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Gurgel RK, Baroody FM, Damask CC, Mims JW, Ishman SL, Baker DP, Contrera KJ, Farid FS, Fornadley JA, Gardner DD, Henry LR, Kim J, Levy JM, Reger CM, Ritz HJ, Stachler RJ, Valdez TA, Reyes J, Dhepyasuwan N. Clinical Practice Guideline: Immunotherapy for Inhalant Allergy. Otolaryngol Head Neck Surg 2024; 170 Suppl 1:S1-S42. [PMID: 38408152 DOI: 10.1002/ohn.648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care. PURPOSE The purpose of this clinical practice guideline (CPG) is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce the risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS The GDG made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitizations, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions (LRs) to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The GDG offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.
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Affiliation(s)
| | - Fuad M Baroody
- The University of Chicago Medicine, Chicago, Illinois, USA
| | | | - James Whit Mims
- Wake Forest Baptist Health, Winston Salem, North Carolina, USA
| | | | - Dole P Baker
- Anderson ENT & Facial Plastics, Anderson, South Carolina, USA
| | | | | | - John A Fornadley
- Associated Otolaryngologists of PA, Inc, Hershey, Pennsylvania, USA
| | | | | | - Jean Kim
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua M Levy
- National Institute on Deafness and Other Communication Disorders, Bethesda, Maryland, USA
| | - Christine M Reger
- Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | - Joe Reyes
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Nui Dhepyasuwan
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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2
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Dogmas, challenges, and promises in phase III allergen immunotherapy studies. World Allergy Organ J 2021; 14:100578. [PMID: 34659627 PMCID: PMC8487954 DOI: 10.1016/j.waojou.2021.100578] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 08/02/2021] [Accepted: 08/10/2021] [Indexed: 12/11/2022] Open
Abstract
The concept of treatment of an allergy with the offending allergen was introduced more than a century ago. Allergen immunotherapy (AIT) is the only disease modifying treatment of allergic diseases caused by inhalational allergens and insect venoms. Despite this, only few AIT products have reached licensure in the US or an official marketing authorization status in European countries. Moreover, most of these AIT products are provided on an individual patient basis as named patient products (NPP) in Europe, while individualized preparations of (mixed) allergenic extract vials for subcutaneous administration (compounding) is common practice in the US. AIT products are generally considered safe and well tolerated, but the major practical clinical development challenge is to define the optimal dose and prove the efficacy and safety of these products using state-of-the art Phase II and pivotal Phase III studies. In planning Phase II-III AIT studies, a thorough understanding of the study challenges is essential (e.g. variability and non-validated status of subjective primary endpoints, limitations of pollen season definitions) and dogmas of these products (e.g., for sublingual immunotherapy (SLIT) trials double-blinding conditions cannot be maintained, resulting in stronger placebo responses in the active treatment group and inflated treatment effects in Phase III). There is future promise for more objective biomarker endpoints (e.g. basophil activation (CD63 and CD203c), subsets of regulatory dendritic, T and B cells, IL-10–producing group 2 innate lymphoid cells; alone or in combination) to overcome several of these dogmas and challenges; innovation in AIT clinical trials can only progress with integral biomarker research to complement the traditional endpoints in Phase II-III clinical development. The aim of this paper is to provide an overview of these dogmas, challenges and recommendations based on published data, to facilitate the design of Phase III studies and improve the evidence basis of safe and effective AIT products.
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3
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Pitsios C. Allergen Immunotherapy: Biomarkers and Clinical Outcome Measures. J Asthma Allergy 2021; 14:141-148. [PMID: 33633455 PMCID: PMC7901403 DOI: 10.2147/jaa.s267522] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/27/2021] [Indexed: 12/14/2022] Open
Abstract
Clinical trials for allergen immunotherapy products’ development and approval are conducted, aiming to monitor safety and efficacy of them. Symptom scores and the use of rescue medication are the primary clinical endpoints used in the conducted clinical trials, while Quality of Life scores and symptom-free days are measurements also used as secondary endpoints. Although the use of in vitro biomarkers might have been more practical and objective, there are yet no broadly used reliable ones accurately reflecting the clinical effects of allergen immunotherapy. On the contrary, in vivo biomarkers, such as the nasal allergy provocation test, are reliable and successfully used. The aim of this review is to describe how to adapt and use biomarkers and clinical outcomes in the everyday practice of Allergists who perform allergen immunotherapy.
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Affiliation(s)
- Constantinos Pitsios
- Allergy Outpatient Clinic, Medical School, University of Cyprus, Nicosia, Cyprus
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4
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Hall J, Lo F, Saha S, Vaidyanathan A, Hess J. Internet searches offer insight into early-season pollen patterns in observation-free zones. Sci Rep 2020; 10:11334. [PMID: 32647115 PMCID: PMC7347639 DOI: 10.1038/s41598-020-68095-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/20/2020] [Indexed: 11/09/2022] Open
Abstract
Tracking concentrations of regional airborne pollen is valuable for a variety of fields including plant and animal ecology as well as human health. However, current methods for directly measuring regional pollen concentrations are labor-intensive, requiring special equipment and manual counting by professionals leading to sparse data availability in select locations. Here, we use publicly available Google Trends data to evaluate whether searches for the term "pollen" can be used to approximate local observed early-season pollen concentrations as reported by the National Allergy Bureau across 25 U.S. regions from 2012-2017, in the context of site-specific characteristics. Our findings reveal that two major factors impact the ability of internet search data to approximate observed pollen: (1) volume/availability of internet search data, which is tied to local population size and media use; and (2) signal intensity of the seasonal peak in searches. Notably, in regions and years where internet search data was abundant, we found strong correlations between local search patterns and observed pollen, thus revealing a potential source of daily pollen data across the U.S. where observational pollen data are not reliably available.
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Affiliation(s)
- Jane Hall
- Department of Emergency Medicine, School of Medicine, University of Washington, 4730 University Way NE, Suite 104, #2021, Seattle, 98105, WA, USA.
| | - Fiona Lo
- Department of Atmospheric Sciences, College of the Environment, University of Washington, 408 Atmospheric Sciences-Geophysics (ATG) Building, Box 351640, Seattle, WA, 98195-1640, USA
| | - Shubhayu Saha
- Rollins School of Public Health, Emory University, Grace Crum Rollins Building, 1518 Clifton road, Atlanta, GA, 30322, USA
| | - Ambarish Vaidyanathan
- School of Environmental Health, Emory University, 1518 Clifton road, Atlanta, GA, 30322, USA.,School of Civil and Environmental Engineering, Georgia Institute of Technology, 790 Atlantic Drive, Atlanta, GA, 30332-0355, USA
| | - Jeremy Hess
- Department of Emergency Medicine, School of Medicine, University of Washington, 4730 university way NE, Suite 104, #2021, Seattle, WA, 98105, USA.,Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, 1959 NE pacific St, Seattle, WA, 98105, USA.,Department of Global Health, Schools of Medicine and Public Health, University of Washington, 4225 Roosevelt Way NE #100, Suite 2330, Box 354695, Seattle, WA, 98105, USA
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5
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Alvaro-Lozano M, Akdis CA, Akdis M, Alviani C, Angier E, Arasi S, Arzt-Gradwohl L, Barber D, Bazire R, Cavkaytar O, Comberiati P, Dramburg S, Durham SR, Eifan AO, Forchert L, Halken S, Kirtland M, Kucuksezer UC, Layhadi JA, Matricardi PM, Muraro A, Ozdemir C, Pajno GB, Pfaar O, Potapova E, Riggioni C, Roberts G, Rodríguez Del Río P, Shamji MH, Sturm GJ, Vazquez-Ortiz M. EAACI Allergen Immunotherapy User's Guide. Pediatr Allergy Immunol 2020; 31 Suppl 25:1-101. [PMID: 32436290 PMCID: PMC7317851 DOI: 10.1111/pai.13189] [Citation(s) in RCA: 137] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Allergen immunotherapy is a cornerstone in the treatment of allergic children. The clinical efficiency relies on a well-defined immunologic mechanism promoting regulatory T cells and downplaying the immune response induced by allergens. Clinical indications have been well documented for respiratory allergy in the presence of rhinitis and/or allergic asthma, to pollens and dust mites. Patients who have had an anaphylactic reaction to hymenoptera venom are also good candidates for allergen immunotherapy. Administration of allergen is currently mostly either by subcutaneous injections or by sublingual administration. Both methods have been extensively studied and have pros and cons. Specifically in children, the choice of the method of administration according to the patient's profile is important. Although allergen immunotherapy is widely used, there is a need for improvement. More particularly, biomarkers for prediction of the success of the treatments are needed. The strength and efficiency of the immune response may also be boosted by the use of better adjuvants. Finally, novel formulations might be more efficient and might improve the patient's adherence to the treatment. This user's guide reviews current knowledge and aims to provide clinical guidance to healthcare professionals taking care of children undergoing allergen immunotherapy.
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Affiliation(s)
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland.,Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland
| | - Mubeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Cherry Alviani
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK.,Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Elisabeth Angier
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Stefania Arasi
- Pediatric Allergology Unit, Department of Pediatric Medicine, Bambino Gesù Children's research Hospital (IRCCS), Rome, Italy
| | - Lisa Arzt-Gradwohl
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Domingo Barber
- School of Medicine, Institute for Applied Molecular Medicine (IMMA), Universidad CEU San Pablo, Madrid, Spain.,RETIC ARADYAL RD16/0006/0015, Instituto de Salud Carlos III, Madrid, Spain
| | - Raphaëlle Bazire
- Allergy Department, Hospital Infantil Niño Jesús, ARADyAL RD16/0006/0026, Madrid, Spain
| | - Ozlem Cavkaytar
- Department of Paediatric Allergy and Immunology, Faculty of Medicine, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Pasquale Comberiati
- Department of Clinical Immunology and Allergology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Clinical and Experimental Medicine, Section of Paediatrics, University of Pisa, Pisa, Italy
| | - Stephanie Dramburg
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Medical University, Berlin, Germany
| | - Stephen R Durham
- Immunomodulation and Tolerance Group; Allergy and Clinical Immunology, Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, UK.,the MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - Aarif O Eifan
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospitals NHS Foundation Trust, London, UK
| | - Leandra Forchert
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Medical University, Berlin, Germany
| | - Susanne Halken
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Max Kirtland
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Inflammation, Repair and Development, National Heart and Lung Institute, Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, UK
| | - Umut C Kucuksezer
- Aziz Sancar Institute of Experimental Medicine, Department of Immunology, Istanbul University, Istanbul, Turkey
| | - Janice A Layhadi
- Immunomodulation and Tolerance Group; Allergy and Clinical Immunology, Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, UK.,the MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK.,Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Inflammation, Repair and Development, National Heart and Lung Institute, Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, UK
| | - Paolo Maria Matricardi
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Medical University, Berlin, Germany
| | - Antonella Muraro
- The Referral Centre for Food Allergy Diagnosis and Treatment Veneto Region, Department of Women and Child Health, University of Padua, Padua, Italy
| | - Cevdet Ozdemir
- Institute of Child Health, Department of Pediatric Basic Sciences, Istanbul University, Istanbul, Turkey.,Faculty of Medicine, Department of Pediatrics, Division of Pediatric Allergy and Immunology, Istanbul University, Istanbul, Turkey
| | | | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Ekaterina Potapova
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Medical University, Berlin, Germany
| | - Carmen Riggioni
- Pediatric Allergy and Clinical Immunology Service, Institut de Reserca Sant Joan de Deú, Barcelona, Spain
| | - Graham Roberts
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK.,NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Paediatric Allergy and Respiratory Medicine (MP803), Clinical & Experimental Sciences & Human Development in Health Academic Units University of Southampton Faculty of Medicine & University Hospital Southampton, Southampton, UK
| | | | - Mohamed H Shamji
- Immunomodulation and Tolerance Group; Allergy and Clinical Immunology, Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, UK.,the MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - Gunter J Sturm
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
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6
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Pfaar O, Agache I, Blay F, Bonini S, Chaker AM, Durham SR, Gawlik R, Hellings PW, Jutel M, Kleine‐Tebbe J, Klimek L, Kopp MV, Nandy A, Rabin RL, Ree R, Renz H, Roberts G, Salapatek A, Schmidt‐Weber CB, Shamji MH, Sturm GJ, Virchow JC, Wahn U, Willers C, Zieglmayer P, Akdis CA. Perspectives in allergen immunotherapy: 2019 and beyond. Allergy 2019; 74 Suppl 108:3-25. [PMID: 31872476 DOI: 10.1111/all.14077] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/23/2019] [Indexed: 12/28/2022]
Abstract
The seventh "Future of the Allergists and Specific Immunotherapy (FASIT)" workshop held in 2019 provided a platform for global experts from academia, allergy clinics, regulatory authorities and industry to review current developments in the field of allergen immunotherapy (AIT). Key domains of the meeting included the following: (a) Biomarkers for AIT and allergic asthma; (b) visions for the future of AIT; (c) progress and data for AIT in asthma and the updates of GINA and EAACI Asthma Guidelines (separated for house dust mite SCIT, SLIT tablets and SLIT drops; patient populations) including a review of clinically relevant endpoints in AIT studies in asthma; (d) regulatory prerequisites such as the "Therapy Allergen Ordinance" in Germany; (e) optimization of trial design in AIT clinical research; (f) challenges planning and conducting phase III (field) studies and the future role of Allergen Exposure Chambers (AEC) in AIT product development from the regulatory point of view. We report a summary of panel discussions of all six domains and highlight unmet needs and possible solutions for the future.
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Affiliation(s)
- Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital Marburg Philipps‐Universität Marburg Marburg Germany
| | - Ioana Agache
- Faculty of Medicine Transylvania University Brasov Romania
| | - Frédéric Blay
- Pneumology Department New Civil Hospital Strasbourg‐Cedex France
| | - Sergio Bonini
- Institute of Translational Medicine Italian National Research Council Rome Italy
| | - Adam M. Chaker
- Department of Otolaryngology and Center of Allergy and Environment TUM School of Medicine Technical University of Munich Munich Germany
| | - Stephen R. Durham
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma London UK
| | - Radoslaw Gawlik
- Department of Internal Medicine, Allergology and Clinical Immunology Silesian University of Medicine Katowice Poland
| | - Peter W. Hellings
- Department of Otorhinolaryngology University Hospitals of Leuven Leuven Belgium
- Department of Otorhinolaryngology Academic Medical Center University of Amsterdam Amsterdam The Netherlands
- Department of Neuroscience University of Ghent Ghent Belgium
| | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- All‐Med Medical Research Institute Wroclaw Poland
| | - Jörg Kleine‐Tebbe
- Allergy & Asthma Center Westend Outpatient Clinic and Clinical Research Center Berlin Germany
| | - Ludger Klimek
- Center for Rhinology and Allergology Wiesbaden Germany
| | - Matthias V. Kopp
- Department of Pediatric Allergy and Pulmonology University of Luebeck Luebeck Germany
- Member of the Deutsches Zentrum für Lungenforschung (DZL) Airway Research Center North (ARCN) Luebeck Germany
| | - Andreas Nandy
- Research & Development Allergopharma GmbH & Co. KG Reinbek Germany
| | - Ronald L. Rabin
- Center for Biologics Evaluation and Research US Food and Drug Administration Silver Spring MD USA
| | - Ronald Ree
- Departments of Experimental Immunology and of Otorhinolaryngology Amsterdam University Medical Centers Amsterdam The Netherlands
| | - Harald Renz
- Department Laboratory Medicine and Pathobiochemistry Molecular Diagnostics University Giessen and Philipps‐Universität Marburg Marburg Germany
| | - Graham Roberts
- Paediatric Allergy and Respiratory Medicine University of Southampton Southampton UK
- David Hide Asthma and Allergy Centre St Mary’s Hospital Isle of Wight UK
| | | | - Carsten B. Schmidt‐Weber
- Center of Allergy and Environment (ZAUM) Technical University of Munich and Helmholtz Center Munich Munich Germany
- Member of the German Center for Lung Research (DZL) Lübeck Germany
| | - Mohamed H. Shamji
- Allergy and Clinical Immunology National Heart and Lung Institute Imperial College London London UK
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma London UK
| | - Gunter J. Sturm
- Department of Dermatology and Venereology Medical University of Graz Graz Austria
- Allergy Outpatient Clinic Reumannplatz Vienna Austria
| | - J. Christian Virchow
- Department Pulmonology & Interdisciplinary Intensive Care Medicine Rostock University Medical Center Rostock Germany
| | - Ulrich Wahn
- Department for Pediatric Pneumology and Immunology Charité Medical University Berlin Germany
| | | | | | - Cezmi A. Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Zurich Switzerland
- Christine‐Kühne‐Center for Allergy Research and Education (CK‐CARE) Davos Switzerland
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7
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Pfaar O, Bachert C, Kuna P, Panzner P, Džupinová M, Klimek L, van Nimwegen MJ, Boot JD, Yu D, Opstelten DJE, de Kam PJ. Sublingual allergen immunotherapy with a liquid birch pollen product in patients with seasonal allergic rhinoconjunctivitis with or without asthma. J Allergy Clin Immunol 2018; 143:970-977. [PMID: 30508538 DOI: 10.1016/j.jaci.2018.11.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 10/16/2018] [Accepted: 11/09/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sublingual allergen immunotherapy (SLIT) has been demonstrated to be both clinically efficacious and safe. However, in line with the current regulatory guidance from the European Medicines Agency, allergen immunotherapy (AIT) products must demonstrate their efficacy and safety in pivotal phase III trials for registration. OBJECTIVE We sought to investigate the efficacy and safety of sublingual high-dose liquid birch pollen extract (40,000 allergy units native [AUN]/mL) in adults with birch pollen allergy. METHODS A randomized, double-blind, placebo-controlled, parallel-group multicenter trial was conducted in 406 adult patients with moderate-to-severe birch pollen-induced allergic rhinoconjunctivitis with or without mild-to-moderate controlled asthma. Treatment was started 3 to 6 months before the birch pollen season and continued during the season in 40 clinical study centers in 5 European countries. For primary end point assessment, the recommended combined symptom and medication score of the European Academy of Allergy and Clinical Immunology was used. Secondary end points included quality-of-life assessments, immunologic parameters, and safety. RESULTS Primary efficacy results demonstrated a significant (P < .0001) and clinically relevant (32%) reduction in the combined symptom and medication score compared with placebo after 3 to 6 months of SLIT. Significantly better rhinoconjunctivitis quality-of-life scores (P < .0001) and the patient's own overall assessment of his or her health status, including the visual analog scale score (Euro Quality of Life Visual Analogue Scale; P = .0025), were also demonstrated. In total, a good safety profile of SLIT was observed. CONCLUSION This study confirmed both the clinical efficacy and safety of a sublingual liquid birch pollen extract in adults with birch pollen allergy in a pivotal phase III trial (EudraCT: 2013-005550-30; ClinicalTrials.gov: NCT02231307).
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Affiliation(s)
- Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Germany; Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Center for Rhinology and Allergology, Wiesbaden, Germany.
| | - Claus Bachert
- Upper Airways Research Laboratory, University of Ghent, Ghent, Belgium
| | - Piotr Kuna
- Division of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Petr Panzner
- Department of Immunology and Allergology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Mária Džupinová
- ALIAN s.r.o. Ambulancia alergológie a klinickej imunológie, Bardejov, Slovakia
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
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8
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Pfaar O, Alvaro M, Cardona V, Hamelmann E, Mösges R, Kleine-Tebbe J. Clinical trials in allergen immunotherapy: current concepts and future needs. Allergy 2018; 73:1775-1783. [PMID: 29446469 PMCID: PMC6175179 DOI: 10.1111/all.13429] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2018] [Indexed: 02/07/2023]
Abstract
Allergen immunotherapy (AIT) is a safe, effective treatment for allergic rhinoconjunctivitis and allergic asthma. However, AIT's clinical effect is still contested—primarily due to heterogeneity in clinical trial designs, study populations, therapeutic formulations, and efficacy criteria. After discussing current concepts and unmet needs, an international panel of experts made several recommendations: (i) explore and validate definitions for (clinical) responders in AIT trials; (ii) use of well‐documented, standardized provocation tests prior to inclusion of subjects with relevant diseases in AIT trials; (iii) monitoring neo‐sensitizations and occurrence of new allergy in extended AIT trials, and exclusion of polyallergic participants; (iv) validation of allergen exposure chambers with regard to natural exposure; (v) in studies of seasonal allergies, focus on peak exposure but also consider organizing two parallel, geographically distinct but otherwise identical trials; (vi) discuss adaptive trial designs with the regulatory authorities; (vii) use e‐health and m‐health technologies to capture more information on individual exposure to allergens; (viii) initiate research on potential psychological, biochemical, immune, neural, and even genomic markers of the placebo response; (ix) identify trial designs and primary endpoints that will give children with allergies easier, faster access to AIT formulations; and (x) promote and apply standardized methods for reporting systemic and local adverse events. The latest technologies and trial designs may provide novel, ethical ways of reducing bias and heterogeneity in AIT clinical trials. There is scope for physicians, patient organizations, companies, and regulators to improve clinical trials in AIT and, ultimately, to provide patients with better treatments.
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Affiliation(s)
- O. Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery; Universitätsmedizin Mannheim; Medical Faculty Mannheim; Heidelberg University; Mannheim Germany
- Center for Rhinology and Allergology Wiesbaden; Wiesbaden Germany
| | - M. Alvaro
- Allergy and Clinical Immunology Section; Hospital Sant Joan de Déu; Universitat de Barcelona; Barcelona Spain
| | - V. Cardona
- Allergy Section; Department of Internal Medicine; Hospital Universitari Vall d'Hebron; Barcelona Spain
| | - E. Hamelmann
- Children's Center Bethel, Protestant Hospital Bielefeld and Allergy Center; Ruhr-University; Bochum Germany
| | - R. Mösges
- Medical Faculty; Institute of Medical Statistics, Informatics, and Epidemiology; University of Köln; Köln Germany
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9
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Köther J, Mandl A, Allekotte S, Astvatsatourov A, Chwieralski J, Liedtke JP, Pieper-Fürst U, Raskopf E, Shah-Hosseini K, Mösges R. Early nonreactivity in the conjunctival provocation test predicts beneficial outcome of sublingual immunotherapy. Clin Transl Allergy 2018; 8:28. [PMID: 29997888 PMCID: PMC6031191 DOI: 10.1186/s13601-018-0214-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/04/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Clinical practice needs a common parameter that can provide an early, reliable estimation of the outcome of sublingual immunotherapy (SLIT) in an upcoming pollen season. We investigated whether the conjunctival provocation test (CPT) can predict the beneficial outcome of SLIT in patients with allergic rhinoconjunctivitis after 4 weeks of treatment. METHODS We conducted two separate prospective, randomized, double-blind, placebo-controlled, multicenter trials. Adults 18-75 years of age received placebo or SLIT tablets containing tree or grass pollen allergoids and underwent CPTs. Participants receiving SLIT were divided into two groups (reactive, nonreactive) according to their CPT reactions after 4 weeks of treatment. These two groups were compared with regard to clinical outcome parameters (total combined score, rhinoconjunctivitis total symptom score, total rescue medication score, well days) assessed during the pollen season for the 14-day (tree) or 30-day (tree/grass) peaks and for the entire 60-day seasons. Participants' global evaluations of therapy after completing treatment were also compared. RESULTS The tree pollen trial randomized 188 participants; 182 participants were evaluable, 76 of whom received SLIT and were suitable for this post hoc analysis. The grass pollen trial included 90 participants; 82 participants were evaluable, 44 of whom underwent SLIT. Comparing SLIT participants who reacted to the CPT after 4 weeks (tree: 77.6%; grass: 79.5%) with those who ceased to show a reaction (tree: 22.4%; grass: 20.5%) (tree: P = 0.0001; grass: P = 0.003), the total combined score for the 14-day (P = 0.017) and 30-day peaks (P = 0.042) as well as the rhinoconjunctivitis total symptom score assessed for the 14-day peak (P = 0.024) were significantly lower in the nonreactive group of the tree pollen trial. In the grass pollen trial, the nonreactive group rated their SLIT treatment significantly better (P = 0.019). CONCLUSIONS Using clinically meaningful outcome parameters during the pollen season, both trials independently led to similar results when comparing participants' reactions to the CPT 4 weeks after beginning SLIT. These results suggest that CPT allows an early estimation of allergic rhinoconjunctivitis symptoms before an upcoming season. Thus, the CPT can be used as a valuable parameter to predict the beneficial outcome of ongoing SLIT. TRIAL REGISTRATION Both trials registered with the Medical Ethics Committee of the North Rhine Medical Council (EudraCT numbers 2012-004916-79 (grass pollen trial) and 2013-002129-43 (tree pollen trial)) and the German Federal Ministry of Health (Paul-Ehrlich-Institut).
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Affiliation(s)
- Janina Köther
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Alicia Mandl
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Silke Allekotte
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
- CRI – Clinical Research International Ltd., Genter Str. 7, 50672 Cologne, Germany
| | - Anatoli Astvatsatourov
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
- Clinical Trials Centre Cologne, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Janin Chwieralski
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Jan-Patrick Liedtke
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Ursula Pieper-Fürst
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
- CRI – Clinical Research International Ltd., Genter Str. 7, 50672 Cologne, Germany
| | - Esther Raskopf
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
- CRI – Clinical Research International Ltd., Genter Str. 7, 50672 Cologne, Germany
| | - Kija Shah-Hosseini
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Ralph Mösges
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
- CRI – Clinical Research International Ltd., Genter Str. 7, 50672 Cologne, Germany
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10
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Liedtke JP, Mandl A, Köther J, Chwieralski J, Shah-Hosseini K, Raskopf E, Pieper-Fürst U, Allekotte S, Mösges R. RCAT reflects symptom control and quality of life in allergic rhinoconjunctivitis patients. Allergy 2018; 73:1101-1109. [PMID: 29159975 DOI: 10.1111/all.13362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Global Allergy and Asthma European Network (GA2 LEN) Taskforce has requested more data on correlations between various patient-reported outcomes (PROs) in clinical trials on allergy. We compared three tools-the Rhinitis Control Assessment Test (RCAT), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and Rhinitis Total Symptom Score (RTSS)-to determine whether the RCAT alone is a sufficient primary outcome parameter in clinical trials on allergic rhinoconjunctivitis. METHODS In two double-blind, placebo-controlled immunotherapy studies, 33 patients allergic to grass pollen and 94 to birch pollen completed two questionnaires (RCAT and RQLQ) and kept their own symptom diary from which the RTSS was calculated. RESULTS Upon comparing RCAT and RQLQ results, we found strong correlations of r = -0.871 for grass pollen-allergic patients and r = -0.795 for birch pollen-allergic patients. The comparison between RCAT and RTSS results showed a strong correlation of r = -0.811 (grass pollen-allergic patients) and a moderate correlation of r = -0.539 (birch pollen-allergic patients). In the RCAT, 69.7% of grass pollen-allergic patients and 45.7% of birch pollen-allergic patients receiving guideline-concordant therapy were regarded as having insufficiently controlled symptoms. CONCLUSION The strong correlations suggest that the RCAT alone is equivalent to the RQLQ with respect to patients' symptom control and quality of life. Patients with uncontrolled symptoms can be identified using the RCAT. Hence, the physician can decide whether symptomatic therapy can be intensified or allergy immunotherapy should be administered.
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Affiliation(s)
- J.-P. Liedtke
- Institute of Medical Statistics, Informatics and Epidemiology; Faculty of Medicine; University of Cologne; Cologne Germany
| | - A. Mandl
- Institute of Medical Statistics, Informatics and Epidemiology; Faculty of Medicine; University of Cologne; Cologne Germany
| | - J. Köther
- Institute of Medical Statistics, Informatics and Epidemiology; Faculty of Medicine; University of Cologne; Cologne Germany
| | - J. Chwieralski
- Institute of Medical Statistics, Informatics and Epidemiology; Faculty of Medicine; University of Cologne; Cologne Germany
| | - K. Shah-Hosseini
- Institute of Medical Statistics, Informatics and Epidemiology; Faculty of Medicine; University of Cologne; Cologne Germany
| | - E. Raskopf
- Institute of Medical Statistics, Informatics and Epidemiology; Faculty of Medicine; University of Cologne; Cologne Germany
| | - U. Pieper-Fürst
- Institute of Medical Statistics, Informatics and Epidemiology; Faculty of Medicine; University of Cologne; Cologne Germany
| | - S. Allekotte
- Institute of Medical Statistics, Informatics and Epidemiology; Faculty of Medicine; University of Cologne; Cologne Germany
| | - R. Mösges
- Institute of Medical Statistics, Informatics and Epidemiology; Faculty of Medicine; University of Cologne; Cologne Germany
- CRI - Clinical Research International Limited; Hamburg Germany
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11
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Allergen Immunotherapy Clinical Trial Outcomes and Design: Working Toward Harmonization of Methods and Principles. Curr Allergy Asthma Rep 2017; 17:18. [PMID: 28293909 DOI: 10.1007/s11882-017-0687-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Progress has been made in the harmonization of efficacy and safety outcome measures for allergen immunotherapy (AIT) trials, but unresolved issues still remain. Furthermore, there are discrepancies in recommendations from professional medical societies and regulatory agencies regarding requirements for AIT trials. In this article, we reviewed published recommendations and current data from recent clinical trials, as well as the criteria applied by regulatory authorities for approval of AIT products, to provide updated considerations for conducting phase 3 AIT trials. Topics discussed include analysis of outcomes and trial designs for pediatric and asthma indications, as well as trial designs for perennial allergic rhinoconjunctivitis. In addition, the need for harmonization of safety reporting is emphasized. Considerations presented in this article may further effort to find common ground among professional medical societies and government agencies in developing future recommendations for AIT trial design.
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12
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Hoffmann HJ, Valovirta E, Pfaar O, Moingeon P, Schmid JM, Skaarup SH, Cardell LO, Simonsen K, Larché M, Durham SR, Sørensen P. Novel approaches and perspectives in allergen immunotherapy. Allergy 2017; 72:1022-1034. [PMID: 28122129 DOI: 10.1111/all.13135] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2017] [Indexed: 01/01/2023]
Abstract
In this review, we report on relevant current topics in allergen immunotherapy (AIT) which were broadly discussed during the first Aarhus Immunotherapy Symposium (Aarhus, Denmark) in December 2015 by leading clinicians, scientists and industry representatives in the field. The aim of this symposium was to highlight AIT-related aspects of public health, clinical efficacy evaluation, mechanisms, development of new biomarkers and an overview of novel therapeutic approaches. Allergy is a public health issue of high socioeconomic relevance, and development of evidence-based action plans to address allergy as a public health issue ought to be on national and regional agendas. The underlying mechanisms are in the focus of current research that lays the ground for innovative therapies. Standardization and harmonization of clinical endpoints in AIT trials as well as current knowledge about potential biomarkers have substantiated proof of effectiveness of this disease-modifying therapeutic option. Novel treatments such as peptide immunotherapy, intralymphatic immunotherapy and use of recombinant allergens herald a new age in which AIT may address treatment of allergy as a public health issue by reaching a large fraction of patients.
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Affiliation(s)
- H. J. Hoffmann
- Department of Clinical Medicine; HEALTH; Aarhus University; Aarhus Denmark
- Department of Respiratory Diseases and Allergy; Aarhus University Hospital; Aarhus Denmark
| | - E. Valovirta
- Department of Lung Diseases and Clinical Immunology; University of Turku; Turku Finland
- Filha; Finnish Lung Health Association; Helsinki Finland
- Terveystalo Allergy Clinic Turku; Finland
| | - O. Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery; Medical Faculty Mannheim; Universitätsmedizin Mannheim; Heidelberg University; Mannheim Germany
- Center for Rhinology and Allergology; Wiesbaden Germany
| | - P. Moingeon
- Research and Development; StallergenesGreer; Antony Cedex France
| | - J. M. Schmid
- Department of Clinical Medicine; HEALTH; Aarhus University; Aarhus Denmark
- Department of Respiratory Diseases and Allergy; Aarhus University Hospital; Aarhus Denmark
| | - S. H. Skaarup
- Department of Clinical Medicine; HEALTH; Aarhus University; Aarhus Denmark
- Department of Respiratory Diseases and Allergy; Aarhus University Hospital; Aarhus Denmark
| | - L.-O. Cardell
- Division of ENT Diseases; Department of Clinical Sciences, Intervention and Technology; Karolinska Institutet; Stockholm Sweden
- Department of ENT Diseases; Karolinska University Hospital; Stockholm Sweden
| | - K. Simonsen
- Anergis SA; BioPole III; Epalinges Switzerland
| | - M. Larché
- Clinical Immunology & Allergy and Respirology Divisions; Department of Medicine; McMaster University; Hamilton ON Canada
- Firestone Institute for Respiratory Health; McMaster University; Hamilton ON Canada
| | - S. R. Durham
- Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College London; London UK
| | - P. Sørensen
- Research and Development; StallergenesGreer; Antony Cedex France
- Department of Biomedicine; HEALTH; Aarhus University & Research; Aarhus Denmark
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13
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Pfaar O, Bastl K, Berger U, Buters J, Calderon MA, Clot B, Darsow U, Demoly P, Durham SR, Galán C, Gehrig R, Gerth van Wijk R, Jacobsen L, Klimek L, Sofiev M, Thibaudon M, Bergmann KC. Defining pollen exposure times for clinical trials of allergen immunotherapy for pollen-induced rhinoconjunctivitis - an EAACI position paper. Allergy 2017; 72:713-722. [PMID: 27874202 DOI: 10.1111/all.13092] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Clinical efficacy of pollen allergen immunotherapy (AIT) has been broadly documented in randomized controlled trials. The underlying clinical endpoints are analysed in seasonal time periods predefined based on the background pollen concentration. However, any validated or generally accepted definition from academia or regulatory authorities for this relevant pollen exposure intensity or period of time (season) is currently not available. Therefore, this Task Force initiative of the European Academy of Allergy and Clinical Immunology (EAACI) aimed to propose definitions based on expert consensus. METHODS A Task Force of the Immunotherapy and Aerobiology and Pollution Interest Groups of the EAACI reviewed the literature on pollen exposure in the context of defining relevant time intervals for evaluation of efficacy in AIT trials. Underlying principles in measuring pollen exposure and associated methodological problems and limitations were considered to achieve a consensus. RESULTS The Task Force achieved a comprehensive position in defining pollen exposure times for different pollen types. Definitions are presented for 'pollen season', 'high pollen season' (or 'peak pollen period') and 'high pollen days'. CONCLUSION This EAACI position paper provides definitions of pollen exposures for different pollen types for use in AIT trials. Their validity as standards remains to be tested in future studies.
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Affiliation(s)
- O. Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery; Medical Faculty Mannheim; Universitätsmedizin Mannheim; Heidelberg University; Mannheim Germany
- Center for Rhinology and Allergology; Wiesbaden Germany
| | - K. Bastl
- Aerobiology and Pollen Information Research Unit; Department of Oto-Rhino-Laryngology; Medical University of Vienna; Vienna Austria
| | - U. Berger
- Aerobiology and Pollen Information Research Unit; Department of Oto-Rhino-Laryngology; Medical University of Vienna; Vienna Austria
| | - J. Buters
- ZAUM; Center of Allergy & Environment; Helmholtz Center Munich/Technische Universität München; Member of the German Center for Lung Research (DZL); Munich Germany
- Kühne Foundation; Christine Kühne-Center for Allergy Research and Education (CK-CARE); Munich Germany
| | - M. A. Calderon
- Section of Allergy and Clinical Immunology; Imperial College London; London UK
- National Heart & Lung Institute; Royal Brompton Hospital; London UK
| | - B. Clot
- Federal Office of Meteorology and Climatology MeteoSwiss; Payerne Switzerland
| | - U. Darsow
- ZAUM; Center of Allergy & Environment; Helmholtz Center Munich/Technische Universität München; Member of the German Center for Lung Research (DZL); Munich Germany
- Department of Dermatology and Allergy Biederstein; Technical University of Munich (TUM); Munich Germany
| | - P. Demoly
- Département de Pneumologie et Addictologie; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- UPMC Paris 06; UMR-S 1136; IPLESP; Equipe EPAR; Sorbonne Universités; Paris France
| | - S. R. Durham
- Section of Allergy and Clinical Immunology; Imperial College London; London UK
| | - C. Galán
- Department of Botany; Ecology and Plant Physiology; University of Córdoba; Córdoba Spain
| | - R. Gehrig
- Federal Office of Meteorology and Climatology MeteoSwiss; Zurich Switzerland
| | - R. Gerth van Wijk
- Section of Allergology; Department of Internal Medicine; Erasmus MC; Rotterdam The Netherlands
| | - L. Jacobsen
- ALC; Allergy Learning and Consulting; Copenhagen Denmark
| | - L. Klimek
- Center for Rhinology and Allergology; Wiesbaden Germany
| | - M. Sofiev
- Finnish Meteorological Institute; Helsinki Finland
| | - M. Thibaudon
- RNSA (Réseau National de Surveillance Aérobiologique); Brussieu France
| | - K. C. Bergmann
- Foundation German Pollen Information Service; Berlin Germany
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14
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Sridharan K, Sivaramakrishnan G. Sublingual immunotherapy in patients with latex allergy: systematic review and meta-analysis of randomized controlled trials. J DERMATOL TREAT 2017; 28:600-605. [PMID: 28320227 DOI: 10.1080/09546634.2017.1303567] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Latex allergy (LA) is a commonly observed entity for which sublingual immunotherapy (SLIT) has been shown to be effective in many small randomized clinical trials. The present study was conducted with an aim of systematically reviewing the existing literature on the efficacy and safety of SLIT in patients with LA and to apply the principles of meta-analysis. A search for randomized controlled trials with appropriate search strategy in PubMed and CENTRAL was conducted. Studies with documented clinical history of LA and SLIT administered in any dose, duration and regimen compared with placebo were included. Outcome measures were symptom scores, glove provocation test score, serum IgE levels, induration following latex skin prick test, medication scores and adverse effects. Random effects model was used when moderate to severe heterogeneity was observed and fixed effects model when there was mild heterogeneity. Forest plots for standardized mean difference (95% confidence interval) for all the continuous outcome measures were created. A total of 152 records were identified from the electronic databases and four studies were finally included in the meta-analysis. A statistically significant reduction for induration following glove provocation test (pooled results from two studies) was observed in the SLIT group with SMD of -0.9 [-1.71, -0.08]. No significant differences were observed in any other outcome measures between the interventions. We did not identify significant reduction in most of the outcome measures with SLIT in patients with LA except for glove provocation test score wherein only two studies were included. Large and more randomized controlled trials are required to ascertain and confirm the utility of SLIT in such patients.
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Affiliation(s)
- Kannan Sridharan
- a Pharmacology, Department of Health Sciences , Fiji National University , Suva , Fiji
| | - Gowri Sivaramakrishnan
- b Prosthodontics, Department of Oral Health, College of Medicine, Nursing and Health Sciences , Fiji National University , Suva , Fiji
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15
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Turkalj M, Banic I, Anzic SA. A review of clinical efficacy, safety, new developments and adherence to allergen-specific immunotherapy in patients with allergic rhinitis caused by allergy to ragweed pollen ( Ambrosia artemisiifolia). Patient Prefer Adherence 2017; 11:247-257. [PMID: 28243068 PMCID: PMC5317300 DOI: 10.2147/ppa.s70411] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Allergic rhinitis is a common health problem in both children and adults. The number of patients allergic to ragweed (Ambrosia artemisiifolia) is on the rise throughout Europe, having a significant negative impact on the patients' and their family's quality of life. Allergen-specific immunotherapy (AIT) has disease-modifying effects and can induce immune tolerance to allergens. Both subcutaneous immunotherapy and sublingual immunotherapy with ragweed extracts/preparations have clear positive clinical efficacy, especially over pharmacological treatment, even years after the treatment has ended. AIT also has very good safety profiles with extremely rare side effects, and the extracts/preparations used in AIT are commonly well tolerated by patients. However, patient adherence to treatment with AIT seems to be quite low, mostly due to the fact that treatment with AIT is relatively time-demanding and, moreover, due to patients not receiving adequate information and education about the treatment before it starts. AIT is undergoing innovations and improvements in clinical efficacy, safety and patient adherence, especially with new approaches using new adjuvants, recombinant or modified allergens, synthetic peptides, novel routes of administration (epidermal or intralymphatic), and new protocols, which might make AIT more acceptable for a wider range of patients and novel indications. Patient education and support (eg, recall systems) is one of the most important goals for AIT in the future, to further enhance treatment success.
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Affiliation(s)
- Mirjana Turkalj
- Children’s Hospital Srebrnjak, Zagreb
- Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
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16
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Grouin JM, Vicaut E, Devillier P. Comparison of scores associating symptoms and rescue medication use for evaluating the efficacy of allergy immunotherapy in seasonal allergic rhinoconjunctivitis: results from five trials. Clin Exp Allergy 2016; 47:254-263. [PMID: 27790763 DOI: 10.1111/cea.12845] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 09/22/2016] [Accepted: 10/02/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Over the past decade, regulatory bodies and scientific societies recommended, as primary efficacy outcome, a score that reflects both symptom severity and use of rescue medication for clinical trials in allergy immunotherapy (AIT). OBJECTIVE We sought to compare the results obtained with two subject-specific scores, the Combined Score (CS) and the Adjusted Symptom Score (AdSS), for assessment of AIT in seasonal allergic rhinoconjunctivitis due to birch and grass pollen allergens. METHODS CS and AdSS were evaluated in subjects receiving a 300IR dose of allergen extract daily, by sublingual route, in four clinical trials with the 5-grass pollen tablet (NCT00367640, NCT00409409, NCT00955825 and NCT00418379) and one with the birch pollen solution (NCT01731249). The CS is derived from the Rhinoconjunctivitis Total Symptom Score (RTSS) and the Rescue Medication Score (RMS) giving equal weight to symptoms and medication use. The AdSS is a symptom score adjusting for rescue medication use. Efficacy end-points were analysed using an analysis of covariance linear model. RESULTS In all trials, despite the different constructs of the two scores, Combined Score or Adjusted Symptom Score were similarly reduced in the 300IR group compared to the placebo group. Treatment effect was consistently demonstrated with both scores, CS and AdSS, used as either daily scores or average of the daily scores over the pollen season. Minor differences with the same statistical conclusions were observed between the results, leading to the same interpretation. CONCLUSIONS AND CLINICAL RELEVANCE The two scores, combined and adjusted scores, for evaluation of clinical efficacy of AIT have led to similar results, with similar statistical conclusions and similar interpretation.
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Affiliation(s)
- J-M Grouin
- INSERM 1219, University of Rouen, Rouen, France
| | - E Vicaut
- Clinical Research Unit Saint-Louis Lariboisière Fernand-Widal, University of Paris-Diderot, Paris, France
| | - P Devillier
- UPRES EA 220, Clinical Research Unit, Airway Diseases Department, Foch Hospital, University of Versailles Saint-Quentin, University Paris Saclay, Suresnes, France
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17
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Zimmer J, Vieths S, Kaul S. Standardization and Regulation of Allergen Products in the European Union. Curr Allergy Asthma Rep 2016; 16:21. [PMID: 26874849 DOI: 10.1007/s11882-016-0599-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Product-specific standardization is of prime importance to ensure persistent quality, safety, and efficacy of allergen products. The regulatory framework in the EU has induced great advancements in the field in the last years although national implementation still remains heterogeneous. Scores of methods for quantification of individual allergen molecules are developed each year and also the challenging characterization of chemically modified allergen products is progressing. However, despite the unquestionable increase in knowledge and the subsequent improvements in control of quality parameters of allergen products, an important aim has not been reached yet, namely cross-product comparability. Still, comparison of allergen product potency, either based on total allergenic activity or individual allergen molecule content, is not possible due to a lack of standard reference preparations in conjunction with validated standard methods. This review aims at presenting the most recent developments in product-specific standardization as well as activities to facilitate cross-product comparability in the EU.
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Affiliation(s)
- Julia Zimmer
- Division of Allergology, Paul-Ehrlich-Institut, Paul-Ehrlich-Str. 51-59, 63225, Langen, Germany.
| | - Stefan Vieths
- Division of Allergology, Paul-Ehrlich-Institut, Paul-Ehrlich-Str. 51-59, 63225, Langen, Germany.
| | - Susanne Kaul
- Division of Allergology, Paul-Ehrlich-Institut, Paul-Ehrlich-Str. 51-59, 63225, Langen, Germany.
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18
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Bozek A, Kolodziejczyk K, Krajewska-Wojtys A, Jarzab J. Pre-seasonal, subcutaneous immunotherapy: a double-blinded, placebo-controlled study in elderly patients with an allergy to grass. Ann Allergy Asthma Immunol 2016; 116:156-61. [PMID: 26815709 DOI: 10.1016/j.anai.2015.12.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/09/2015] [Accepted: 12/14/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is limited evidence indicating that specific immunotherapy in elderly patients is safe and effective. OBJECTIVE To evaluate the safety and efficacy of pre-seasonal specific subcutaneous immunotherapy (SCIT) against grass pollen allergens in patients older than 65 years with seasonal allergic rhinitis and to measure the prime outcome of area under the curve for the combined symptoms and medication score during grass pollen season after 3 years of SCIT in a double-blinded, placebo-controlled trial. METHODS This study included 60 65- to 75-year-old patients with seasonal allergic rhinitis and grass pollen allergy. Patients were individually randomized to the active or placebo group. Thirty-three subjects in the SCIT group and 27 subjects in the placebo group were monitored for 3 years. Patients were required to record each use of anti-allergy medication. RESULTS Thirty-one patients completed 3 years of pre-seasonal SCIT and 24 subjects finished placebo treatment. The median area under the curve for the combined symptoms and medication score after the third grass pollen season after SCIT was significantly decreased from 7.85 (range 3.67-8.98) to 4.63 (range 3.56-7.80) in the active group and did not significantly change in the placebo group. In the active group, the combined symptoms and medication score was decreased by 41%, the symptoms score was decreased by 55%, and the medication score was decreased by 64% after 3 years of immunotherapy. CONCLUSION Pre-seasonal SCIT in the elderly is safe and efficacious and elicits an immune response comparable to what is found in studies of younger patients.
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Affiliation(s)
- Andrzej Bozek
- Clinical Department of Internal Disease, Dermatology and Allergology, Zabrze, Medical University of Silesia, Katowice, Poland.
| | | | - Anna Krajewska-Wojtys
- Clinical Department of Internal Disease, Dermatology and Allergology, Zabrze, Medical University of Silesia, Katowice, Poland
| | - Jerzy Jarzab
- Clinical Department of Internal Disease, Dermatology and Allergology, Zabrze, Medical University of Silesia, Katowice, Poland
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Florack J, Brighetti MA, Perna S, Pizzulli A, Pizzulli A, Tripodi S, Costa C, Travaglini A, Pelosi S, Bianchi A, Tsilochristou O, Gabrielli F, Matricardi PM. Comparison of six disease severity scores for allergic rhinitis against pollen counts a prospective analysis at population and individual level. Pediatr Allergy Immunol 2016; 27:382-90. [PMID: 26992008 DOI: 10.1111/pai.12562] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Many different symptom (medication) scores are nowadays used as measures of allergic rhinoconjunctivitis severity in individual patients and in clinical trials. Their differences contribute to the heterogeneity of the primary end-point in meta-analyses, so that calls for symptom (medication) score harmonization have been launched. OBJECTIVE To prospectively compare six different severity scores for allergic rhinitis (AR) against pollen counts at both population and individual levels. METHODS Two groups of children with seasonal AR and grass pollen sensitization were recruited in Ascoli, Italy (n = 76) and Berlin, Germany (n = 29). Symptoms and drug intake were monitored daily for 40 and 30 days of the grass pollen season in 2011 (Ascoli) and 2013 (Berlin), respectively, through an Internet-based platform (AllergyMonitor(™) , TPS Production srl, Rome, Italy). From the gathered data, the informatics platform automatically generated one symptom score (RTSS) and five symptom-medication scores (RC-ACS(©) , ACS, RTSS[LOCF], RTSS[WC] and AdSS). Values were then statistically normalized for reciprocal comparison and matched against the daily variations of local grass pollen counts (Spearman's rank correlation). RESULTS The grass pollen counts were higher in Ascoli than in Berlin (peak values 194 vs. 59 grains/m(3) ). At population level, the trajectories of the normalized average values of the six scores differed only slightly in both studies and correlated well with the pollen counts (ranges r(2) : 0.38-0.50 in Ascoli, 0.41-0.56 in Berlin). By contrast, in individual patients, trajectories of different scores were often quite heterogeneous. The RTSS[WC] had a very low discriminatory power and generated in many patients long, flat horizontal segments. CONCLUSIONS Disease severity scores for seasonal AR, as evaluated via an Internet-based platform, tend to provide similar results at population level but can often produce heterogeneous slopes in individual patients. The choice of the disease severity score might have only a low impact on the outcome of a very large clinical trial, but it may be crucial in the management of individual patients.
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Affiliation(s)
- Jakob Florack
- Department of Paediatric Pneumology and Immunology, Charité Medical University, Berlin, Germany
| | | | - Serena Perna
- Department of Paediatric Pneumology and Immunology, Charité Medical University, Berlin, Germany.,Statistics Institute, University 'La Sapienza', Rome, Italy
| | - Antonio Pizzulli
- Department of Paediatric Pneumology and Immunology, Charité Medical University, Berlin, Germany.,Pediatric Allergy and Pulmonology HC Practice, Berlin, Germany
| | - Antje Pizzulli
- Pediatric Allergy and Pulmonology HC Practice, Berlin, Germany
| | - Salvatore Tripodi
- Pediatric Department and Pediatric Allergology Unit, Sandro Pertini Hospital, Rome, Italy.,TPS Production srl, Rome, Italy
| | - Corrado Costa
- Consiglio per la ricerca in agricoltura e l'analisi dell'economia agraria (CREA), Unità di ricerca per l'ingegneria agraria, Monterotondo, Italy
| | | | | | - Annamaria Bianchi
- Operative Complex Unit of Pediatrics, San Camillo-Forlanini Hospital, Rome, Italy
| | - Olympia Tsilochristou
- Department of Paediatric Pneumology and Immunology, Charité Medical University, Berlin, Germany
| | - Francesca Gabrielli
- ARPAM, Marche Aerobiological Monitoring Service, Castel di Lama, Ascoli Piceno, Italy
| | - Paolo Maria Matricardi
- Department of Paediatric Pneumology and Immunology, Charité Medical University, Berlin, Germany
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20
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Caimmi D, Calderon MA, Bousquet J, Demoly P. Allergen Immunotherapy Outcomes and Unmet Needs. Immunol Allergy Clin North Am 2016; 36:181-9. [DOI: 10.1016/j.iac.2015.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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21
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Lee S, Nolte H, Benninger MS. Clinical considerations in the use of sublingual immunotherapy for allergic rhinitis. Am J Rhinol Allergy 2016; 29:106-14. [PMID: 25785750 DOI: 10.2500/ajra.2015.29.4148] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Allergen immunotherapy (AIT) has been in practice for more than 100 years. However, research in novel routes and delivery methods of immunotherapy to treat allergic rhinitis (AR) and conjunctivitis has only recently occurred in the United States, where the predominant form of AIT provided is largely via a subcutaneous immunotherapy (SCIT) route. AIT may prevent new sensitizations, improve symptoms, decrease medication usage, and prevent allergic asthma. Although AIT is the only potentially curative treatment for AR, access and adherence continue to be problematic. Only a fraction of eligible patients actually undergo treatment, and attrition rates are high. An obvious limitation of SCIT includes the requirement of regular injections to be provided in the physician's office due to the potential for anaphylaxis. Sublingual immunotherapy (SLIT) for home administration has been investigated as a potential alternative to address this limitation of SCIT. METHODS A literature review was performed including the current findings from randomized clinical trials and meta-analyses with a discussion of the most recent evidence for the efficacy, safety, and dosing of allergen SLIT. RESULTS The current data suggest that SLIT is effective for treatment of seasonal allergies, can potentially prevent asthma, and has a favorable safety profile. Head-to-head studies, however, are few, and comparative effectiveness still remains to be answered. Optimal treatment algorithms for SLIT have not yet been established, with wide variation in dosage selection and schedules. Similarly to SCIT, only a few allergens such as ragweed and grass pollen have been found to be effective in large clinical trials. CONCLUSION Recent data indicate that SLIT is an effective treatment modality for seasonal AR, improve quality of life, and can potentially prevent asthma but head-to head studies comparing SLIT to SCIT are needed.
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Affiliation(s)
- Stella Lee
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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22
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Schaffer FM, Garner LM, Ebeling M, Adelglass JM, Hulsey TC, Naples AR. The efficacy assessment of a self-administered immunotherapy protocol. Int Forum Allergy Rhinol 2015; 6:148-55. [PMID: 26467843 PMCID: PMC4860610 DOI: 10.1002/alr.21653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 06/26/2015] [Accepted: 08/18/2015] [Indexed: 01/19/2023]
Abstract
Background We previously reported the safety of a self‐administered subcutaneous immunotherapy (SCIT) protocol. Here we report the results of the retrospective efficacy trial of the United Allergy Service (UAS) self‐administered SCIT protocol. We hypothesized that by utilizing a slow SCIT buildup phase, designed to attain recommended allergen concentrations on a cumulative basis, efficacious outcomes and clinical relevance would be achieved. Methods We enrolled 60 SCIT patients and 56 control patients. The study contrasted baseline and treatment period combined symptom plus medication scores (CSMS) as the primary outcome measure and rhinoconjunctivitis quality of life questionnaire (RQLQ) scores as the secondary study outcome measure. Changes in pollen counts were also examined with regard to effects on these efficacy parameters. Results The treatment group showed significantly improved CSMS (standardized mean difference [SMD]: −1.57; 95% confidence interval [CI], −1.97 to −1.18; p < 0.001) and RQLQ (SMD: −0.91; 95% CI, −1.23 to −0.59; p < 0.001). These treatment group outcome measures were respectively improved by 33% and 29% compared to baseline and greater than 40% in comparison to the control group (p < 0.0001). Significant results were also shown when examining these outcome measures with regards to either monotherapy or poly‐allergen SCIT. Furthermore, a comparison to recent meta‐analyses of SCIT studies showed equivalent efficacy and clinical relevance. Assessment of pollen counts during the baseline and treatment periods further corroborated the efficacy of the UAS SCIT protocol. Conclusion These efficacy results, and our previous safety results, show that a carefully designed and implemented self‐administered SCIT protocol is efficacious and safe.
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Affiliation(s)
- Frederick M Schaffer
- United Allergy Services (UAS), San Antonio, TX.,Division of Pediatric Pulmonary, Allergy and Immunology, Medical University of South Carolina, Charleston, SC
| | | | - Myla Ebeling
- Division of Pediatric Epidemiology, Medical University of South Carolina, Charleston, SC
| | | | - Thomas C Hulsey
- Division of Pediatric Epidemiology, Medical University of South Carolina, Charleston, SC
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23
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Demoly P, Emminger W, Rehm D, Backer V, Tommerup L, Kleine-Tebbe J. Effective treatment of house dust mite-induced allergic rhinitis with 2 doses of the SQ HDM SLIT-tablet: Results from a randomized, double-blind, placebo-controlled phase III trial. J Allergy Clin Immunol 2015; 137:444-451.e8. [PMID: 26292778 DOI: 10.1016/j.jaci.2015.06.036] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 06/16/2015] [Accepted: 06/17/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND The SQ HDM SLIT-tablet (ALK) has been developed for treatment of house dust mite (HDM)-induced respiratory allergic disease. OBJECTIVE This trial investigated the efficacy and safety of the SQ HDM SLIT-tablet in adults with moderate-to-severe HDM-induced allergic rhinitis (AR). METHODS The trial was a randomized, double-blind, placebo-controlled phase III trial conducted in 12 European countries including 992 adults with moderate-to-severe HDM-induced AR despite treatment with pharmacotherapy. Subjects were randomized 1:1:1 to 1 year of daily treatment with placebo, 6 SQ-HDM, or 12 SQ-HDM. The primary end point was the total combined rhinitis score (ie, the sum of rhinitis symptom and medication scores) during the efficacy assessment period (approximately the last 8 weeks of the treatment period). Key secondary end points were rhinitis symptoms, medication scores, quality of life, and the combined rhinoconjunctivitis score. RESULTS Analysis of the primary end point (observed data) demonstrated absolute reductions in total combined rhinitis score of 1.18 (P = .002) and 1.22 (P = .001) compared with placebo for 6 SQ-HDM and 12 SQ-HDM, respectively. The statistically significant treatment effect was evident from 14 weeks of treatment onward. For all key secondary end points, efficacy was confirmed for 12 SQ-HDM, with statistically significant reductions of rhinitis symptoms and medication scores, improved quality of life, and a reduced combined rhinoconjunctivitis score in the efficacy assessment period compared with placebo. The treatment was well tolerated. CONCLUSION The trial confirmed the efficacy and favorable safety profile of both 6 SQ-HDM and 12 SQ-HDM in adults with HDM-induced AR. The treatment effect was present from 14 weeks of treatment onward.
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Affiliation(s)
- Pascal Demoly
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Paris, France.
| | | | | | - Vibeke Backer
- Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | | | - Jörg Kleine-Tebbe
- Allergy & Asthma Center Westend, Outpatient Clinic & Research Center, Berlin, Germany
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24
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Bozek A, Kolodziejczyk K, Warkocka-Szoltysek B, Jarzab J. Grass pollen sublingual immunotherapy: a double-blind, placebo-controlled study in elderly patients with seasonal allergic rhinitis. Am J Rhinol Allergy 2015; 28:423-7. [PMID: 25198030 DOI: 10.2500/ajra.2014.28.4091] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND This study evaluates the safety and efficacy of specific sublingual immunotherapy (SLIT) against grass pollen allergens in patients >60 years of age with seasonal allergic rhinitis (SAR) and/or asthma. This study sought to assess nasal symptoms during the grass pollen season, reduce medication use, and monitor adverse reactions during immunotherapy. METHODS Seventy-eight 60- to 70-year-old patients with SAR and a confirmed grass pollen allergy according to skin-prick tests, nasal provocation, and measurement of serum IgE were included in the study. The patients were individually randomized to the active or placebo groups using a double-blind method. A total of 41 subjects in the SLIT group (5 grass pollen mixture) and 37 subjects in the placebo group were monitored for 3 years. The patients were required to record each use of an antiallergy medication on a diary card. RESULTS Thirty-eight patients completed 3 years (preseasonal) of SLIT, and 34 subjects finished the placebo treatment in the same time period. The total nasal symptom score decreased by 64% in the active group and 7% in the placebo group after SLIT. This difference was only significant in the active group (p < 0.05). At the end of therapy, the total medication score of the active group decreased significantly by a maximum of 51% (p < 0.05), whereas the total medication score of the placebo group had an insignificant decrease. None of the study participants had systemic adverse reactions during the study period. CONCLUSIONS SLIT in elderly patients with a grass pollen allergy generated a significant clinical improvement in the active group compared with the placebo group for grass pollen season. This therapy was well tolerated.
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Affiliation(s)
- Andrzej Bozek
- Clinical Department of Internal Disease, Dermatology, and Allergology, Medical University School of Silesia, Zabrze, Poland
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25
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Conjunctival provocation tests: a predictive factor for patients' seasonal allergic rhinoconjunctivitis symptoms. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:381-6. [PMID: 25609338 DOI: 10.1016/j.jaip.2014.10.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 10/15/2014] [Accepted: 10/29/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND No parameters currently exist that can reliably predict the impact of preseasonal immunotherapy on the symptoms occurring during the season. OBJECTIVE The purpose of our studies was to prove a correlation between preseasonal conjunctival allergen challenge and coseasonal primary clinical endpoints using the total combined score, ie, a combination of symptoms and medication score, as the primary outcome parameter. METHODS Twelve weeks before both the birch and the grass pollen seasons, 2 separate prospective, double-blind, randomized, controlled studies were conducted followed by posttrial observations for each study during the active season. In the studies, patients who reacted to conjunctival allergen challenge were treated with sublingual immunotherapy tablets that contain either birch and/or alder or grass pollen allergoids. RESULTS In all, 158 patients were included in the grass and 160 in the tree pollen study; of these, 100 and 109 patients, respectively, took part in the posttrial observations. When comparing patients with and without a positive reaction in the final conjunctival allergen challenge, the results revealed a significant difference in the total combined score (grass: P < .001; birch: P = .025). The same applied to the rescue medication score (P = .005; P = .025). A significant difference regarding the rhinoconjunctivitis symptom score was shown in the grass pollen study (P = .002), and the difference of well days was significant in the tree pollen study (P = .049). CONCLUSION When comparing patients based on their reaction to allergen challenge after immunotherapy, each study leads to similarly significant results. Therefore, conjunctival allergen challenge can be used effectively as a parameter to predict allergic rhinoconjunctivitis symptoms during the season in patients treated with preseasonal sublingual immunotherapy tablets. Whether this can be transferred to untreated patients needs to be determined.
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26
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Leitlinie zur (allergen-)spezifischen Immuntherapie bei IgE-vermittelten allergischen Erkrankungen. ALLERGO JOURNAL 2014. [DOI: 10.1007/s15007-014-0707-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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27
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Rösner-Friese K, Kaul S, Vieths S, Pfaar O. Environmental exposure chambers in allergen immunotherapy trials: Current status and clinical validation needs. J Allergy Clin Immunol 2014; 135:636-43. [PMID: 25528360 DOI: 10.1016/j.jaci.2014.10.045] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 09/24/2014] [Accepted: 10/31/2014] [Indexed: 11/17/2022]
Abstract
As required by the European Medicines Agency and the US Food and Drug Administration for pivotal trials involving allergen immunotherapy (AIT) products, clinical efficacy assessment is currently based on double-blind, placebo-controlled field studies with natural allergen exposure during the allergen season. However, this study design is associated with several drawbacks, such as the high variability of allergen exposure in different trial sites or seasons and the presence of confounding environmental factors. On the contrary, environmental exposure chambers (EECs) aim to operate with a stable and reproducible allergen exposure under highly standardized environmental conditions. Technical validation parameters for different EECs worldwide have been published by several groups. However, full clinical validation of EEC study outcomes is required for their classification as an appropriate alternative to natural allergen exposure for AIT product efficacy assessment. Some clinical validation parameters have already been addressed for EEC units. The reliability of provoked symptoms in repeated EEC sessions is high, but the predictive power of EEC settings for the clinical response on natural exposure and the impact of seasonal priming on test results still have to be validated systematically, as does the inter-EEC variability. Thus the authors recommend a continued in-depth validation of EECs to exploit the potential of this technology for future AIT product development.
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Affiliation(s)
- Karen Rösner-Friese
- Division of Allergology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
| | - Susanne Kaul
- Division of Allergology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany.
| | - Stefan Vieths
- Division of Allergology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
| | - Oliver Pfaar
- Center for Rhinology and Allergology Wiesbaden and the Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
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28
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Klimek L, Uhlig J, Mösges R, Rettig K, Pfaar O. A high polymerized grass pollen extract is efficacious and safe in a randomized double-blind, placebo-controlled study using a novel up-dosing cluster-protocol. Allergy 2014; 69:1629-38. [PMID: 25130503 PMCID: PMC4238814 DOI: 10.1111/all.12513] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cluster immunotherapy represents an interesting alternative to conventional up-dosing schedules because it allows achieving the maintenance dose within a shorter time interval. In this study, the efficacy and safety of cluster immunotherapy with a high polymerized allergen extract of a grass/rye pollen mixture have been evaluated in a randomized, double-blind, placebo-controlled, multicenter study. METHODS In total, 121 patients with allergic rhinoconjunctivitis due to grass pollen were randomized 1 : 1 to verum or placebo group. A short cluster up-dosing schedule of only 1 week was applied to achieve the maintenance dose which was administered monthly during the study period of 1 year. Total combined symptom and medication score (TCS) was defined as primary outcome parameter. Secondary outcome parameters were individual symptom and medication scores, 'well days,' global improvement as well as immunological effects and nasal allergen challenge. The safety profile was evaluated based on the European academy of allergy and clinical immunology grading system. RESULTS Significant reduction in the verum compared to the placebo group (intention-to-treat, population, verum: n = 55; placebo: n = 47) was found regarding TCS (P = 0.005), rhinoconjunctivitis total symptom score (RTSS, P = 0.006), and total rescue medication score (TRMS, P = 0.002). Additionally, secondary outcomes such as 'well days,' nasal challenge results, and increase of specific IgG4 were in favor of the active treatment. All systemic adverse reactions (0.8% of all injections in the verum group) were of mild intensity. No severe reactions related to the study medication were observed. CONCLUSION Cluster immunotherapy with high polymerized grass pollen extracts resulted in significant clinical efficacy and has been shown to be a safe treatment for grass pollen-allergic patients.
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Affiliation(s)
- L Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
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29
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Calderon MA, Bernstein DI, Blaiss M, Andersen JS, Nolte H. A comparative analysis of symptom and medication scoring methods used in clinical trials of sublingual immunotherapy for seasonal allergic rhinitis. Clin Exp Allergy 2014; 44:1228-39. [DOI: 10.1111/cea.12331] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- M. A. Calderon
- Imperial College London - National Heart and Lung Institute; Royal Brompton Hospital NHS; London UK
| | - D. I. Bernstein
- Bernstein Clinical Research Center and University of Cincinnati College of Medicine; Cincinnati OH USA
| | - M. Blaiss
- University of Tennessee Health Science Center; Memphis TN USA
| | | | - H. Nolte
- Merck & Co., Inc.; Whitehouse Station NJ USA
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30
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Pfaar O, Demoly P, Gerth van Wijk R, Bonini S, Bousquet J, Canonica GW, Durham SR, Jacobsen L, Malling HJ, Mösges R, Papadopoulos NG, Rak S, Rodriguez del Rio P, Valovirta E, Wahn U, Calderon MA. Recommendations for the standardization of clinical outcomes used in allergen immunotherapy trials for allergic rhinoconjunctivitis: an EAACI Position Paper. Allergy 2014; 69:854-67. [PMID: 24761804 DOI: 10.1111/all.12383] [Citation(s) in RCA: 311] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Allergen immunotherapy (AIT) has been thoroughly documented in randomized controlled trials (RCTs). It is the only immune-modifying and causal treatment available for patients suffering from IgE-mediated diseases such as allergic rhinoconjunctivitis, allergic asthma and insect sting allergy. However, there is a high degree of clinical and methodological heterogeneity among the endpoints in clinical studies on AIT, for both subcutaneous and sublingual immunotherapy (SCIT and SLIT). At present, there are no commonly accepted standards for defining the optimal outcome parameters to be used for both primary and secondary endpoints. METHODS As elaborated by a Task Force (TF) of the European Academy of Allergy and Clinical Immunology (EAACI) Immunotherapy Interest Group, this Position Paper evaluates the currently used outcome parameters in different RCTs and also aims to provide recommendations for the optimal endpoints in future AIT trials for allergic rhinoconjunctivitis. RESULTS Based on a thorough literature review, the TF members have outlined recommendations for nine domains of clinical outcome measures. As the primary outcome, the TF recommends a homogeneous combined symptom and medication score (CSMS) as a simple and standardized method that balances both symptoms and the need for antiallergic medication in an equally weighted manner. All outcomes, grouped into nine domains, are reviewed. CONCLUSION A standardized and globally harmonized method for analysing the clinical efficacy of AIT products in RCTs is required. The EAACI TF highlights the CSMS as the primary endpoint for future RCTs in AIT for allergic rhinoconjunctivitis.
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Affiliation(s)
- O. Pfaar
- Center for Rhinology and Allergology Wiesbaden; Department of Otorhinolaryngology, Head and Neck Surgery; University Hospital Mannheim; Mannheim Germany
| | - P. Demoly
- Département de Pneumologie et Addictologie; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- Sorbonne Universités; UPMC Paris 06, UMR-S 1136, IPLESP; Equipe EPAR; Paris France
| | - R. Gerth van Wijk
- Section of Allergology; Department of Internal Medicine; Erasmus MC; Rotterdam the Netherlands
| | - S. Bonini
- Second University of Naples and Institute of Translational Pharmacology; Italian National Research Council (IFT-CNR); Rome Italy
| | - J. Bousquet
- Département de Pneumologie et Addictologie; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- 1018, Respiratory and Environmental Epidemiology Team; INSERM; CESP Centre for research in Epidemiology and Population Health; Villejuif France
| | - G. W. Canonica
- Respiratory Diseases & Allergy Clinic; University of Genova; IRCCS AOU San Martino; Genova Italy
| | - S. R. Durham
- Section of Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College; London UK
| | - L. Jacobsen
- ALC, Allergy Learning and Consulting; Copenhagen Denmark
| | - H. J. Malling
- Allergy Clinic; University Hospital Gentofte; Copenhagen Denmark
| | - R. Mösges
- Institute of Medical Statistics; Informatics and Epidemiology (IMSIE); University of Cologne; Cologne Germany
| | - N. G. Papadopoulos
- Allergy Department; 2nd Pediatric Clinic; University of Athens; Athens Greece
- Centre for Paediatrics and Child Health; Institute of Human Development; University of Manchester; Manchester UK
| | - S. Rak
- Department of Respiratory Medicine and Allergology; Sahlgrenska University Hospital; Goteborg Sweden
| | | | - E. Valovirta
- Department of Clinical Allergology and Pulmonary Diseases; University of Turku; Finland
- Suomen Terveystalo Allergy Clinic; Turku Finland
| | - U. Wahn
- Department for Pediatric Pneumology and Immunology; Charité Medical University; Berlin Germany
| | - M. A. Calderon
- Section of Allergy and Clinical Immunology; National Heart and Lung Institute; Imperial College; London UK
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31
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Canonica GW, Cox L, Pawankar R, Baena-Cagnani CE, Blaiss M, Bonini S, Bousquet J, Calderón M, Compalati E, Durham SR, van Wijk RG, Larenas-Linnemann D, Nelson H, Passalacqua G, Pfaar O, Rosário N, Ryan D, Rosenwasser L, Schmid-Grendelmeier P, Senna G, Valovirta E, Van Bever H, Vichyanond P, Wahn U, Yusuf O. Sublingual immunotherapy: World Allergy Organization position paper 2013 update. World Allergy Organ J 2014; 7:6. [PMID: 24679069 PMCID: PMC3983904 DOI: 10.1186/1939-4551-7-6] [Citation(s) in RCA: 328] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 02/07/2014] [Indexed: 02/07/2023] Open
Abstract
We have prepared this document, "Sublingual Immunotherapy: World Allergy Organization Position Paper 2013 Update", according to the evidence-based criteria, revising and updating chapters of the originally published paper, "Sublingual Immunotherapy: World Allergy Organization Position Paper 2009", available at http://www.waojournal.org. Namely, these comprise: "Mechanisms of sublingual immunotherapy;" "Clinical efficacy of sublingual immunotherapy" - reporting all the data of all controlled trials published after 2009; "Safety of sublingual immunotherapy" - with the recently published Grading System for adverse reactions; "Impact of sublingual immunotherapy on the natural history of respiratory allergy" - with the relevant evidences published since 2009; "Efficacy of SLIT in children" - with detailed analysis of all the studies; "Definition of SLIT patient selection" - reporting the criteria for eligibility to sublingual immunotherapy; "The future of immunotherapy in the community care setting"; "Methodology of clinical trials according to the current scientific and regulatory standards"; and "Guideline development: from evidence-based medicine to patients' views" - including the evolution of the methods to make clinical recommendations.Additionally, we have added new chapters to cover a few emerging crucial topics: "Practical aspects of schedules and dosages and counseling for adherence" - which is crucial in clinical practice for all treatments; "Perspectives and new approaches" - including recombinant allergens, adjuvants, modified allergens, and the concept of validity of the single products. Furthermore, "Raising public awareness about sublingual immunotherapy", as a need for our patients, and strategies to increase awareness of allergen immunotherapy (AIT) among patients, the medical community, all healthcare stakeholders, and public opinion, are also reported in detail.
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Affiliation(s)
- Giorgio Walter Canonica
- Respiratory and Allergy Clinic, DIMI—Department of Internal Medicine, University of Genoa, IRCCS Aou San Martino, Largo Rosanna Benzi 10, Genoa 1-16132, Italy
| | - Linda Cox
- Department of Medicine, Nova Southeastern University, College of Osteopathic Medicine, Davie Florida, USA
| | - Ruby Pawankar
- Division of Allergy, Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Carlos E Baena-Cagnani
- Research Center for Respiratory Medicine (CIMER), Catholic University, Fundación LIBRA, Córdoba, Argentina
| | - Michael Blaiss
- Department of Pediatrics and Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sergio Bonini
- Department of Medicine, Second University of Naples, Institute of Translational Pharmacology, Italian National Research Council, Rome, Italy
| | - Jean Bousquet
- Centre Hospitalier Regional Universitaire de Montpellier, Université de Montpellier, Montpellier, France
| | - Moises Calderón
- Section of Allergy and Clinical Immunology, Imperial College of London, National Heart and Lung Institute, Royal Brompton Hospital, London, UK
| | - Enrico Compalati
- Allergy and Respiratory Diseases Clinic, Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Stephen R Durham
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College of London, London, UK
| | - Roy Gerth van Wijk
- Department of Allergology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Harold Nelson
- National Jewish Health, University of Colorado – Denver School of Medicine, Denver, Colorado, USA
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino IST, University of Genoa, Genova, Italy
| | - Oliver Pfaar
- Center for Rhinology and Allergology Wiesbaden, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Nelson Rosário
- Pediatric Allergy and Immunology Division, Hospital de Clínicas, Federal University of Parana, Curitiba, Brazil
| | - Dermot Ryan
- Academic Centre of Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Lanny Rosenwasser
- Children’s Mercy Hospital, University of Missouri – Kansas City School of Medicine, Kansas City, Missouri
| | | | | | - Erkka Valovirta
- Department of Clinical Allergology and Pulmonary Diseases, University of Turku, Finland, and Allergy Clinic, Terveystalo, Turku, Finland
| | - Hugo Van Bever
- Department of Paediatrics, University Children’s Medical Institute, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Pakit Vichyanond
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ulrich Wahn
- Department of Pediatric Pneumology and Immunology, Charité, Humboldt University, Berlin, Germany
| | - Osman Yusuf
- The Allergy and Asthma Institute, Islamabad, Pakistan
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Health-Related Quality of Life and Rhinitis Control Measures in Allergic Rhinitis. CURRENT TREATMENT OPTIONS IN ALLERGY 2014. [DOI: 10.1007/s40521-013-0007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ciepiela O, Zawadzka-Krajewska A, Kotuła I, van Overveld F, Kulus M, Demkow U. Sublingual Immunotherapy for Asthma: Affects T-Cells but Does not Impact Basophil Activation. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2014; 27:17-23. [PMID: 24669352 DOI: 10.1089/ped.2014.0328] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 02/03/2014] [Indexed: 01/04/2023]
Abstract
Objective: Allergen-specific immunotherapy (SIT) is the unique modifying treatment of atopic diseases. Dysregulation of T-cell apoptosis plays a crucial role in the in the development of asthma. Nevertheless, the effect of sublingual immunotherapy (SLIT) on T-cell apoptosis has not been elucidated. The aim of the study was to evaluate the influence of 1 year of SIT in atopic children on the frequency of Th1 and Th2 cells in peripheral blood, on T-cell apoptosis, and on the response of basophils to allergen challenge. Methods: Children suffering from bronchial asthma were treated with SLIT for 12 months (Staloral 300). Basophil activation was evaluated by measurement of CD203c antigen expression. Th1 and Th2 cells frequencies and their associated frequencies of apoptosis by the expression of Bcl-2 were evaluated with flow cytometry. Results: Basophil activation showed no difference in response before and after therapy. The frequency of Th1 cells increased (p=0.01, n=19), whereas the frequency of Th2 cells remained stable. Additionally, a significant increase of Bcl-2 positive Th1 cells was found (p=0.0465, n=19). Conclusions: We conclude that the increase in frequency of Th1 cells secondary to SLIT might be associated with increased resistance to apoptotic signals. The basophil activation is not useful in evaluation of patient desensitization.
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Affiliation(s)
- Olga Ciepiela
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw , Poland
| | | | - Iwona Kotuła
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw , Poland
| | | | - Marek Kulus
- Department of Pediatric Pneumonology and Allergology, Medical University of Warsaw , Poland
| | - Urszula Demkow
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw , Poland
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Allergen Immunotherapy: Clinical Outcomes Assessment. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:123-9; quiz 130. [DOI: 10.1016/j.jaip.2014.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/20/2014] [Accepted: 01/22/2014] [Indexed: 12/16/2022]
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Pfaar O, Bachert C, Bufe A, Buhl R, Ebner C, Eng P, Friedrichs F, Fuchs T, Hamelmann E, Hartwig-Bade D, Hering T, Huttegger I, Jung K, Klimek L, Kopp MV, Merk H, Rabe U, Saloga J, Schmid-Grendelmeier P, Schuster A, Schwerk N, Sitter H, Umpfenbach U, Wedi B, Wöhrl S, Worm M, Kleine-Tebbe J, Kaul S, Schwalfenberg A. Guideline on allergen-specific immunotherapy in IgE-mediated allergic diseases: S2k Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Society for Pediatric Allergy and Environmental Medicine (GPA), the Medical Association of German Allergologists (AeDA), the Austrian Society for Allergy and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Dermatology (DDG), the German Society of Oto- Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), the German Society of Pediatrics and Adolescent Medicine (DGKJ), the Society for Pediatric Pneumology (GPP), the German Respiratory Society (DGP), the German Association of ENT Surgeons (BV-HNO), the Professional Federation of Paediatricians and Youth Doctors (BVKJ), the Federal Association of Pulmonologists (BDP) and the German Dermatologists Association (BVDD). ALLERGO JOURNAL INTERNATIONAL 2014; 23:282-319. [PMID: 26120539 PMCID: PMC4479478 DOI: 10.1007/s40629-014-0032-2] [Citation(s) in RCA: 245] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The present guideline (S2k) on allergen-specific immunotherapy (AIT) was established by the German, Austrian and Swiss professional associations for allergy in consensus with the scientific specialist societies and professional associations in the fields of otolaryngology, dermatology and venereology, pediatric and adolescent medicine, pneumology as well as a German patient organization (German Allergy and Asthma Association; Deutscher Allergie- und Asthmabund, DAAB) according to the criteria of the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). AIT is a therapy with disease-modifying effects. By administering allergen extracts, specific blocking antibodies, toler-ance-inducing cells and mediators are activated. These prevent further exacerbation of the allergen-triggered immune response, block the specific immune response and attenuate the inflammatory response in tissue. Products for SCIT or SLIT cannot be compared at present due to their heterogeneous composition, nor can allergen concentrations given by different manufacturers be compared meaningfully due to the varying methods used to measure their active ingredients. Non-modified allergens are used for SCIT in the form of aqueous or physically adsorbed (depot) extracts, as well as chemically modified allergens (allergoids) as depot extracts. Allergen extracts for SLIT are used in the form of aqueous solutions or tablets. The clinical efficacy of AIT is measured using various scores as primary and secondary study endpoints. The EMA stipulates combined symptom and medication scores as primary endpoint. A harmonization of clinical endpoints, e. g., by using the combined symptom and medication scores (CSMS) recommended by the EAACI, is desirable in the future in order to permit the comparison of results from different studies. The current CONSORT recommendations from the ARIA/GA2LEN group specify standards for the evaluation, presentation and publication of study results. According to the Therapy allergen ordinance (TAV), preparations containing common allergen sources (pollen from grasses, birch, alder, hazel, house dust mites, as well as bee and wasp venom) need a marketing authorization in Germany. During the marketing authorization process, these preparations are examined regarding quality, safety and efficacy. In the opinion of the authors, authorized allergen preparations with documented efficacy and safety, or preparations tradeable under the TAV for which efficacy and safety have already been documented in clinical trials meeting WAO or EMA standards, should be preferentially used. Individual formulations (NPP) enable the prescription of rare allergen sources (e.g., pollen from ash, mugwort or ambrosia, mold Alternaria, animal allergens) for specific immunotherapy. Mixing these allergens with TAV allergens is not permitted. Allergic rhinitis and its associated co-morbidities (e. g., bronchial asthma) generate substantial direct and indirect costs. Treatment options, in particular AIT, are therefore evaluated using cost-benefit and cost-effectiveness analyses. From a long-term perspective, AIT is considered to be significantly more cost effective in allergic rhinitis and allergic asthma than pharmacotherapy, but is heavily dependent on patient compliance. Meta-analyses provide unequivocal evidence of the efficacy of SCIT and SLIT for certain allergen sources and age groups. Data from controlled studies differ in terms of scope, quality and dosing regimens and require product-specific evaluation. Therefore, evaluating individual preparations according to clearly defined criteria is recommended. A broad transfer of the efficacy of certain preparations to all preparations administered in the same way is not endorsed. The website of the German Society for Allergology and Clinical Immunology (www.dgaki.de/leitlinien/s2k-leitlinie-sit; DGAKI: Deutsche Gesellschaft für Allergologie und klinische Immunologie) provides tables with specific information on available products for AIT in Germany, Switzerland and Austria. The tables contain the number of clinical studies per product in adults and children, the year of market authorization, underlying scoring systems, number of randomized and analyzed subjects and the method of evaluation (ITT, FAS, PP), separately given for grass pollen, birch pollen and house dust mite allergens, and the status of approval for the conduct of clinical studies with these products. Strong evidence of the efficacy of SCIT in pollen allergy-induced allergic rhinoconjunctivitis in adulthood is well-documented in numerous trials and, in childhood and adolescence, in a few trials. Efficacy in house dust mite allergy is documented by a number of controlled trials in adults and few controlled trials in children. Only a few controlled trials, independent of age, are available for mold allergy (in particular Alternaria). With regard to animal dander allergies (primarily to cat allergens), only small studies, some with methodological deficiencies are available. Only a moderate and inconsistent therapeutic effect in atopic dermatitis has been observed in the quite heterogeneous studies conducted to date. SCIT has been well investigated for individual preparations in controlled bronchial asthma as defined by the Global Initiative for Asthma (GINA) 2007 and intermittent and mild persistent asthma (GINA 2005) and it is recommended as a treatment option, in addition to allergen avoidance and pharmacotherapy, provided there is a clear causal link between respiratory symptoms and the relevant allergen. The efficacy of SLIT in grass pollen-induced allergic rhinoconjunctivitis is extensively documented in adults and children, whilst its efficacy in tree pollen allergy has only been shown in adults. New controlled trials (some with high patient numbers) on house dust mite allergy provide evidence of efficacy of SLIT in adults. Compared with allergic rhinoconjunctivitis, there are only few studies on the efficacy of SLIT in allergic asthma. In this context, newer studies show an efficacy for SLIT on asthma symptoms in the subgroup of grass pollen allergic children, adolescents and adults with asthma and efficacy in primary house dust mite allergy-induced asthma in adolescents aged from 14 years and in adults. Aspects of secondary prevention, in particular the reduction of new sensitizations and reduced asthma risk, are important rationales for choosing to initiate treatment early in childhood and adolescence. In this context, those products for which the appropriate effects have been demonstrated should be considered. SCIT or SLIT with pollen or mite allergens can be performed in patients with allergic rhinoconjunctivitis using allergen extracts that have been proven to be effective in at least one double-blind placebo-controlled (DBPC) study. At present, clinical trials are underway for the indication in asthma due to house dust mite allergy, some of the results of which have already been published, whilst others are still awaited (see the DGAKI table "Approved/potentially completed studies" via www.dgaki.de/Leitlinien/s2k-Leitlinie-sit (according to www.clinicaltrialsregister.eu)). When establishing the indication for AIT, factors that favour clinical efficacy should be taken into consideration. Differences between SCIT and SLIT are to be considered primarily in terms of contraindications. In individual cases, AIT may be justifiably indicated despite the presence of contraindications. SCIT injections and the initiation of SLIT are performed by a physician experienced in this type of treatment and who is able to administer emergency treatment in the case of an allergic reaction. Patients must be fully informed about the procedure and risks of possible adverse events, and the details of this process must be documented (see "Treatment information sheet"; available as a handout via www.dgaki.de/Leitlinien/s2k-Leitlinie-sit). Treatment should be performed according to the manufacturer's product information leaflet. In cases where AIT is to be performed or continued by a different physician to the one who established the indication, close cooperation is required in order to ensure that treatment is implemented consistently and at low risk. In general, it is recommended that SCIT and SLIT should only be performed using preparations for which adequate proof of efficacy is available from clinical trials. Treatment adherence among AIT patients is lower than assumed by physicians, irrespective of the form of administration. Clearly, adherence is of vital importance for treatment success. Improving AIT adherence is one of the most important future goals, in order to ensure efficacy of the therapy. Severe, potentially life-threatening systemic reactions during SCIT are possible, but - providing all safety measures are adhered to - these events are very rare. Most adverse events are mild to moderate and can be treated well. Dose-dependent adverse local reactions occur frequently in the mouth and throat in SLIT. Systemic reactions have been described in SLIT, but are seen far less often than with SCIT. In terms of anaphylaxis and other severe systemic reactions, SLIT has a better safety profile than SCIT. The risk and effects of adverse systemic reactions in the setting of AIT can be effectively reduced by training of personnel, adhering to safety standards and prompt use of emergency measures, including early administration of i. m. epinephrine. Details on the acute management of anaphylactic reactions can be found in the current S2 guideline on anaphylaxis issued by the AWMF (S2-AWMF-LL Registry Number 061-025). AIT is undergoing some innovative developments in many areas (e. g., allergen characterization, new administration routes, adjuvants, faster and safer dose escalation protocols), some of which are already being investigated in clinical trials. Cite this as Pfaar O, Bachert C, Bufe A, Buhl R, Ebner C, Eng P, Friedrichs F, Fuchs T, Hamelmann E, Hartwig-Bade D, Hering T, Huttegger I, Jung K, Klimek L, Kopp MV, Merk H, Rabe U, Saloga J, Schmid-Grendelmeier P, Schuster A, Schwerk N, Sitter H, Umpfenbach U, Wedi B, Wöhrl S, Worm M, Kleine-Tebbe J. Guideline on allergen-specific immunotherapy in IgE-mediated allergic diseases - S2k Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Society for Pediatric Allergy and Environmental Medicine (GPA), the Medical Association of German Allergologists (AeDA), the Austrian Society for Allergy and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Dermatology (DDG), the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO-KHC), the German Society of Pediatrics and Adolescent Medicine (DGKJ), the Society for Pediatric Pneumology (GPP), the German Respiratory Society (DGP), the German Association of ENT Surgeons (BV-HNO), the Professional Federation of Paediatricians and Youth Doctors (BVKJ), the Federal Association of Pulmonologists (BDP) and the German Dermatologists Association (BVDD). Allergo J Int 2014;23:282-319.
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Affiliation(s)
- Oliver Pfaar
- />Center for Rhinology and Allergology, Wiesbaden, Germany
- />Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany
- />Center for Rhinology and Allergology Wiesbaden, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, An den Quellen 10, 65189 Wiesbaden, Germany
| | - Claus Bachert
- />Department of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
| | - Albrecht Bufe
- />Department of Experimental Pneumology, Ruhr-University Bochum, Bochum, Germany
| | - Roland Buhl
- />Pulmonary Department, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Christof Ebner
- />Outpatient Clinic for Allergy and Clinical Immunology, Vienna, Austria
| | - Peter Eng
- />Department of Children and Adolescent Medicine, Aarau and Children‘s Hospital Lucerne, Lucerne, Switzerland
| | - Frank Friedrichs
- />Pediatric and Adolescent Medicine Practice, Laurensberg, Germany
| | - Thomas Fuchs
- />Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Eckard Hamelmann
- />Department of Pediatric and Adolescent Medicine, Pediatric Center Bethel, Evangelical Hospital, Bielefeld, Germany
| | | | - Thomas Hering
- />Pulmonary Outpatient Practice, Tegel, Berlin, Germany
| | - Isidor Huttegger
- />Department of Pediatric and Adolescent Medicine, Paracelsus Private Medical University, Salzburg Regional Hospitals, Salzburg, Austria
| | | | - Ludger Klimek
- />Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Matthias Volkmar Kopp
- />Clinic of Pediatric and Adolescent Medicine, Lübeck University, Airway Research Center North (ARCN), Member of the German Lung Center (DZL), Lübeck, Germany
| | - Hans Merk
- />Department of Dermatology and Allergology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Uta Rabe
- />Department of Allergology, Johanniter-Krankenhaus im Fläming Treuenbrietzen GmbH, Treuenbrietzen Germany, Treuenbrietzen, Germany
| | - Joachim Saloga
- />Department of Dermatology, University Medical Center, Johannes-Gutenberg University, Mainz, Germany
| | | | - Antje Schuster
- />Center for Pediatric and Adolescent Medicine, University Medical Center, Düsseldorf, Germany
| | - Nicolaus Schwerk
- />University Children’s hospital, Department of Pediatric Pneumology, Allergology and Neonatology, Hanover Medical University, Hannover, Germany
| | - Helmut Sitter
- />Institute for Theoretical Surgery, Marburg University, Marburg, Germany
| | | | - Bettina Wedi
- />Department of Dermatology, Allergology and Venereology, Hannover Medical University, Hannover, Germany
| | | | - Margitta Worm
- />Allergy-Centre-Charité, Department of Dermatology, Venereology, and Allergology, Charité University Hospital, Berlin, Germany
| | | | - Susanne Kaul
- />Division of Allergology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
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Pfaar O, Biedermann T, Klimek L, Sager A, Robinson DS. Depigmented-polymerized mixed grass/birch pollen extract immunotherapy is effective in polysensitized patients. Allergy 2013; 68:1306-13. [PMID: 23991896 DOI: 10.1111/all.12219] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although many patients with allergic rhinoconjunctivitis have symptoms due to sensitization with more than one pollen allergen, and mixed pollen extracts are widely used for allergen immunotherapy in practice, there are few published trials. METHODS We performed a 2-year multicentre, double-blind, placebo-controlled trial of subcutaneous immunotherapy with mixed depigmented-polymerized birch and grass pollen extract in 285 patients with allergic rhinoconjunctivitis symptomatic during both birch and grass pollen seasons. Primary outcome was combined symptom and medication score (SMS) assessed by daily visual analogue scales (VAS). Analysis included a placebo-based analysis examining the effect of treatment only on days when placebo patients were symptomatic. RESULTS There was a significant reduction in median SMS for actively treated patients (median 5.70 (interquartile range 2.62-10.02) compared with 7.07 (3.47-10.71) for placebo, P = 0.0385). Rhinitis quality-of-life scores were significantly better for active compared with placebo, and other secondary endpoints were not significantly different. Placebo-based analysis showed a 33.7% reduced SMS at year 2 for active treatment compared with placebo on days when placebo patients were symptomatic. Both birch pollen- and grass pollen-specific IgG4 increased with active treatment. CONCLUSIONS This study shows efficacy of mixed pollen extracts for immunotherapy for patients symptomatic to both birch and grass pollen allergens. The relatively modest effect may reflect 50% dose reduction for each allergen in the mixture. It supports VAS for symptom assessment and placebo-based analysis as useful for the analysis of immunotherapy trials. The safety of modified extracts may allow study of mixed extracts without dose reduction to improve efficacy.
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Affiliation(s)
- O. Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery; Center for Rhinology and Allergology; University Hospital Mannheim; Wiesbaden; Germany
| | - T. Biedermann
- Clinic for Dermatology; University Hospital Tübingen; Tübingen; Germany
| | - L. Klimek
- Department of Otorhinolaryngology, Head and Neck Surgery; Center for Rhinology and Allergology; University Hospital Mannheim; Wiesbaden; Germany
| | | | - D. S. Robinson
- Leukocyte Biology Section; National Heart and Lung Institute; Imperial College London; London; UK
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Dretzke J, Meadows A, Novielli N, Huissoon A, Fry-Smith A, Meads C. Subcutaneous and sublingual immunotherapy for seasonal allergic rhinitis: a systematic review and indirect comparison. J Allergy Clin Immunol 2013; 131:1361-6. [PMID: 23557834 DOI: 10.1016/j.jaci.2013.02.013] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 01/23/2013] [Accepted: 02/14/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND Severe allergic rhinitis uncontrolled by pharmacotherapy can adversely affect quality of life. Both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) have demonstrated effectiveness in this patient group; however, it remains uncertain which route of administration is more effective. OBJECTIVES We sought to update existing systematic reviews on the clinical effectiveness of SCIT and SLIT versus placebo, to undertake a systematic review of head-to-head trials, and to compare the relative effectiveness of SCIT and SLIT in an adjusted indirect comparison. METHODS Standard systematic review methods aimed at minimizing bias were used. Double-blind, randomized, placebo-controlled trials of SCIT or SLIT or trials of SCIT versus SLIT were included. Meta-analysis and indirect comparison meta-analysis with meta-regression were performed. RESULTS Updated meta-analyses confirmed statistically significant benefits for SCIT and SLIT compared with placebo in adults and, to a lesser extent, in children. Only 1 head-to-head trial met the inclusion criteria; both this and the indirect comparisons did not provide conclusive results in favor of either SCIT or SLIT based on symptom-medication or quality-of-life scores. There was a trend toward favoring SCIT for symptom and medication scores. CONCLUSIONS Although there is clear evidence of effectiveness of both SCIT and SLIT, superiority of one mode of administration over the other could not be consistently demonstrated through indirect comparison, and further research is needed to establish the comparative effectiveness of SCIT versus SLIT.
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Affiliation(s)
- Janine Dretzke
- Department of Public Health, Epidemiology & Biostatistics, University of Birmingham, Birmingham, United Kingdom.
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Bozek A, Ignasiak B, Filipowska B, Jarzab J. House dust mite sublingual immunotherapy: a double-blind, placebo-controlled study in elderly patients with allergic rhinitis. Clin Exp Allergy 2013; 43:242-8. [DOI: 10.1111/cea.12039] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 09/08/2012] [Accepted: 10/04/2012] [Indexed: 12/01/2022]
Affiliation(s)
- A. Bozek
- Clinical Department of Internal Disease, Dermatology and Allergology; Medical University School of Silesia; Zabrze; Poland
| | - B. Ignasiak
- Allergy Outpatient Clinic; Swietochlowice; Poland
| | - B. Filipowska
- Clinical Department of Internal Disease, Dermatology and Allergology; Medical University School of Silesia; Zabrze; Poland
| | - J. Jarzab
- Clinical Department of Internal Disease, Dermatology and Allergology; Medical University School of Silesia; Zabrze; Poland
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Cox L, Calderón M, Pfaar O. Subcutaneous allergen immunotherapy for allergic disease: examining efficacy, safety and cost-effectiveness of current and novel formulations. Immunotherapy 2012; 4:601-16. [PMID: 22788128 DOI: 10.2217/imt.12.36] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Subcutaneous immunotherapy (SCIT) is a unique therapy for allergic disease because it provides symptomatic relief while modifying the allergic disease by targeting the underlying immunological mechanism. Its efficacy and safety have been established in the treatment of asthma, allergic rhinitis/rhinoconjunctivitis and stinging insect hypersensitivity in numerous controlled clinical trials. This review evaluates a spectrum of clinical factors, ranging from efficacy to cost-effectiveness, which should be considered in evaluating SCIT. The evidence for SCIT safety and efficacy for these conditions is reviewed in an evaluation of the systematic reviews and meta-analyses. The evidence for the persistent and preventive effects of SCIT is also examined. An overview of the SCIT outcomes measures utilized in clinical trials is presented. The cost-effectiveness of SCIT compared with conventional medication treatment, novel indications and formulations for SCIT are also explored in this review.
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Affiliation(s)
- Linda Cox
- Department of Medicine, Nova Southeastern University, 5333 North Dixie Highway, Fort Lauderdale, FL 33334, USA.
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Zuberbier T, Canonica GW, da Silva B. Specific immunotherapy with allergens: an important tool in the treatment of the allergic diseases. J Dtsch Dermatol Ges 2012; 10:879-85. [PMID: 23072584 DOI: 10.1111/j.1610-0387.2012.08017.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Immunotherapy was introduced 100 years ago and still is the only treatment that modifies the course of allergic diseases. The success of its use depends on correct indications, use of standardized extracts and monitoring the therapeutic response.
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Affiliation(s)
- Torsten Zuberbier
- Department of Dermatology and Allergy, Charité- Universitätsmedizin Berlin, Germany.
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Häfner D, Reich K, Zschocke I, Lotzin A, Meyer H, Kettner J, Narkus A. Prospective validation of the "rhino conjunctivitis allergy-control-SCORE©" (RC-ACS©). Clin Transl Allergy 2012; 2:17. [PMID: 22992280 PMCID: PMC3490945 DOI: 10.1186/2045-7022-2-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 09/02/2012] [Indexed: 01/27/2023] Open
Abstract
Background Recently we reported the validation of the “Allergy-Control-SCORE© (ACS)” which assesses symptom severity as well as medication use on three dimensions lung, nose and eyes. The aim of this study was to test the validity of the score for eyes and nose. Methods One-hundred-twenty-one consenting subjects (age 19-65y), including 81 patients with allergic rhino-conjunctivitis (RC) and 40 healthy controls, participated in the study. Patients rated daily nasal and eye symptoms using a 4-point scale (none, mild, moderate, and severe) and their use of anti-symptomatic medication. Validation criteria were pollen counts in the course of the study period. Discrimination capacity was analyzed by comparing the rhino-conjunctivitis Allergy-Control-SCORE© (RC-ACS©) values of allergic patients and healthy controls. Convergent reliability was assessed by correlating RC-ACS© values with the global severity of allergy, the quality of life, and the allergy-related medical consultations. Retest reliability was assessed by the correlation of the repeated measured RC-ACS© scores during each of two consecutive weeks. Results Convergent reliability analysis indicated a significant correlation between RC-Allergy-Control-SCORE© and global severity of allergy (r = 0.691; p < 0.0001), quality of life (r = 0.757; p < 0.0001) and allergy-related medical consultations (r = 0.329; p = 0.0019). RC-Allergy-Control-SCORE© showed a good retest reliability (r = 0.813; p < 0.001) and discriminated extremely well between allergic patients and healthy controls (Median: 3.7 range: 0; 14.1 vs. Median: 0 range: 0; 2.9; p < 0.001), with a sensitivity of 93.8% and a specificity of 92.5% at a score value of 0.786. Conclusions The RC-ACS© can be considered as valid and reliable to assess the severity of rhino-conjunctivitis severity in clinical trials and observational studies.
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Affiliation(s)
- Dietrich Häfner
- Medical Department, Allergopharma J, Ganzer KG, Hermann-Körner-Str, 52, Reinbek, 21465, Germany.
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High-dose sublingual immunotherapy with single-dose aqueous grass pollen extract in children is effective and safe: a double-blind, placebo-controlled study. J Allergy Clin Immunol 2012; 130:886-93.e5. [PMID: 22939758 DOI: 10.1016/j.jaci.2012.06.047] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 05/24/2012] [Accepted: 06/21/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Sublingual allergen-specific immunotherapy is a viable alternative to subcutaneous immunotherapy particularly attractive for use in children. OBJECTIVE This study investigated efficacy and safety of high-dose sublingual immunotherapy (SLIT) in children allergic to grass pollen in a randomized, double-blind, placebo-controlled trial. METHODS After a baseline seasonal observation, 207 children aged 4 to 12 years with grass pollen-allergic rhinitis/rhinoconjunctivitis with/without bronchial asthma (Global Initiative for Asthma I/II) received either high-dose grass pollen SLIT or placebo daily for 1 pre-/co-seasonal period. The primary end point was the change of the area under the curve of the symptom-medication score (SMS) from the baseline season to the first season after start of treatment. Secondary outcomes were well days, responders, immunologic changes, and safety. RESULTS Mean changes in the area under the curve of the SMS from the baseline to the first grass pollen season after the start of treatment were -212.5 for the active group and -97.8 for the placebo group (P = .0040). Rhinoconjunctivitis SMS (P = .0020) and separated symptom and medication scores were also statistically different between the 2 groups (P = .0121 and P = .0226, respectively). The number of well days and the percentage of responders were greater in the active group. Changes in allergen-specific IgE and IgG levels indicated a significant immunologic effect. The treatment was well tolerated, and no serious treatment-related events were reported. CONCLUSIONS This study confirmed that this SLIT preparation significantly reduced symptoms and medication use in children with grass pollen-allergic rhinoconjunctivitis. The preparation showed significant effects on allergen-specific antibodies, was well tolerated, and appeared to be a valid therapeutic option in children allergic to grass pollen. This trial was registered at www.clinicaltrials.gov as NCT00841256.
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Jacobsen L, Wahn U, Bilo MB. Allergen-specific immunotherapy provides immediate, long-term and preventive clinical effects in children and adults: the effects of immunotherapy can be categorised by level of benefit -the centenary of allergen specific subcutaneous immunotherapy. Clin Transl Allergy 2012; 2:8. [PMID: 22500494 PMCID: PMC3348084 DOI: 10.1186/2045-7022-2-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 04/13/2012] [Indexed: 12/24/2022] Open
Abstract
Allergen Specific Immunotherapy (SIT) for respiratory allergic diseases is able to significantly improve symptoms as well as reduce the need for symptomatic medication, but SIT also has the capacity for long-term clinical effects and plays a protective role against the development of further allergies and symptoms. The treatment acts on basic immunological mechanisms, and has the potential to change the pathological allergic immune response. In this paper we discuss some of the most important achievements in the documentation of the benefits of immunotherapy, over the last 2 decades, which have marked a period of extensive research on the clinical effects and immunological background of the mechanisms involved. The outcome of immunotherapy is described as different levels of benefit from early reduction in symptoms over progressive clinical effects during treatment to long-term effects after discontinuation of the treatment and prevention of asthma. The efficacy of SIT increases the longer it is continued and immunological changes lead to potential long-term benefits. SIT alone and not the symptomatic treatment nor other avoidance measures has so far been documented as the therapy with long-term or preventive potential. The allergic condition is driven by a subset of T-helper lymphocytes (Th2), which are characterised by the production of cytokines like IL-4, and IL-5. Immunological changes following SIT lead to potential curative effects. One mechanism whereby immunotherapy suppresses the allergic response is through increased production of IgG4 antibodies. Induction of specific IgG4 is able to influence the allergic response in different ways and is related to immunological effector mechanisms, also responsible for the reduced late phase hyperreactivity and ongoing allergic inflammation. SIT is the only treatment which interferes with the basic pathophysiological mechanisms of the allergic disease, thereby creating the potential for changes in the long-term prognosis of respiratory allergy. SIT should not only be recognised as first-line therapeutic treatment for allergic rhinoconjunctivitis but also as secondary preventive treatment for respiratory allergic diseases.
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Affiliation(s)
- Lars Jacobsen
- Research Centre for Prevention and Health, Glostrup University Hospital, Copenhagen, Denmark.
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Pfaar O, Urry Z, Robinson DS, Sager A, Richards D, Hawrylowicz CM, Bräutigam M, Klimek L. A randomized placebo-controlled trial of rush preseasonal depigmented polymerized grass pollen immunotherapy. Allergy 2012; 67:272-9. [PMID: 22107266 DOI: 10.1111/j.1398-9995.2011.02736.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Specific subcutaneous immunotherapy (SCIT) for seasonal rhinoconjunctivitis with unmodified allergen extracts is effective, but limited by risk of side-effects and involves treatment over 3 years. We examined a depigmented polymerized grass pollen extract for immunogenicity and for clinical efficacy in a rush preseasonal regimen. METHODS Depigmented polymerized grass pollen extract was tested for proliferation and cytokine production by peripheral blood mononuclear cells. A prospective, double-blind, placebo-controlled trial of 195 grass pollen allergic patients treated with preseasonal rush immunotherapy using depigmented polymerized allergenic extract of mixed grass pollen was performed over 2 years. Primary outcome was combined symptom and medication score (SMS) during the peak of the second grass pollen season. Secondary outcomes included combined score over the whole season, during the first grass pollen season, individual symptom and medication scores, quality of life, well days/hell days and responder analysis. Adverse events were classified using the EAACI scale. Grass pollen-specific IgE and IgG4 were measured before and during treatment. RESULTS Depigmented polymerized extract stimulated dose-dependent T-cell proliferation and cytokine production. Patients treated with preseasonal SCIT showed improved combined scores during peak season at year 2 (median 3.93, interquartile range 0.77-6.27 vs median 5.86 for placebo, 3.11-8.36, P < 0.01). Most secondary outcomes were significantly better for active treatment. Side-effects were minimal, with no grade 3 or 4 reactions. CONCLUSIONS Depigmented polymerized grass pollen extract is immunogenic and clinically effective in rush preseasonal SCIT. This form of immunotherapy may be an attractive option for some patients.
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Affiliation(s)
- O Pfaar
- Center for Rhinology and Allergology Wiesbaden, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Germany.
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13C CP-MAS study of the gel phases of 1,2-dipalmitoylphosphatidylcholine. J Allergy Clin Immunol 1990; 131:412-20. [PMID: 2337426 DOI: 10.1016/j.jaci.2012.10.056] [Citation(s) in RCA: 105] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 10/23/2012] [Accepted: 10/31/2012] [Indexed: 12/14/2022]
Abstract
The multilamellar liposomes of the racemic 1,2-dipalmitoylphosphatidylcholine (DL-DPPC) existing in the various gel phases were investigated by means of the cross-polarization/magic angle spinning (CP-MAS) 13C-NMR. The intensity and the width of the 13C-NMR signals were found to depend to a large extent on temperature. In the metastable gel phase (L beta) signals from all carbon atoms are apparent, with the signals arising from the glycerol backbone significantly broader than those of the choline function. The signal from C-2 of the glycerol backbone undergoes additional broadening between 298 K and 307 K, and at 307 K its coalescence is observed. In the P beta' phase all carbon atoms give rise to relatively sharp separate resonance lines. In the liquid crystalline phase (L alpha) the signals from the choline function and from the terminal methyl groups of hydrocarbon are not observed in the spectrum. The recorded spectral changes are explained in terms of the rate of motional processes occurring in the lipid bilayer in different phases.
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