCLUSIONS

Continued SCIT use is associated with decreased emergency room visits and inpatient stays, decreased oral corticosteroid use, and lower respiratory-related costs, compared with early discontinuation.

The efficacy of evolocumab in the management of hyperlipidemia: a systematic review

BACKGROUND

Hyperlipidemia or dyslipidemia has been a concern for a long time, with various guidelines emphasizing the importance of managing the lipid profile to prevent cardiac incidences. Although statins have been found to be highly effective, resistance and intolerability to side effects will continue to be a stumbling block for certain patients. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors tackle lipid profile via a novel mechanism and therefore provide an additional effective option for managing lipid profile. The overarching aim of this systematic review was to evaluate the efficacy of evolocumab among various populations with hypercholesterolemia.

METHODS

A comprehensive search was conducted in ProQuest Health & Medical Complete, Google Scholar, ScienceDirect, and PubMed to identify potential records; then titles, abstracts, and full texts were screened using the inclusion criteria to filter out irrelevant studies. Data extraction and quality assessment were undertaken using standardized tools and the results were narratively synthesized and presented in tables.

RESULTS

Eight studies were included in this systematic review after screening 1191 records. All studies demonstrated a statistically significant reduction in low-density lipoprotein cholesterol (LDL-C) values in the groups that received evolocumab compared with the comparator groups ( p < 0.05). The decline in LDL-C levels from baseline in the majority of studies ranged from 40% to 80%, whether used alone or in combination with other agents. Also, high-density lipoprotein cholesterol, lipoprotein (a) and apolipoprotein B were improved with the use of evolocumab.

CONCLUSIONS

This study helped to collate evidence from studies that tested the effectiveness of evolocumab in the management of hyperlipidemia. Evolocumab seems to be highly effective in reducing LDL-C and other lipid parameters. Hence, it provides an excellent alternative for patients with refractory disease or patients who develop intolerable side effects, therefore helping to overcome the stumbling block to achieving optimal lipid management.

[Adherence in specific immunotherapy]

Allergies are steadily gaining in importance in the Western world. For over one hundred years, immunology has been the only causal treatment. Specific immunotherapy (SIT) aims at the cure of allergy or at least freedom from allergy symptoms. In association with this, adherence poses a complex problem. Both treatment applications commonly used in Germany-sublingual and subcutaneous immunotherapy-show poor persistence on the part of the patients. In most cases, SIT is not carried out to the end of the recommended duration and instead is discontinued prematurely. Corresponding figures from 3‑year studies in the literature range from 41- 93% for uncompleted SLIT and from 40-77% for uncompleted SCIT. Patient adherence is subject to influencing factors of various dimensions that are interdependent in complex relationships. The physician-patient relationship is just as decisive a factor for treatment success as the patient's understanding of allergy, treatment, and the importance of adherence.

Physician's recommendation and explanation is important in the initiation and maintenance of allergen immunotherapy

BACKGROUND

Allergen immunotherapy (AIT) is currently the only immune-modifying treatment for allergic disease. The clinical efficacy of AIT for the treatment of allergic rhinitis and bronchial asthma is well documented. However, many factors including inconvenience, cost, side effects, and adherence influence the initiation and persistence of AIT, and patients lack knowledge and have misconceptions about the treatment.

OBJECTIVE

We evaluated the knowledge, attitude, and satisfaction of patients who received AIT.

METHODS

We conducted a retrospective analysis of medical records of 167 patients who received AIT, and compared the clinical characteristics between conventional immunotherapy (CIT) and rush immunotherapy (RIT). Ninety-nine patients completed a questionnaire survey.

RESULTS

Of the total 167 patients, 65.9% (n=110) were treated with CIT and 34.1% (n=57) with RIT. More than half of the patients (68.7%) initiated AIT according to their physician's recommendation. Frequent hospital visits were the main barrier for persistence of AIT. RIT patients were younger and started AIT earlier than CIT patients. The majority (77%) of patients who received AIT were satisfied, with no significant difference between CIT and RIT groups. RIT and fewer allergens used in AIT were related with preference for AIT to pharmacotherapy. The longer duration of AIT was associated with higher treatment satisfaction.

CONCLUSION

A majority of patients initiated AIT by the physician's recommendation and were satisfied with treatment regardless of CIT or RIT schedule. Adequate patient education and a strict patient-physician relationship in early AIT period could improve the effectiveness and compliance of AIT.

Adherence and systemic reaction rates to allergy immunotherapy among veterans

Background:

Although allergen immunotherapy (AIT) is effective and safe, nonadherence is common. Limited data exist regarding adherence to AIT, factors that affect adherence, and systemic reactions associated with AIT among veteran populations.

Objective:

To evaluate adherence to AIT and the prevalence of reactions secondary to AIT among patients at the Veterans Affairs Medical Center, Memphis, Tennessee.

Methods:

A retrospective chart review was performed of veterans who received AIT at a single Veterans Affairs facility. Age, race, sex, the total number of shots, travel distance, a diagnosis of posttraumatic stress disorder (PTSD), and the number of severe adverse reactions were compared between the veterans who were adherent and veterans who were nonadherent.

Results:

The overall adherence rate was 60.9%. Factors associated with adherence were a chart diagnosis of PTSD (29.3% [adherent group] versus 13.6% [nonadherent group]; p = 0.03) and home residence being a further distance from the facility (21.9 miles / 35.2 kilometers [adherent group] versus 18.0 miles / 28.9 kilometers [nonadherent group]; p = 0.03). Patients who were adherent received an average of more total injections compared with patients who were nonadherent. Age, sex, race, and history of systemic reactions during AIT displayed no statistically significant differences between the groups. There were a total of 20 systemic reactions, and the systemic reaction rate was 0.2% per AIT encounter and 0.1% per injection.

Conclusion:

AIT adherence and systemic reaction rates among veterans at our facility was comparable with similar studies. Adherence was associated with a chart diagnosis of PTSD and home residence that was further away from the clinic.

Long-term adherence to sublingual therapy: literature review and suggestions for management strategies based on patients' needs and preferences

Sublingual immunotherapy (SLIT) is an at-home, self-administered, long-term therapy. As with other chronic diseases, patient adherence is a prerequisite for the success of SLIT. Its ease of intake and convenience should ensure adequate patient compliance; however, a recent post-marketing manufacturers' survey has shown a very high rate of discontinuation. The available literature on patient adherence to SLIT is reviewed in the present article. Great differences exist between controlled studies, which show a satisfactory adherence rate, and long-term real-life studies, which show poor compliance with SLIT. Remarkable divergence in the weight placed on different reasons for SLIT discontinuation is reported in the various studies. The main reasons for withdrawal are analysed and discussed. Data from placebo-controlled studies demonstrate that adherence depends less on the patient's perception of the inefficacy of therapy or other causes than on the patient's motivation, that is the patient's decision to participate in the trial and to meet the researcher's expectations. The enrolment of patients who agree to enter a blind, placebo-controlled trial is conceptually similar to a concordance process. Concordance is a consultation process that aims to establish a therapeutic alliance between the physician and patient and to bring about agreement on a therapeutic programme. Concordance is based on the patient's beliefs and needs and implies actions that support the patient's adherence. Suggestions are given for a SLIT management strategy based on the concordance process and designed to integrate the patient's viewpoints into treatment-related decisions and to meet patients' preferences and their health-system-related needs.

Prospective adherence to specific immunotherapy in Europe (PASTE) survey protocol

BACKGROUND

Adherence to allergen immunotherapy is important for its effectiveness. There is currently limited data available on allergen immunotherapy adherence outside of clinical trials i.e. in real-life clinical practice. As part of a European Academy of Allergy and Clinical Immunology Immunotherapy Interest group initiative, we endeavoured to design a survey in order to prospectively evaluate adherence to subcutaneous and sublingual immunotherapy across different European countries.

METHOD/DESIGN

The inclusion criteria for this prospective, multi-country survey were set as: adults, starting clinically indicated allergen immunotherapy for respiratory allergic disorders or Hymenoptera venom allergy. An online survey was designed in order to enrol participants and assess adherence to immunotherapy. Eight countries (Czech Republic, Georgia, Germany, Greece, Italy, Poland, Portugal, Spain) were selected to reflect different parts of Europe and differences in allergens and routes of immunotherapy administration. Each country has an allocated National co-ordinator that has identified local Allergy departments willing to enrol participants in this survey. Each participant will be followed up for a total of three years. In order to assess adherence, a 4-monthly follow-up form detailing any missed doses and reasons will be completed online. In case of a participant discontinuing treatment, reasons for this will be recorded.

DISCUSSION

The use of online survey software has enabled us to make this survey a reality and reach clinicians in different countries. Forty-five centres have enrolled a total of over 1,350 participants. It is hoped that this prospective real life survey will enable us to gain a better understanding of reasons that affect adherence to subcutaneous and sublingual immunotherapy and assist in developing ways to improve this.

Mixing compatibilities of Aspergillus and American cockroach allergens with other high-protease fungal and insect extracts

BACKGROUND

Recent studies have shown that Alternaria and German cockroach allergens can be degraded by endogenous proteases from other insect and fungal extracts when combined for immunotherapy, but data supporting the compatibilities of other high-protease products in comparable mixtures have not been reported.

OBJECTIVE

To assess the stabilities and compatibilities of Aspergillus fumigatus and American cockroach allergens after mixing with protease-rich extracts from other insects or fungi at concentrations similar to those recommended for subcutaneous immunotherapy.

METHODS

Mixtures containing A fumigatus, American cockroach, and other fungal or insect extracts were evaluated by quantitative (enzyme-linked immunosorbent assays) and qualitative (immunoblotting) methods. Test mixtures and control samples at 10% to 50% glycerin concentrations were analyzed after storage for up to 12 months at 2°C to 8°C.

RESULTS

Moderate to high recoveries of Aspergillus extract activities were retained in control samples and extract mixtures under all conditions examined. American cockroach extract controls were partly degraded at 10% to 25% glycerin, and cockroach allergen compatibilities were decreased significantly in mixtures with several fungal extracts at 25% glycerin. Mixing with other insects did not compromise the stability of American cockroach allergens at 25% to 50% glycerin.

CONCLUSION

Aspergillus extracts exhibited favorable stabilities after mixing with other high-protease products. American cockroach extract potencies were unstable in less than 50% glycerin, even in the absence of other protease-containing allergens, and were destabilized in mixtures with several fungal extracts. Addition of fungal and insect extracts to separate treatment vials or preparation of fungal-insect mixtures at elevated glycerin concentrations might be necessary to produce compatible patient formulations for allergen immunotherapy injections.

Sublingual immunotherapy in allergic rhinitis: efficacy, safety, adherence and guidelines

Allergic rhinitis (AR) is a globally increasing health problem affecting the quality of life. Specific immunotherapy is an available causal treatment changing the basic allergic mechanisms of the disease. Over one hundred years, subcutaneous immunotherapy (SCIT) was developed and proved its efficacy but many adverse effects were recorded including anaphylaxis. In 1986, sublingual immunotherapy (SLIT) was introduced as an alternative solution to solve this problem. Our study aims to discuss SLIT from the points of efficacy, safety, adherence and guidelines developed. A literature search was conducted in Medline/PubMed and the Cochrane Library in January 2013 using the keywords "allergic rhinitis, sublingual immunotherapy, efficacy, safety, compliance, adherence, guidelines." All types of publications were included. We augmented our study by searching the reference lists of identified reviews. SLIT has been established in many guidelines as an evidence-based effective treatment in AR with safer profile than SCIT. The meta-analyses confirmed its efficacy and showed a significant reduction in both symptoms and medication scores. The most common recorded adverse effects were minor local effects in the mouth, gastrointestinal reactions with few cases of anaphylaxis and no fatality. Adherence is more favorable for SLIT mainly because it is safe, noninvasive and easily taken at home. We support the call to conduct large multi-centric studies to gain more statistical power and overcome the problem of heterogeneity observed in the meta-analyses.

Is faster safer? Cluster versus short conventional subcutaneous allergen immunotherapy

AIM

Few studies have compared cluster immunotherapy and conventional administration regimens. The aim of this study was to establish the safety profile of these different regimens in patients with allergic respiratory diseases who received index-of-reactivity (IR)-standardized allergen extracts by the subcutaneous route.

MATERIALS & METHODS

The safety of subcutaneous immunotherapy (SCIT), administered by means of a 4-week cluster titration schedule (cluster-SCIT) or by an 8-week short conventional titration schedule (SC-SCIT), both with a target dose of 8 IR, was assessed in a retrospective, observational, multicenter study.

RESULTS

A total of 658 patients (339 cluster-SCIT and 319 SC-SCIT) were recruited from 92 sites in Spain. Injection site reactions occurred in 25.1 and 27.3% of patients treated with cluster-SCIT and SC-SCIT, respectively. Systemic reactions (European Academy of Allergy and Clinical Immunology criteria) were reported for 0.2% of doses and 1.5% of patients with cluster-SCIT, and 0.7% of doses and 4.4% of patients with SC-SCIT. Most reactions were mild and there were no grade 3 or 4 systemic reactions. No life-threatening systemic reactions, anaphylactic shock, or adverse events leading to therapy discontinuation were reported.

CONCLUSION

The safety profile of the cluster regimen supports the use of accelerated SCIT schedules with IR-standardized allergen extracts compared with short conventional schedules, particularly if similar extracts and application methods are used.

Safety of immunotherapy in patients with rhinitis, asthma or atopic dermatitis using an ultra-rush buildup. A retrospective study

BACKGROUND

Allergen-specific immunotherapy is a proven, highly effective treatment for IgE-mediated diseases. However, ultra-rush immunotherapy is prescribed infrequently because of the perception that accelerated immunotherapy buildup leads to a higher rate of systemic reactions.

OBJECTIVE

To evaluate the frequency of adverse reactions in patients with IgE-mediated diseases receiving house dust mite (HDM) ultra-rush immunotherapy.

METHODS

A retrospective, observational study was conducted for patients with IgE-mediated diseases receiving allergen-specific immunotherapy. Subcutaneous immunotherapy with depigmented polymerized mites extract was administered in two refracted doses of 0.2 and 0.3 ml at first injection, and in single 0.5 ml doses in subsequent monthly injections. A 30 min observation time was required after each injection. Systemic reactions were graded using the World Allergy Organisation grading system.

RESULTS

575 patients were included. The age range was 1-83 years. Most patients had respiratory diseases (544) and 101 patients had atopic dermatitis. A total of 27 patients (4.6%) experienced 139 reactions (reactions/injections: 1.9%); 22 patients (3.8%) experienced 134 local reactions (local reactions/injections: 1.8%). Eight patients (1.3%) experienced eight systemic reactions (systemic reactions/injections: 0.1%). Five systemic reactions were grade 2 and three grade 1. Two systemic reactions were reported during buildup. There were no fatalities.

CONCLUSION

Taking into account the possible bias for the retrospective design of this study we observed that immunotherapy for patients with IgE-mediated diseases using a depigmented polymerized mites extract, with an ultra-rush buildup, has similar frequency of systemic reactions than that seen in slower buildup immunotherapy in other studies. Accelerated buildup could improve patients' adherence and reduce dropout rates.

Trends in Specific Immunotherapy for Allergic Rhinitis: A Survey of Chinese ENT Specialists

Purpose

Specific immunotherapy (SIT) is a suitable but uncommon treatment option for allergic rhinitis (AR) in China. The current understanding and attitude of Chinese ENT (ear, nose, and throat) specialists in regards to SIT is unclear. This study investigates current trends in the awareness and application status of SIT among Chinese ENT specialists.

Methods

We performed a nationwide, cross-sectional survey with a specially designed questionnaire given to 800 ENT specialists in China. A member of the trained research group conducted face-to-face interviews with each respondent.

Results

Most of the respondents considered AR (96.0%) and allergic asthma (96.0%) the most suitable indications for SIT. Of all respondents, 77.0% recommended the application of SIT as early as possible; in addition, SIT was considered 'relatively controllable and safe' by most respondents (80.6%). The highest allergen-positive rate in AR was associated with house dust mite (47.7%) and obvious differences existed among geographical regions. Conventional subcutaneous immunotherapy was the most highly recommended treatment option (96.2%). 'The high cost of SIT' (86.6%) and 'lack of patient knowledge of SIT' (85.2%) were probably the main reasons for the lower clinical use of SIT in China.

Conclusions

Most cases showed that the opinions of Chinese ENT specialists appeared to be in agreement with recent SIT progress and international guidelines; however, many areas still need to enhance the standardization and use of SIT in China. Clinical guidelines for SIT require improvement; in addition, Chinese ENT specialists need continuing medical education on SIT.

Patient adherence to allergy immunotherapy

PURPOSE OF REVIEW

This article reviews the literature on patient adherence to two different approaches to allergen-specific immunotherapy for allergic disease. Factors related to adherence in general, as well as the various methods used to measure adherence, will be discussed.

RECENT FINDINGS

Although a complex interaction of factors related to both the physician and the patient influence the adherence to a particular therapeutic regimen, effective communication between these two parties and the simplicity of the regimen are frequently noted to be of primary importance. Variability with respect to the definition of adherence, the method of measuring adherence, and the length of the measuring period has resulted in a wide range of adherence rates to allergy immunotherapy reported in the literature. Patients most often site inconvenience, side-effects, and poor efficacy as reasons for discontinuing allergy immunotherapy.

SUMMARY

Adherence to therapy not only improves individual patient outcomes, but also helps determine the best treatment modalities and reduces the burden of disease on society. As new methods of delivering immunotherapy are being developed, such as allergy immunotherapy tablets and oral mucosal immunotherapy, the factors associated with patient adherence should be carefully considered.

Local reactions from subcutaneous allergen immunotherapy

Local reactions from subcutaneous allergen immunotherapy are very common during the course of immunotherapy. These local reactions are not bothersome to patients. Local reactions from immunotherapy also do not predict future local or systemic reactions. This review discusses the studies that show that local reactions are not predictive of future reactions and that dose adjustments for local reactions from allergen immunotherapy are unnecessary. The article also focuses on factors that lead to patient noncompliance with immunotherapy and evaluates methods to prevent local reactions from subcutaneous allergen immunotherapy.

Adherence to pharmacological treatment and specific immunotherapy in allergic rhinitis

The term compliance simply indicates how much doses of the prescribed medication are taken, whereas the term adherence implies also an agreement between patient and physician about the therapeutic plan, and it is therefore preferred. Adherence is a main problem in all long-term treatments. Thus, it represents a problem also in the case of rhinitis, expecially concerning specific immunotherapy that must be assumed continuously for several years. Many factors can affect the adherence, depending on patient, on treatment itself and on the healthcare context, and all those factors usually interact. The adherence measured in controlled trials is usually good, but this does not reflect what happens in real life, where adherence should be preferably measured. There are few data on the adherence in real life for pharmacological treatments of allergic rhinitis (e.g. nasal steroids or antihistamines), whereas more data are available for specific immunotherapy. In this latter case, in real life, adherence seems to be far from optimal, for both sublingual and subcutaneous immunotherapy, although the recent studies agree on the fact that some interventions (i.e. patients' education, strict follow-up, regular contacts) could effectively improve the adherence. In this article, the literature concerning the adherence to pharmacological treatments and immunotherapy in allergic rhinitis was searched and reviewed.

Real-life compliance and persistence among users of subcutaneous and sublingual allergen immunotherapy

BACKGROUND

Subcutaneous allergen immunotherapy (SCIT) and sublingual allergen immunotherapy (SLIT) are safe and effective treatments of allergic rhinitis, but high levels of compliance and persistence are crucial to achieving the desired clinical effects.

OBJECTIVE

Our objective was to assess levels and predictors of compliance and persistence among grass pollen, tree pollen, and house dust mite immunotherapy users in real life and to estimate the costs of premature discontinuation.

METHODS

We performed a retrospective analysis of a community pharmacy database from The Netherlands containing data from 6486 patients starting immunotherapy for 1 or more of the allergens of interest between 1994 and 2009. Two thousand seven hundred ninety-six patients received SCIT, and 3690 received SLIT. Time to treatment discontinuation was analyzed and included Cox proportional hazard models with time-dependent covariates, where appropriate.

RESULTS

Overall, only 18% of users reached the minimally required duration of treatment of 3 years (SCIT, 23%; SLIT, 7%). Median durations for SCIT and SLIT users were 1.7 and 0.6 years, respectively (P < .001). Other independent predictors of premature discontinuation were prescriber, with patients of general practitioners demonstrating longer persistence than those of allergologists and other medical specialists; single-allergen immunotherapy, lower socioeconomic status; and younger age. Of the persistent patients, 56% were never late in picking up their medication from the pharmacy. Direct medication costs per nonpersistent patient discontinuing in the third year of treatment were €3800, an amount that was largely misspent.

CONCLUSION

Real-life persistence is better in SCIT users than in SLIT users, although it is low overall. There is an urgent need for further identification of potential barriers and measures that will enhance persistence and compliance.

Adherence to imported fire ant subcutaneous immunotherapy

BACKGROUND

Imported fire ant (IFA) subcutaneous immunotherapy (SCIT) is safe and effective. For optimal protection, SCIT is given monthly for 3 to 5 years. Successful outcomes require patient adherence.

OBJECTIVE

To evaluate SCIT adherence in IFA allergic patients in an endemic area.

METHODS

Patients with systemic reactions to an IFA sting, with detectable specific IgE, who received a recommendation to start IFA SCIT were included. Initial reaction severity and demographic data were collected. Patients were contacted at 1 year regarding interval reactions to stings, SCIT adherence, and reason for nonadherence. Adherence rates were analyzed for association with age, sex, and severity of initial reaction.

RESULTS

Seventy-six patients were enrolled, and 71% adhered to the recommendation to start IFA SCIT. Subgroup analysis did not find significant differences. At 1 year, 97% completed follow-up for analysis, and only 35% remained adherent. Subgroup analysis did not find significant differences. Inconvenience and fear were reported as reasons for not following the recommendation to start or continue with IFA SCIT.

CONCLUSION

IFA SCIT is a life-saving therapy that is safe and effective. Despite this, only 71% followed the recommendation to start, and at 1 year only 35% remained adherent. Adherence was not statistically related to age, sex, or severity of initial reaction. Logistical constraints and fear were significant impediments.

One hundred years of allergen immunotherapy European Academy of Allergy and Clinical Immunology celebration: review of unanswered questions

Allergen immunotherapy was introduced by Leonard Noon 100 years ago and is the only disease-modifying treatment for allergic individuals. Improved understanding of immunology has taught us a great deal about the underlying mechanisms involved in allergen immunotherapy; however, despite these developments, a number of important questions remain unanswered. Several of these questions relate to the practice of allergen immunotherapy in the clinic, such as: Is it possible to unify units of allergen potency? Which treatment schedules are best? Is allergen immunotherapy effective in all patient groups? Is there a dose-response relationship for efficacy and safety?, and Is there evidence for long-term effects following allergen immunotherapy? Others are related to new developments, such as new indications, or developments in the production of allergens. On the centenary of Noon's discovery, European experts in the field of immunotherapy met in Geneva under the aegis of the EAACI to discuss these controversial issues. This study presents outcomes and conclusions from these discussions.

Factors affecting time required to reach maintenance dose during subcutaneous immunotherapy

BACKGROUND

Subcutaneous immunotherapy (SCIT) demands a significant time commitment on the part of the patient, especially during the escalation period when weekly visits are required. Many patients refuse or discontinue treatment in spite of the demonstrated clinical efficacy of SCIT. Understanding the factors that affect the length of the escalation phase would allow for counseling of patients, which may improve patient compliance. The aims of this study were to determine the mean time required to reach maintenance dose during conventional protocol SCIT and to identify factors that significantly affect the time required to reach maintenance dose.

METHODS

We conducted a retrospective chart review of 55 patients (total of 79 treatment vials) who began SCIT between January 2007 and December 2010 and reached maintenance dose. The effect of demographic data, medical and social history, and SCIT allergen data on the time required to reach maintenance dose were examined using bivariate and multivariate analyses.

RESULTS

The mean time to maintenance dose for the 79 treatment vials was 240.2 days (range, 76-720 days). Males (mean 294.7 days) took significantly longer than females (mean 205.1 days) to reach maintenance dose (p = 0.007). Asthmatics (mean 285.5 days) took significantly longer than nonasthmatics (mean 218.0 days) to reach maintenance dose (p = 0.008). Age also significantly affected the length of the escalation phase; each additional year of age was associated with an increase in 3.9 days needed to reach maintenance dose (p = 0.002).

CONCLUSION

Gender, asthma, and age significantly impact the time required to reach maintenance dose during SCIT.

A comparison of attrition rates in patients undergoing sublingual immunotherapy vs subcutaneous immunotherapy

BACKGROUND

Effective allergy immunotherapy (IT) requires patient compliance. Numerous studies have shown high noncompliance rates in patients undergoing IT. For patients enrolled in subcutaneous IT (SCIT), noncompliance rates were noted to range from 11% to 50%, whereas sublingual IT (SLIT) patients had noncompliance rates ranging from 3% to 25%. Comparing noncompliance rates is difficult because noncompliance in SCIT is defined as withdrawal from therapy, whereas in SLIT it is considered poor adherence to daily administration. The aim of this study was to compare attrition rates in patients enrolled in SCIT vs SLIT, as well as major factors leading to termination of IT.

METHODS

We retrospectively compared attrition rates, IT duration, and reasons for termination between patients enrolled in SCIT (n = 139) and SLIT (n = 78), over a 4-year period.

RESULTS

Attrition rates for SCIT and SLIT were 45% and 41%, respectively (p = 0.669). No significant difference in duration of IT was observed between the groups (≤1 month, p = 0.079; 1-2 months, p = 0.486; 2-3 months, p = 0.165; 3-6 months, p = 0.575; 6-12 months, p = 0.361; 12-24 months, p = 1.000; and ≥24 months, p = 0.258). Among reasons cited for discontinuing IT, SCIT patients reported inconvenience (p = 0.001), whereas SLIT patients indicated efficacy concerns (p = 0.022) as the major basis for withdrawal.

CONCLUSION

No significant difference was observed in attrition rates between SCIT and SLIT. While there was no significant difference in duration of IT prior to withdrawal, there was a trend toward earlier withdrawal in SCIT patients. The reasons for withdrawal, however, were considerably different between the 2 groups.

Safety of allergen immunotherapy: a review of premedication and dose adjustment

From the first allergen immunotherapy proposed in the early 1900s to the present day, numerous studies have proven the efficacy of allergen immunotherapy for the treatment of allergic rhinitis, allergic conjunctivitis, allergic asthma and stinging insect hypersensitivity. The major risk, however small, with allergen immunotherapy is anaphylaxis. There has been considerable interest and debate regarding risk factors for immunotherapy reactions (local and systemic) and interventions to reduce the occurrence of these reactions. One of these interventions that is especially debated regards dose adjustment for various reasons, but in particular for local reactions. In this review, we discuss the safety of immunotherapy and provide a comprehensive review of the literature regarding immunotherapy schedules and doses.

Determinants of patient compliance in allergic rhinoconjunctivitis

PURPOSE OF REVIEW

Noncompliance to the prescribed therapeutic regimen is a worldwide problem, especially for diseases in which symptoms can vary with different patient factors and with seasons. The consequences are poor health outcomes, progression of disease and increased healthcare costs. Reviews conducted across countries and addressing different diseases are consistent in estimating noncompliance between 30 and 50%. To implement strategies and interventions that enhance compliance, a comprehensive analysis of its determinants is essential.

RECENT FINDINGS

Lack of efficacy was reported as the number one reason for discontinuing the intake of medications prescribed for nasal allergies. Studies on glucocorticosteroids, allergen-specific immunotherapy and antihistamines highlighted the importance of patient education, demographic factors, duration of therapy, side-effects and treatment costs, as well as minor details, such as taste and odour, in improving compliance.

SUMMARY

The variation in the methodologies used and the durations of treatments assessed in current compliance research in the field of allergic rhinoconjunctivitis decreases the comparability of results. Therefore, a clear definition of compliance measured in clinical trials with allergic rhinoconjunctivitis sufferers is needed. Moreover, a gold standard for measuring and reporting compliance should be determined to enable better interstudy comparability of the rates and determinants of compliance.

Subcutaneous injection immunotherapy for optimal effectiveness

Immunotherapy by the subcutaneous injection of increasing doses and then maintenance doses of extracts of inhalant allergens has been practiced for 100 years. Controlled clinical trials have established its efficacy in treating allergic rhinitis, asthma, and stinging insect sensitivity, and there are preliminary data to suggest a favorable response in some patients with atopic dermatitis. The response to subcutaneous injection immunotherapy is dose dependent. Disease-modifying actions include blocking development of new sensitivities in monosensitized patients, blocking progression to asthma in patients with allergic rhinitis, and persistence of treatment effects for up to 7 to 10 years after an initial course.

The health economics of allergen immunotherapy

In contrast to symptomatic drug treatment, which only temporarily relieves allergy symptoms, allergen-specific immunotherapy (SIT) has the potential to alter the course of allergic disease, thereby reducing the need for long-term treatment, the progression of allergic rhinitis (AR) to asthma, and the development of new allergies. The clinical benefits of SIT have been shown to persist for an additional 3 to 12 years after discontinuation of a 2.5- to 5.0-year treatment. It therefore stands to reason that the clinical benefits of SIT also extend to economic benefits. A growing number of studies have evaluated the economic benefits of SIT in patients with AR and/or asthma. The authors critically examine each of these studies published from 1995 to present.

Safety evaluation of rapid build-up schedules with IR-standardized allergen extracts for subcutaneous immunotherapy of allergic respiratory diseases

INTRODUCTION

The conventional schedule used in specific subcutaneous immunotherapy (SCIT) is a slow treatment that often leads to poor compliance or discontinuation of treatment. These disadvantages have led to design administration schedules that shorten the build-up phase without increasing the adverse reactions rate.

AREAS COVERED

This report reviews the available scientific documentation of the safety profile of build-up schedules for SCIT with Alustal Rapid® (a suspension of standardized allergen extracts adsorbed on aluminum hydroxide gel for specific immunotherapy) in the treatment of IgE-mediated rhinitis, conjunctivitis and bronchial asthma to inhaled allergens.

EXPERT OPINION

Cluster and shortened conventional schedules may offer a safe method of SCIT for the treatment of respiratory allergy and reduce the inconvenience associated with conventional schedules by reaching the maintenance dose in less time and with fewer visits; thereby this method could reduce discontinuation rates and increase compliance.

Subcutaneous specific immunotherapy for seasonal allergic rhinitis: a review of treatment practices in the US and Europe

BACKGROUND

Subcutaneous specific immunotherapy (SCIT) is claimed to be successful both in the US and Europe, yet treatment methodology differs.

METHODS

The authors review current literature surrounding guidelines and clinical trials in Europe and the US and contrast the treatment approach to SCIT for allergic rhinitis. Search methodology employs MEDLINE and PubMed, selecting articles on SCIT and allergic rhinitis, limited between 1990-2009. They focus on the safety and efficacy of vaccines, and the differences in formulations. Also mentioned are: standardization, new approaches in SCIT and sublingual immunotherapy (SLIT).

RESULTS

SCIT treatment differs in many respects regarding availability of SCIT products, regulatory controls, guidelines (e.g. multiple allergen vaccines in US, single allergen vaccines in Europe) and in location of formulation (US, clinician's office; Europe, manufacturers).

CONCLUSIONS

SCIT is an effective and safe therapy, but major evidence for efficacy is provided from European studies of single allergen extract vaccines; these vaccines may gain more acceptance because of increasing regulatory approval and lower numbers of injections. The potential impact upon public health (e.g. arrest of the 'allergic march') should not be overlooked.

Double-blind, placebo-controlled study of azelastine and fluticasone in a single nasal spray delivery device

BACKGROUND

A proof-of-concept study suggested that combination therapy with commercial azelastine hydrochloride nasal spray and fluticasone propionate nasal spray significantly improved nasal symptoms of seasonal allergic rhinitis compared with either agent alone.

OBJECTIVE

To compare an azelastine-fluticasone combination nasal spray administered in a single-delivery device with a commercially available azelastine nasal spray and fluticasone nasal spray.

METHODS

This 14-day, multicenter, randomized, double-blind study was conducted during the Texas mountain cedar season. After a 5-day placebo lead-in, 610 patients with moderate-to-severe nasal symptoms were randomized to treatment with (1) azelastine nasal spray, (2) fluticasone nasal spray, (3) combination azelastine and fluticasone nasal spray, or (4) placebo nasal spray. All treatments were given as 1 spray per nostril twice daily. The primary efficacy variable was the change from baseline in the total nasal symptom score (TNSS), consisting of nasal congestion, runny nose, itchy nose, and sneezing.

RESULTS

All 3 active groups were statistically superior (P <or= .02) to placebo, and the combination was statistically superior (P <or= .003) to either agent alone. The TNSS improved by 28.4% with combination azelastine-fluticasone, 20.4% with fluticasone, 16.4% with azelastine, and 11.2% with placebo. All 3 treatments were well tolerated.

CONCLUSIONS

The combination azelastine-fluticasone nasal spray provided statistically significant improvement in the TNSS and additive clinical benefit compared with either agent alone in patients with moderate-to-severe seasonal allergic rhinitis.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00660517.