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Eremija J, Carr TF. Immunotherapy for Asthma. Semin Respir Crit Care Med 2022; 43:709-719. [PMID: 35714626 DOI: 10.1055/s-0042-1749454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Asthma represents one of the biggest global health concerns with increasing prevalence and influence on global health. Several distinct asthma phenotypes have been identified with one of the most common, earliest recognized, and described being the allergic asthma phenotype, in which allergens trigger asthma through mechanisms involving allergen-specific immunoglobulin E (IgE). Allergen-specific immunotherapy (AIT), in the forms of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT), has been used for many decades as a tool for reducing IgE-mediated sensitization and controlling symptoms of allergic disease, most commonly for allergic rhinitis, and it remains the only currently available disease modifying therapy in atopic patients. AIT has been studied for use in mild to moderate allergic asthma. While the data are often inconsistent, and utilize a multitude of different methods, antigens, and outcome measures, in general, AIT may have several beneficial effects on asthma disease control, quality of life, and requirement for medication. These benefits are notable when immunotherapy is used as an adjunct to pharmacologic treatment in carefully selected and monitored patients with mild to moderate persistent asthma. Patients with severe asthma are excluded from these trials. Importantly, patients with asthma, and in particular severe asthma, may have a higher rate of systemic adverse reactions to SCIT, including anaphylaxis, however, these events are overall rare. Future research in the area is needed to definitively assess the benefit of SCIT and SLIT for patients with asthma, comparing outcomes with different methods, addressing the role of AIT in severe asthma, significance of multiallergen AIT in allergic asthma, and safety concerns in asthma.
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Affiliation(s)
- Jelena Eremija
- Section of Allergy & Immunology, Department of Medicine, Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
| | - Tara F Carr
- Section of Allergy & Immunology, Department of Medicine, Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
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2
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Chen L, Lei L, Cai Y, Li T. Specific sublingual immunotherapy in children with perennial rhinitis: a systemic review and meta-analysis. Int Forum Allergy Rhinol 2020; 10:1226-1235. [PMID: 32329187 DOI: 10.1002/alr.22589] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/12/2020] [Accepted: 04/13/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Allergic rhinitis (AR) is a major public health problem and is increasing worldwide. AR affects children's learning efficiency, sleep quality, and other major aspects of life. Sublingual immunotherapy (SLIT) is effective and safe for children with seasonal AR, but for children with perennial allergic rhinitis (PAR) caused by house dust mites (HDM), its effectiveness and safety is less convincing. METHODS Medical literature databases up to 2019 were searched for published and unpublished pieces of evidence. Studies were individually screened by 2 reviewers against the eligibility criteria. Primary outcomes were total nasal symptoms scores (TNSS) and total medication scores (TMS). The secondary outcomes were total ocular symptoms scores and adverse events (AEs). Random effect models and fixed-effect models were used to calculate the standard mean difference (SMD) and risk ratio (RR), respectively. RESULTS We identified 3772 abstracts, of which only 16 studies met our established criteria. SLIT significantly reduced TNSS (SMD -1.73; 95% CI, -2.62 to -0.84; p = 0.0001) and TMS (SMD -1.21; 95% CI, -1.75 to -0.67; p < 0.00001). Compared with children taking placebo, children taking SLIT were 1.08 (95% CI, 1 to 1.17; p = 0.05), 1.15 (95% CI, 0.87 to 1.51; p = 0.32), and 1.68 (95% CI, 0.68 to 4.11; p = 0.26) times more likely to develop mild, moderate, and severe AEs, respectively. CONCLUSION HDM SLIT can effectively alleviate TNSS and TMS in children with PAR, but care should be taken to avoid harm due to possible adverse drug reactions.
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Affiliation(s)
- Liang Chen
- Department of Pulmonary, Allergy & Clinical Care Medicine, Xiamen Chang Gung Memorial Hospital, Xiamen, China
| | - Lijuan Lei
- Department of Pulmonary, Allergy & Clinical Care Medicine, Xiamen Chang Gung Memorial Hospital, Xiamen, China
| | - Yinghuang Cai
- Department of Pulmonary, Allergy & Clinical Care Medicine, Xiamen Chang Gung Memorial Hospital, Xiamen, China
| | - Tianlin Li
- Department of Pulmonary, Allergy & Clinical Care Medicine, Xiamen Chang Gung Memorial Hospital, Xiamen, China
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Caffarelli C, Mastrorilli C, Procaccianti M, Santoro A. Use of Sublingual Immunotherapy for Aeroallergens in Children with Asthma. J Clin Med 2020; 9:E3381. [PMID: 33096894 PMCID: PMC7589061 DOI: 10.3390/jcm9103381] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 12/25/2022] Open
Abstract
Asthma is a heterogeneous disease that in children is often allergen-driven with a type 2 inflammation. Sublingual immunotherapy represents an important progress in the use of personalized medicine in children with allergic asthma. It is a viable option for house dust mite-driven asthma and in subjects with the asthma associated with allergic rhinitis. The use and indications for isolated asthma caused by other allergens are still controversial owing to heterogeneity of commercially available products and methodological limitations of studies in children. Nevertheless, most studies and meta-analyses found the efficacy of sublingual immunotherapy. Sublingual immunotherapy is safe but cannot be recommended in children with uncontrolled asthma.
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Affiliation(s)
- Carlo Caffarelli
- Clinica Pediatrica, Dipartimento di Medicina e Chirurgia, Università di Parma, Azienda Ospedaliero-Universitaria di Parma, 43126 Parma, Italy; (M.P.); (A.S.)
| | - Carla Mastrorilli
- UO Pediatria e Pronto Soccorso, Azienda Ospedaliero-Universitaria Consorziale Policlinico, Ospedale Pediatrico Giovanni XXIII, 70126 Bari, Italy;
| | - Michela Procaccianti
- Clinica Pediatrica, Dipartimento di Medicina e Chirurgia, Università di Parma, Azienda Ospedaliero-Universitaria di Parma, 43126 Parma, Italy; (M.P.); (A.S.)
| | - Angelica Santoro
- Clinica Pediatrica, Dipartimento di Medicina e Chirurgia, Università di Parma, Azienda Ospedaliero-Universitaria di Parma, 43126 Parma, Italy; (M.P.); (A.S.)
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Abstract
BACKGROUND Asthma is a common long-term respiratory disease affecting approximately 300 million people worldwide. Approximately half of people with asthma have an important allergic component to their disease, which may provide an opportunity for targeted treatment. Sublingual immunotherapy (SLIT) aims to reduce asthma symptoms by delivering increasing doses of an allergen (e.g. house dust mite, pollen extract) under the tongue to induce immune tolerance. Fifty-two studies were identified and synthesised in the original Cochrane Review in 2015, but questions remained about the safety and efficacy of sublingual immunotherapy for people with asthma. OBJECTIVES To assess the efficacy and safety of sublingual immunotherapy compared with placebo or standard care for adults and children with asthma. SEARCH METHODS The original searches for trials from the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov, WHO ICTRP, and reference lists of all primary studies and review articles found trials up to 25 March 2015. The most recent search for trials for the current update was conducted on 29 October 2019. SELECTION CRITERIA We included parallel randomised controlled trials, irrespective of blinding or duration, that evaluated sublingual immunotherapy versus placebo or as an add-on to standard asthma management. We included both adults and children with asthma of any severity and with any allergen-sensitisation pattern. We included studies that recruited participants with asthma, rhinitis, or both, providing at least 80% of trial participants had a diagnosis of asthma. We selected outcomes to reflect recommended outcomes for asthma clinical trials and those most important to people with asthma. Primary outcomes were asthma exacerbations requiring a visit to the emergency department (ED) or admission to hospital, validated measures of quality of life, and all-cause serious adverse events (SAEs). Secondary outcomes were asthma symptom scores, exacerbations requiring systemic corticosteroids, response to provocation tests, and dose of inhaled corticosteroids (ICS). DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results for included trials, extracted numerical data, and assessed risk of bias, all of which were cross-checked for accuracy. Any disagreements were resolved by discussion. We analysed dichotomous data as odds ratios (ORs) or risk differences (RDs) using study participants as the unit of analysis; we analysed continuous data as mean differences (MDs) or standardised mean differences (SMDs) using random-effects models. We considered the strength of evidence for all primary and secondary outcomes using the GRADE approach. MAIN RESULTS Sixty-six studies met the inclusion criteria for this update, including 52 studies from the original review. Most studies were double-blind and placebo-controlled, varied in duration from one day to three years, and recruited participants with mild or intermittent asthma, often with comorbid allergic rhinitis. Twenty-three studies recruited adults and teenagers; 31 recruited only children; three recruited both; and nine did not specify. The pattern of reporting and results remained largely unchanged from the original review despite 14 further studies and a 50% increase in participants studied (5077 to 7944). Reporting of primary efficacy outcomes to measure the impact of SLIT on asthma exacerbations and quality of life was infrequent, and selective reporting may have had a serious effect on the completeness of the evidence; 16 studies did not contribute any data, and a further six studies could only be included in a post hoc analysis of all adverse events. Allocation procedures were generally not well described; about a quarter of the studies were at high risk of performance or detection bias (or both); and participant attrition was high or unknown in around half of the studies. The primary outcome in most studies did not align with those of interest to the review (mostly asthma or rhinitis symptoms), and only two small studies reported our primary outcome of exacerbations requiring an ED or hospital visit; the pooled estimate from these studies suggests SLIT may reduce exacerbations compared with placebo or usual care, but the evidence is very uncertain (OR 0.35, 95% confidence interval (CI) 0.10 to 1.20; n = 108; very low-certainty evidence). Nine studies reporting quality of life could not be combined in a meta-analysis and, whilst the direction of effect mostly favoured SLIT, the effects were often uncertain and small. SLIT likely does not increase SAEs compared with placebo or usual care, and analysis by risk difference suggests no more than 1 in 100 people taking SLIT will have a serious adverse event (RD -0.0004, 95% CI -0.0072 to 0.0064; participants = 4810; studies = 29; moderate-certainty evidence). Regarding secondary outcomes, asthma symptom and medication scores were mostly measured with non-validated scales, which precluded meaningful meta-analysis or interpretation, but there was a general trend of SLIT benefit over placebo. Changes in ICS use (MD -17.13 µg/d, 95% CI -61.19 to 26.93; low-certainty evidence), exacerbations requiring oral steroids (studies = 2; no events), and bronchial provocation (SMD 0.99, 95% CI 0.17 to 1.82; low-certainty evidence) were not often reported. Results were imprecise and included the possibility of important benefit or little effect and, in some cases, potential harm from SLIT. More people taking SLIT had adverse events of any kind compared with control (OR 1.99, 95% CI 1.49 to 2.67; high-certainty evidence; participants = 4251; studies = 27), but events were usually reported to be transient and mild. Lack of data prevented most of the planned subgroup and sensitivity analyses. AUTHORS' CONCLUSIONS Despite continued study in the field, the evidence for important outcomes such as exacerbations and quality of life remains too limited to draw clinically useful conclusions about the efficacy of SLIT for people with asthma. Trials mostly recruited mixed populations with mild and intermittent asthma and/or rhinitis and focused on non-validated symptom and medication scores. The review findings suggest that SLIT may be a safe option for people with well-controlled mild-to-moderate asthma and rhinitis who are likely to be at low risk of serious harm, but the role of SLIT for people with uncontrolled asthma requires further evaluation.
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Affiliation(s)
- Rebecca Fortescue
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Kayleigh M Kew
- Cochrane Editorial and Methods Department, Cochrane, London, UK
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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: 126] [Impact Index Per Article: 31.5] [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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Li Y, Yu SY, Tang R, Zhao ZT, Sun JL. Sublingual Immunotherapy Tablets Relieve Symptoms in Adults with Allergic Rhinitis: A Meta-analysis of Randomized Clinical Trials. Chin Med J (Engl) 2019; 131:2583-2588. [PMID: 30381592 PMCID: PMC6213837 DOI: 10.4103/0366-6999.244108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Sublingual immunotherapy (SLIT) has been proven to be effective against house dust mite-induced allergic rhinitis. However, the efficacy in adults with allergic rhinitis has never been reported on SLIT tablets. The current meta-analysis aimed to illustrate the differentiated efficacy of SLIT tablets on allergic rhinitis. Methods: Our systematic review and meta-analysis were performed on allergic rhinitis patients and aimed to summarize those randomized controlled studies (RCTs). PubMed, EMBASE, Cochrane library, and MEDLINE were screened for associated articles. We included RCTs on allergic rhinitis patients undergoing SLIT therapy and reporting outcomes on symptom relief and serum-specific IgE levels. The effect of SLIT tablets on the Rhinitis Quality Life Questionnaire Score (RQLQ), Rhinitis Total Symptom Score (RTSS), and serum-specific IgE levels was evaluated using RevMan 5.3. Results: Seven studies were included, with 2723 patients identified. All of the studies were RCT. The included seven studies were all conducted on adults. Among the included seven articles, five researches administered patients with SLIT tablets and were eligible for meta-analysis of RTSS, consisting of 1490 patients. Overall, RTSS was significantly reduced in the SLIT tablet group compared with that in the placebo group (standard mean difference = −0.33, 95% confidence interval [−0.54, −0.13], P < 0.01). There was no significant difference in specific IgE levels between SLIT and placebo patients. Conclusions: SLIT tablets effectively relieve rhinitis symptoms in adults with allergic rhinitis. Nevertheless, the current evidence may be limited due to sample size and the heterogeneity between studies. Large sample size and multiple center RCTs on the efficacy of different formulations of SLIT drugs are still needed to provide further evidence and a more precise recommendation.
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Affiliation(s)
- Yi Li
- Emergency Department, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Shi-Yuan Yu
- Emergency Department, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Rui Tang
- Department of Allergy, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment on Allergic Diseases, Beijing 100730, China
| | - Zuo-Tao Zhao
- Department of Dermatology, Peking University First Hospital, Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing 100034, China
| | - Jin-Lyu Sun
- Department of Allergy, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment on Allergic Diseases, Beijing 100730, China
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Allergenspezifische Immuntherapie bei IgE-vermittelten Erkrankungen im Kindes- und Jugendalter. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-018-0448-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Lin SY, Azar A, Suarez-Cuervo C, Diette GB, Brigham E, Rice J, Ramanathan M, Robinson KA. Role of sublingual immunotherapy in the treatment of asthma: An updated systematic review. Int Forum Allergy Rhinol 2018; 8:982-992. [PMID: 29885036 DOI: 10.1002/alr.22152] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 04/21/2018] [Accepted: 05/08/2018] [Indexed: 11/05/2022]
Abstract
BACKGROUND The purpose of the systematic review is to evaluate the efficacy and safety of sublingual immunotherapy (SLIT) for the treatment of allergic asthma. METHODS PubMed, Embase, and CENTRAL databases were searched, updating an earlier review (January 1, 2005 through May 8, 2017). Randomized, controlled studies (RCTs) were included, which reported one of the prespecified outcomes: asthma symptoms measured by control composite scores; quality of life; medication use; pulmonary physiology; and health-care utilization. For safety outcomes, RCTs and observational studies were included. Two independent reviewers extracted data, assessed risk of bias, and graded strength of evidence (SOE) for each outcome. RESULTS Fourteen RCTs (n = 2585) assessed the efficacy of SLIT for asthma. The RCTs utilized house dust mite (HDM), birch, or grass allergen. SLIT improved asthma symptoms (high SOE), decreased use of long-term control medication, and improved forced expiratory volume in 1 second (FEV1 ) (moderate SOE). SLIT may decrease quick-relief medication use, and improve disease-specific quality of life (low SOE). For safety, 20 RCTs and 10 observational studies (n = 3621) were identified. Local (risk differences ranged from -0.03 to +0.765) and systemic allergic reactions (risk differences ranged from -0.03 to +0.06) were a common occurrence in SLIT and control groups. Life-threatening reactions were uncommon, with 3 cases of anaphylaxis and no deaths reported. CONCLUSION There is moderate-to-high strength evidence that SLIT improves allergic asthma symptoms, reduces long-term control medication use, and improves FEV1 based on studies of HDM, birch, and grass. SLIT rarely is associated with life-threatening adverse events.
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Affiliation(s)
- Sandra Y Lin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Antoine Azar
- Department of Medicine, Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Catalina Suarez-Cuervo
- School of Public Health-Health and Policy Management, EPC, Johns Hopkins University, Baltimore, MD
| | - Gregory B Diette
- Department of Medicine, Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emily Brigham
- Department of Medicine, Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jessica Rice
- Department of Pediatrics, Pediatric Pulmonology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Murugappan Ramanathan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Karen A Robinson
- Department of Medicine, General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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9
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Kurzfassung zur allergenspezifischen Immuntherapie bei IgE-vermittelten Erkrankungen im Kindes- und Jugendalter. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-018-0478-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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10
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Rice JL, Diette GB, Suarez-Cuervo C, Brigham EP, Lin SY, Ramanathan M, Robinson KA, Azar A. Allergen-Specific Immunotherapy in the Treatment of Pediatric Asthma: A Systematic Review. Pediatrics 2018; 141:peds.2017-3833. [PMID: 29572287 DOI: 10.1542/peds.2017-3833] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2018] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Treatment options for allergic asthma include allergen avoidance, pharmacotherapy, and allergen immunotherapy. OBJECTIVES Summarize and update current evidence for the efficacy and safety of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) in pediatric allergic asthma. DATA SOURCES PubMed, Embase, Cochrane Central Register of Controlled Trials (January 1, 2005, through May 8, 2017), ClinicalTrials.gov, and the US Food and Drug Administration Adverse Event Reporting System. We reevaluated trials from our 2013 systematic review. STUDY SELECTION We included studies with children ≤18 years of age in which researchers reported on prespecified outcomes and had an intervention arm receiving aeroallergen SCIT or SLIT. Only randomized controlled trials (RCTs) were included for efficacy. RCTs and non-RCTs were included for safety outcomes. DATA EXTRACTION Two reviewers extracted data. We included 40 studies (17 SCIT trials, 11 SLIT trials, 8 non-RCTs for SCIT safety, and 4 non-RCTs for SLIT safety). RESULTS We found moderate-strength evidence that SCIT reduces long-term asthma medication use. We found low-strength evidence that SCIT improves asthma-related quality of life and forced expiratory volume in 1 second. There was also low-strength evidence that SLIT improves medication use and forced expiratory volume in 1 second. There was insufficient evidence on asthma symptoms and health care use. LIMITATIONS There were no trials in which researchers evaluated asthma symptoms using a validated tool. Study characteristics and outcomes were reported heterogeneously. CONCLUSIONS In children with allergic asthma, SCIT may reduce long-term asthma medication use. Local and systemic allergic reactions are common, but anaphylaxis is reported rarely.
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Affiliation(s)
| | | | - Catalina Suarez-Cuervo
- Evidence-based Practice Center, Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Emily P Brigham
- Department of Medicine, Pulmonary and Critical Care Medicine
| | - Sandra Y Lin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Murugappan Ramanathan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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11
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Richards JR, Stumpf JL. House Dust Mite Sublingual Immunotherapy for Pediatric Patients With Allergic Asthma. Ann Pharmacother 2018; 52:1019-1030. [PMID: 29642713 DOI: 10.1177/1060028018769443] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To review the published literature evaluating administration of house dust mite (HDM) sublingual immunotherapy (SLIT) in pediatric patients with allergic asthma. DATA SOURCES PubMed database search (1966 to November 2017) using the search terms allergy, allergic rhinitis, asthma, allergic asthma, house dust mite, allergen immunotherapy, subcutaneous immunotherapy, sublingual immunotherapy, MK-8237, children, and pediatric. Package labeling and references from identified articles were also reviewed. STUDY SELECTION AND DATA EXTRACTION Studies published in English evaluating the efficacy of HDM SLIT in children <18 years of age were included. DATA SYNTHESIS Patients with allergic asthma who fail to improve with pharmacotherapy may require disease-modifying, HDM-specific immunotherapy. Acceptance of subcutaneous immunotherapy (SCIT) in the pediatric population is limited by the need for weekly injections and the risk of systemic adverse effects. Trials in pediatric patients with allergic rhinitis and asthma monosensitized to HDM demonstrated mixed results, likely because of variability in methodologies. SLIT reduced asthma symptoms in 8 placebo-controlled studies; however, asthma medication use was reduced in just 4 trials. Compared with pharmacotherapy alone, SLIT and SCIT decreased asthma symptom scores similarly for up to 3 years. Sequential SCIT/SLIT decreased both asthma symptoms and medication scores and was more effective than SLIT alone. CONCLUSIONS Sublingual HDM immunotherapy reduces symptom scores in pediatric patients with allergic asthma but may be slower in onset and less effective than SCIT in reducing asthma medication use.
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Affiliation(s)
- Jessika R Richards
- 1 St. John Hospital and Medical Center Department of Pharmacy Services, Detroit, MI, USA
| | - Janice L Stumpf
- 2 Michigan Medicine Department of Pharmacy Services, Ann Arbor, MI, USA.,3 University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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12
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van de Griendt EJ, Tuut MK, de Groot H, Brand PLP. Applicability of evidence from previous systematic reviews on immunotherapy in current practice of childhood asthma treatment: a GRADE (Grading of Recommendations Assessment, Development and Evaluation) systematic review. BMJ Open 2017; 7:e016326. [PMID: 29288175 PMCID: PMC5770836 DOI: 10.1136/bmjopen-2017-016326] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Because most children with asthma now use inhaled corticosteroids (ICS), the added benefit of immunotherapy in asthmatic children needs to be examined. We re-assessed the effectiveness of subcutaneous (SCIT) and sublingual immunotherapy (SLIT) in childhood asthma treatment focusing on studies with patient-relevant outcome measures and children using ICS. METHODS We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to systematically search and appraise the evidence using predefined critical patient-relevant outcomes (asthma symptoms, asthma control and exacerbations). We searched to retrieve systematic reviews and randomised controlled trials on immunotherapy for asthma in children (1960-2017). We assessed the quality of the body of evidence with GRADE criteria. RESULTS The quality of the evidence for SCIT was very low due to a large risk of bias and indirectness (dated studies in children not using ICS). No effect of SCIT was found for asthma symptoms; no studies reported on asthma control. For asthma exacerbations, studies favoured SCIT. We have little confidence in this effect estimate, due to the very low quality of evidence. For SLIT, quality of the evidence was very low due to a large risk of bias, indirectness and imprecision. The outcome 'asthma symptoms' could not be calculated due to lack of standardisation and large clinical heterogeneity. Other predefined outcomes were not reported. CONCLUSION The beneficial effects of immunotherapy in childhood asthma found in earlier reviews are no longer considered applicable, because of indirectness (studies performed in children not being treated according to current asthma guidelines with ICS). There was absence of evidence to properly determine the effectiveness or lack thereof of immunotherapy in asthma treatment in children with ICS.
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Affiliation(s)
- Erik-Jonas van de Griendt
- Department of Paediatrics, De Kinderkliniek, Almere, The Netherlands
- Department of Paediatric Pulmonology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Mariska K Tuut
- Guideline Development and Research, PROVA, Varsseveld, The Netherlands
| | - Hans de Groot
- Department of Paediatric Allergology, Reinier de Graaf Group, Delft, The Netherlands
| | - Paul L P Brand
- Princess Amalia Children’s Clinic, Isala Hospital, Zwolle, The Netherlands
- UMCG Postgraduate School of Medicine, University Medical Center and University of Groningen, Groningen, The Netherlands
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Dhami S, Kakourou A, Asamoah F, Agache I, Lau S, Jutel M, Muraro A, Roberts G, Akdis CA, Bonini M, Cavkaytar O, Flood B, Gajdanowicz P, Izuhara K, Kalayci Ö, Mosges R, Palomares O, Pfaar O, Smolinska S, Sokolowska M, Asaria M, Netuveli G, Zaman H, Akhlaq A, Sheikh A. Allergen immunotherapy for allergic asthma: A systematic review and meta-analysis. Allergy 2017; 72:1825-1848. [PMID: 28543086 DOI: 10.1111/all.13208] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND To inform the development of the European Academy of Allergy and Clinical Immunology's (EAACI) Guidelines on Allergen Immunotherapy (AIT) for allergic asthma, we assessed the evidence on the effectiveness, cost-effectiveness and safety of AIT. METHODS We performed a systematic review, which involved searching nine databases. Studies were screened against predefined eligibility criteria and critically appraised using established instruments. Data were synthesized using random-effects meta-analyses. RESULTS 98 studies satisfied the inclusion criteria. Short-term symptom scores were reduced with a standardized mean difference (SMD) of -1.11 (95% CI -1.66, -0.56). This was robust to a prespecified sensitivity analyses, but there was evidence suggestive of publication bias. Short-term medication scores were reduced SMD -1.21 (95% CI -1.87, -0.54), again with evidence of potential publication bias. There was no reduction in short-term combined medication and symptom scores SMD 0.17 (95% CI -0.23, 0.58), but one study showed a beneficial long-term effect. For secondary outcomes, subcutaneous immunotherapy (SCIT) improved quality of life and decreased allergen-specific airway hyperreactivity (AHR), but this was not the case for sublingual immunotherapy (SLIT). There were no consistent effects on asthma control, exacerbations, lung function, and nonspecific AHR. AIT resulted in a modest increased risk of adverse events (AEs). Although relatively uncommon, systemic AEs were more frequent with SCIT; however no fatalities were reported. The limited evidence on cost-effectiveness was mainly available for sublingual immunotherapy (SLIT) and this suggested that SLIT is likely to be cost-effective. CONCLUSIONS AIT can achieve substantial reductions in short-term symptom and medication scores in allergic asthma. It was however associated with a modest increased risk of systemic and local AEs. More data are needed in relation to secondary outcomes, longer-term effectiveness and cost-effectiveness.
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Affiliation(s)
- S. Dhami
- Evidence-Based Health Care Ltd; Edinburgh UK
| | - A. Kakourou
- Department of Hygiene and Epidemiology; University of Ioannina School of Medicine; Ioannina Greece
| | - F. Asamoah
- Centre for Environmental and Preventive Medicine; Wolfson Institute of Preventive Medicine Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
| | - I. Agache
- Faculty of Medicine; Department of Allergy and Clinical Immunology; Transylvania University Brasov; Brasov Romania
| | - S. Lau
- Department of Pediatric Pneumology and Immunology; Charité Universitätsmedizin; Berlin Germany
| | - M. Jutel
- Wroclaw Medical University; Wroclaw Poland
- ALL-MED Medical Research Institute; Wroclaw Poland
| | - A. Muraro
- Food Allergy Referral Centre Veneto Region; University Hospital of Padua; Padua Italy
| | - G. Roberts
- The David Hide Asthma and Allergy Research Centre; St Mary's Hospital; Newport UK
- NIHR Biomedical Research Centre; University Hospital Southampton NHS Foundation Trust; Southampton UK
- Faculty of Medicine; University of Southampton; Southampton UK
| | - C. A. Akdis
- Swiss Institute for Allergy and Asthma Research; Christine Kühne-Center for Allergy Research and Education (CK-CARE); Davos Switzerland
| | - M. Bonini
- National Heart and Lung Institute; Imperial College London; London UK
| | - O. Cavkaytar
- Department of Allergy and Clinical Immunology; Sami Ulus Women's & Children's Diseases Training and Research Hospital; Ankara Turkey
- Department of Pediatric Allergy and Immunology; Ulus Women's & Children's Diseases Training and Research Hospital; Ankara Turkey
| | - B. Flood
- European Federation of Allergy and Airways Diseases Patients Association; Brussels Belgium
| | | | | | | | - R. Mosges
- Institute of Medical Statistics, Informatics and Epidemiology (IMSIE); University of Cologne; Köln Germany
| | - O. Palomares
- Department of Biochemistry and Molecular Biology; Complutense University of Madrid; Madrid Spain
| | - O. Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery; Universitätsmedizin Mannheim; Medical Faculty Mannheim; Heidelberg University; Mannheim Germany
- Center for Rhinology and Allergology; Wiesbaden Germany
| | - S. Smolinska
- Wroclaw Medical University; Wroclaw Poland
- ALL-MED Medical Research Institute; Wroclaw Poland
| | - M. Sokolowska
- Swiss Institute for Allergy and Asthma Research; Christine Kühne-Center for Allergy Research and Education (CK-CARE); Davos Switzerland
| | - M. Asaria
- Centre for Health Economics; University of York; York UK
| | - G. Netuveli
- Institute for Health and Human Development; University of East London; London UK
| | - H. Zaman
- Bradford School of Pharmacy; Bradford UK
| | - A. Akhlaq
- Health and Hospital Management; Institute of Business Management; Karachi Pakistan
| | - A. Sheikh
- Asthma UK Centre for Applied Research; The University of Edinburgh; Edinburgh UK
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Dhami S, Nurmatov U, Arasi S, Khan T, Asaria M, Zaman H, Agarwal A, Netuveli G, Roberts G, Pfaar O, Muraro A, Ansotegui IJ, Calderon M, Cingi C, Durham S, Wijk RG, Halken S, Hamelmann E, Hellings P, Jacobsen L, Knol E, Larenas‐Linnemann D, Lin S, Maggina P, Mösges R, Oude Elberink H, Pajno G, Panwankar R, Pastorello E, Penagos M, Pitsios C, Rotiroti G, Timmermans F, Tsilochristou O, Varga E, Schmidt‐Weber C, Wilkinson J, Williams A, Worm M, Zhang L, Sheikh A. Allergen immunotherapy for allergic rhinoconjunctivitis: A systematic review and meta-analysis. Allergy 2017; 72:1597-1631. [PMID: 28493631 DOI: 10.1111/all.13201] [Citation(s) in RCA: 186] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing Guidelines on Allergen Immunotherapy (AIT) for Allergic Rhinoconjunctivitis. To inform the development of clinical recommendations, we undertook a systematic review to assess the effectiveness, cost-effectiveness, and safety of AIT in the management of allergic rhinoconjunctivitis. METHODS We searched nine international biomedical databases for published, in-progress, and unpublished evidence. Studies were independently screened by two reviewers against predefined eligibility criteria and critically appraised using established instruments. Our primary outcomes of interest were symptom, medication, and combined symptom and medication scores. Secondary outcomes of interest included cost-effectiveness and safety. Data were descriptively summarized and then quantitatively synthesized using random-effects meta-analyses. RESULTS We identified 5960 studies of which 160 studies satisfied our eligibility criteria. There was a substantial body of evidence demonstrating significant reductions in standardized mean differences (SMD) of symptom (SMD -0.53, 95% CI -0.63, -0.42), medication (SMD -0.37, 95% CI -0.49, -0.26), and combined symptom and medication (SMD -0.49, 95% CI -0.69, -0.30) scores while on treatment that were robust to prespecified sensitivity analyses. There was in comparison a more modest body of evidence on effectiveness post-discontinuation of AIT, suggesting a benefit in relation to symptom scores. CONCLUSIONS AIT is effective in improving symptom, medication, and combined symptom and medication scores in patients with allergic rhinoconjunctivitis while on treatment, and there is some evidence suggesting that these benefits are maintained in relation to symptom scores after discontinuation of therapy.
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The role of regulatory T cells and genes involved in their differentiation in pathogenesis of selected inflammatory and neoplastic skin diseases. Part II: The Treg role in skin diseases pathogenesis. Postepy Dermatol Alergol 2017; 34:405-417. [PMID: 29507554 PMCID: PMC5835974 DOI: 10.5114/ada.2017.71105] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 01/10/2017] [Indexed: 12/22/2022] Open
Abstract
Regulatory FOXP3+ T cells (Tregs) constitute 5% to 10% of T cells in the normal human skin. They play an important role in the induction and maintenance of immunological tolerance. The suppressive effects of these cells are exerted by various mechanisms including the direct cytotoxic effect, anti-inflammatory cytokines, metabolic disruption, and modulation of the dendritic cells function. The deficiency of Treg cells number or function are one of the basic elements of the pathogenesis of many skin diseases, such as psoriasis, atopic dermatitis, bacterial and viral infections. They also play a role in the pathogenesis of T cell lymphomas of the skin (cutaneous T cell lymphomas - CTCL), skin tumors and mastocytosis. Here, in the second part of the cycle, we describe dysfunctions of Tregs in selected skin diseases.
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Lim JH, Kim JY, Han DH, Lee CH, Hong SN, Wee JH, Park SK, Rhee CS. Sublingual immunotherapy (SLIT) for house dust mites does not prevent new allergen sensitization and bronchial hyper-responsiveness in allergic rhinitis children. PLoS One 2017; 12:e0182295. [PMID: 28806766 PMCID: PMC5555666 DOI: 10.1371/journal.pone.0182295] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 07/14/2017] [Indexed: 12/30/2022] Open
Abstract
Introduction The aim of this study is to identify the effects of sublingual immunotherapy (SLIT) on immunologic parameters and bronchial-hyper-responsiveness in children with allergic rhinitis to house-dust mite (HDM), through long-term follow-up cohort. Methods Among the Allergic Rhinitis Cohort Study for Kids, pediatric patients who visited the hospital for rhinitis symptoms and proven allergy to HDM through skin prick test were studied. In this cohort, 37 patients received SLIT more than 3-years (SLIT group), and 184 patients received only pharmacologic therapy (non-SLIT group) were included in this study. The results of skin prick test, eosinophil percent and count, total immunoglobulin E (IgE), and bronchial provocation test at initial and 3-year followed-up were compared in the two groups. Results After 3 year follow-up, only the serum eosinophil percent decreased more significantly in SLIT group than that in the non-SLIT group. New-sensitization rate other than HDM between SLIT and non-SLIT group did not show any significant differences. The distribution of sensitized allergen other than HDM showed increasing tendency after 3 years in both groups. Older age and a small number of sensitized allergen affected the improvement of bronchial hyper-responsiveness regardless of SLIT. Conclusion HDM SLIT in allergic rhinitis children for 3 years in Korea does not affect prevention of new sensitization and poly-sensitization rate increment, and improvement of bronchial hyper-responsiveness.
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Affiliation(s)
- Jae Hyun Lim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Youp Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Doo Hee Han
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chul Hee Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seung-No Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jee Hye Wee
- Department of Otorhinolaryngology-Head and Neck Surgery, Bundang Jesaeng General Hospital, Deajin Medical Center, Seongnam, Korea
| | - Sue K. Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Chae-Seo Rhee
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
- Sensory Organ Research Center, Seoul National University Medical Research Center, Seoul, Korea
- * E-mail:
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Feng B, Wu J, Chen B, Xiang H, Chen R, Li B, Chen S. Efficacy and Safety of Sublingual Immunotherapy for Allergic Rhinitis in Pediatric Patients: A Meta-Analysis of Randomized Controlled Trials. Am J Rhinol Allergy 2017; 31:27-35. [PMID: 28234149 DOI: 10.2500/ajra.2017.31.4382] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Allergic rhinitis (AR) has become a global health problem that constantly affects a large part of the general population, especially children. Objective Sublingual allergen immunotherapy (SLIT) has been used extensively for pediatric AR, although its efficacy and safety are often questioned. In this meta-analysis of randomized controlled trials (RCT), we evaluated the use of SLIT for pediatric AR. Methods A number of medical literature data bases were searched through January 2016 to identify RCTs that examined the use of SLIT for pediatric AR and that assessed clinical outcomes related to efficacy. Descriptive and quantitative information was abstracted. Standardized mean differences (SMD) were calculated by using fixed- and random-effects models. Subgroup analyses were performed. Heterogeneity was assessed by using the I2 metric. A network meta-analysis was used to estimate SMDs between two SLIT protocols for pediatric seasonal AR. All data were extracted from publications or received from the authors. Results Twenty-six studies were eligible for inclusion in the meta-analysis of rhinitis or rhinoconjunctivitis symptom scores, and 19 studies were eligible for the meta-analysis of medication scores. Descriptive and quantitative data were extracted. SLIT differed significantly from placebo in terms of symptom scores (SMD -0.55 [95% confidence interval {CI}, -0.86 to -0.25]; p = 0.0003, I2 = 90%) and medication scores (SMD -0.67 [95% CI, -0.96 to -0.38J; p < 0.00001, I2 = 83%). Oral pruritus was the adverse effect, which occurred most commonly in children who were receiving SLIT. Network meta-analysis revealed no significant difference between the pre-coseasonal and continuous SLIT protocols for seasonal AR in symptom scores (SMD -6.55 [95% CI, -25.38 to 12.29]; p = 0.496) and medication scores (SMD -8.83 [95% CI, -22.10 to 4.43]; p = 0.192). Conclusions Our meta-analysis results indicated that SLIT provided significant symptom relief and reduced the need for medication in pediatric patients Moreover, the safety of SLIT needs to be confirmed in RCTs with larger samples.
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Affiliation(s)
- Bohai Feng
- Department of Otolaryngology, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China This study was supported by the National Key Clinical Opening Program on Pediatric Respiratory of China. No.523302
| | - Jueting Wu
- Department of Otolaryngology, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China This study was supported by the National Key Clinical Opening Program on Pediatric Respiratory of China. No.523302
| | - Bobei Chen
- Department of Otolaryngology, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China This study was supported by the National Key Clinical Opening Program on Pediatric Respiratory of China. No.523302
| | - Haijie Xiang
- Department of Otolaryngology, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China This study was supported by the National Key Clinical Opening Program on Pediatric Respiratory of China. No.523302
| | - Ruru Chen
- Department of Otolaryngology, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China This study was supported by the National Key Clinical Opening Program on Pediatric Respiratory of China. No.523302
| | - Bangliang Li
- Department of Otolaryngology, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China This study was supported by the National Key Clinical Opening Program on Pediatric Respiratory of China. No.523302
| | - Si Chen
- Department of Otolaryngology, the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China This study was supported by the National Key Clinical Opening Program on Pediatric Respiratory of China. No.523302
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Feng B, Xiang H, Jin H, Gao J, Huang S, Shi Y, Chen R, Chen B. Efficacy of Sublingual Immunotherapy for House Dust Mite-Induced Allergic Rhinitis: A Meta-Analysis of Randomized Controlled Trials. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2017; 9:220-228. [PMID: 28293928 PMCID: PMC5352573 DOI: 10.4168/aair.2017.9.3.220] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/06/2016] [Accepted: 10/11/2016] [Indexed: 01/04/2023]
Abstract
Purpose Allergic rhinitis (AR) has become a global issue for a large part of the general population. Sublingual immunotherapy (SLIT) has been used extensively to treat persistent allergic rhinitis (PAR). Although systematic reviews have confirmed the effectiveness of SLIT for the treatment of AR, a considerable number of studies using extracts of house dust mites (HDMs) for immunotherapy found no consensus on basic treatment parameters and questioned the efficacy of SLIT. Methods In this study, we evaluated SLIT for PAR by a meta-analysis of randomized controlled trials (RCTs). Medline, Embase, and Cochrane Library database searches were performed for RCTs on the treatment of PAR by SLIT that assessed clinical outcomes related to efficacy through May 2016. Descriptive and quantitative information was abstracted. An analysis was performed with standardized mean differences (SMDs) under a fixed or random effects model. Subgroup analyses were performed. Heterogeneity was assessed using the I2 metric. Results In total, 25 studies were eligible for inclusion in the meta-analysis for symptom scores and 15 studies for medication scores. SLIT was significantly different from the controls for symptom scores (SMD=1.23; 95% confidence interval [CI]=1.74 to 0.73; P<0.001). For medication scores, significant differences for SLIT were also observed versus the controls (SMD=-1.39; 95% CI=-1.90 to -0.88; P<0.001). Conclusions Our meta-analysis indicates that SLIT provided significant symptom relief and reduced the need for medications in PAR. In this study, significant evidence was obtained despite heterogeneity with regard to the use of mite extract. Specifically, the mite extract used was provided by the patients with PAR. Furthermore, to confirm both the objective outcomes and the effective doses of HDM allergen extracts, experimental data should be obtained from large high-quality population-based studies.
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Affiliation(s)
- Bohai Feng
- Department of Otolaryngology, the Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Haijie Xiang
- Department of Otolaryngology, the Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Haiyong Jin
- Department of Otolaryngology, the Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jinjian Gao
- Department of Otolaryngology, the Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Saiyu Huang
- Department of Otolaryngology, the Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yunbin Shi
- Department of Otolaryngology, the Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ruru Chen
- Department of Otolaryngology, the Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Bobei Chen
- Department of Otolaryngology, the Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.
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Đurić-Filipović I, Caminati M, Kostić G, Filipović Đ, Živković Z. Allergen specific sublingual immunotherapy in children with asthma and allergic rhinitis. World J Pediatr 2016; 12:283-290. [PMID: 27351563 DOI: 10.1007/s12519-016-0022-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 01/02/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND The incidence of asthma and allergic rhinitis (AR) is significantly increased, especially in younger children. Current treatment for children with asthma and allergic rhinitis include allergen avoidance, standard pharmacotherapy, and immunotherapy. Since standard pharmacotherapy is prescribed for symptoms, immunotherapy at present plays an important role in the treatment of allergic diseases. This article presents insights into the up-to-date understanding of immunotherapy in the treatment of children with allergic rhinitis and asthma. DATA SOURCES PubMed articles published from 1990 to 2014 were reviewed using the MeSH terms "asthma", "allergic rhinitis", "children", and "immune therapy". Additional articles were identified by hand searching of the references in the initial search. RESULTS Numerous studies have shown that sublingual application of allergen specific immunotherapy (SLIT) is an adequate, safe and efficient substitution to subcutaneous route of allergens administration (SCIT) in the treatment of IgE-mediated respiratory tract allergies in children. According to the literature, better clinical efficacy is connected with the duration of treatment and mono sensitized patients. CONCLUSIONS At least 3 years of treatment and stable asthma before the immunotherapy are positive predictors of good clinical efficacy and tolerability of SLIT. SLIT reduces the symptoms of allergic diseases and the use of medicaments, and improves the quality of life of children with the diseases.
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Affiliation(s)
- Ivana Đurić-Filipović
- Faculty of Medical Science Kragujevac, Department of Immunology, Svetozara Markovica 69, Kragujevac, 34000, Serbia.
| | - Marco Caminati
- Unita di Allergologia Centro Regionale di riferimento per la prevenzione, la diagnosi e la terapia delle malattie allergiche Ospedale Universitario Borgo Trento, Piazzale Stefani 1, Verona, Italy
| | - Gordana Kostić
- Children's Hospital, Clinical Centre Kragujevac, Zmaj Jovina 30, 34000, Kragujevac, Serbia
| | - Đorđe Filipović
- Institution for Emergency Medical Care, Bulevar Franša Depera 5, 11000, Belgrade, Serbia
| | - Zorica Živković
- Children's Hospital for Lung Diseases and Tuberculosis, Medical Center "Dr Dragisa Misovic", Heroja Mihajla Tepića 1, 11000, Belgrade, Serbia
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Passalacqua G, Guerra L, Fumagalli F, Canonica GW. Safety profile of sublingual immunotherapy. ACTA ACUST UNITED AC 2016; 5:225-34. [PMID: 16808542 DOI: 10.2165/00151829-200605040-00001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Sublingual immunotherapy (SLIT) was proposed for clinical practice about 20 years ago with the main aim of improving the safety and avoiding the adverse effects of traditional treatment for allergic airways disease. To date, 32 randomized controlled trials and 6 postmarketing surveys have been published that provide a robust documentation of the safety profile of the treatment.Looking at the randomized trials it emerges that the more frequent adverse event of SLIT is oral itching or swelling, followed by gastrointestinal complaints. These adverse events are invariably described as mild and easily managed by adjusting the dose. Relevant systemic adverse events (asthma, urticaria, angioedema) occur sporadically and, with the exception of oral/gastrointestinal adverse events, the incidence of adverse events seems not to differ between the placebo and active groups. The safety profile of SLIT does not differ between adults and children.The postmarketing surveys consistently show that the incidence of adverse events associated with SLIT is less than 10%, corresponding to less than 1 adverse event per 1000 doses, and is thus quite superior to the safety profile of subcutaneous immunotherapy. Of note, the most recent data show that the rate of adverse events with SLIT is not increased in children below the age of 5 years.
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Affiliation(s)
- Giovanni Passalacqua
- Department of Internal Medicine, Allergy and Respiratory Diseases, University of Genoa, Genoa, Italy
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Gueguen C, Bouley J, Moussu H, Luce S, Duchateau M, Chamot-Rooke J, Pallardy M, Lombardi V, Nony E, Baron-Bodo V, Mascarell L, Moingeon P. Changes in markers associated with dendritic cells driving the differentiation of either TH2 cells or regulatory T cells correlate with clinical benefit during allergen immunotherapy. J Allergy Clin Immunol 2015; 137:545-58. [PMID: 26522402 DOI: 10.1016/j.jaci.2015.09.015] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 08/27/2015] [Accepted: 09/11/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Regulatory dendritic cell (DC) markers, such as C1Q, are upregulated in PBMCs of patients with grass pollen allergy exhibiting clinical benefit during allergen immunotherapy (AIT). OBJECTIVES We sought to define markers differentially expressed in human monocyte-derived DCs differentiated toward a proallergic (DCs driving the differentiation of TH2 cells [DC2s]) phenotype and investigate whether changes in such markers in the blood correlate with AIT efficacy. METHODS Transcriptomes and proteomes of monocyte-derived DCs polarized toward DCs driving the differentiation of TH1 cells (DC1s), DC2s, or DCs driving the differentiation of regulatory T cells (DCreg cells) profiles were compared by using genome-wide cDNA microarrays and label-free quantitative proteomics, respectively. Markers differentially regulated in DC2s and DCreg cells were assessed by means of quantitative PCR in PBMCs from 80 patients with grass pollen allergy before and after 2 or 4 months of sublingual AIT in parallel with rhinoconjunctivitis symptom scores. RESULTS We identified 20 and 26 new genes/proteins overexpressed in DC2s and DCreg cells, respectively. At an individual patient level, DC2-associated markers, such as CD141, GATA3, OX40 ligand, and receptor-interacting serine/threonine-protein kinase 4 (RIPK4), were downregulated after a 4-month sublingual AIT course concomitantly with an upregulation of DCreg cell-associated markers, including complement C1q subcomponent subunit A (C1QA), FcγRIIIA, ferritin light chain (FTL), and solute carrier organic anion transporter family member 2B1 (SLCO2B1), in the blood of clinical responders as opposed to nonresponders. Changes in such markers were better correlated with clinical benefit than alterations of allergen-specific CD4(+) T-cell or IgG responses. CONCLUSIONS A combination of 5 markers predominantly expressed by blood DCs (ie, C1Q and CD141) or shared with lymphoid cells (ie, FcγRIIIA, GATA3, and RIPK4) reflecting changes in the balance of regulatory/proallergic responses in peripheral blood can be used as early as after 2 months to monitor the early onset of AIT efficacy.
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Affiliation(s)
- Claire Gueguen
- Research and Pharmaceutical Development, Stallergenes, Antony, France
| | - Julien Bouley
- Research and Pharmaceutical Development, Stallergenes, Antony, France
| | - Hélène Moussu
- Research and Pharmaceutical Development, Stallergenes, Antony, France
| | - Sonia Luce
- Research and Pharmaceutical Development, Stallergenes, Antony, France
| | - Magalie Duchateau
- Unité de Spectrométrie de Masse Structurale et Protéomique, Institut Pasteur, Paris, France
| | - Julia Chamot-Rooke
- Unité de Spectrométrie de Masse Structurale et Protéomique, Institut Pasteur, Paris, France
| | - Marc Pallardy
- Université Paris-Sud, INSERM UMR 996, Faculté de Pharmacie, Châtenay-Malabry, France
| | - Vincent Lombardi
- Research and Pharmaceutical Development, Stallergenes, Antony, France
| | - Emmanuel Nony
- Research and Pharmaceutical Development, Stallergenes, Antony, France
| | | | - Laurent Mascarell
- Research and Pharmaceutical Development, Stallergenes, Antony, France
| | - Philippe Moingeon
- Research and Pharmaceutical Development, Stallergenes, Antony, France.
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Abstract
BACKGROUND Asthma is a common long-term respiratory disease affecting approximately 300 million people worldwide. Approximately half of people with asthma have an important allergic component to their disease, which may provide an opportunity for targeted treatment. Sublingual immunotherapy (SLIT) aims to reduce asthma symptoms by delivering increasing doses of an allergen (e.g. house dust mite, pollen extract) under the tongue to induce immune tolerance. However, it is not clear whether the sublingual delivery route is safe and effective in asthma. OBJECTIVES To assess the efficacy and safety of sublingual immunotherapy compared with placebo or standard care for adults and children with asthma. SEARCH METHODS We identified trials from the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov (www.ClinicalTrials.gov), the World Health Organization (WHO) trials portal (www.who.int/ictrp/en/) and reference lists of all primary studies and review articles. The search is up to date as of 25 March 2015. SELECTION CRITERIA We included parallel randomised controlled trials (RCTs), irrespective of blinding or duration, that evaluated sublingual immunotherapy versus placebo or as an add-on to standard asthma management. We included both adults and children with asthma of any severity and with any allergen-sensitisation pattern. We included studies that recruited participants with asthma, rhinitis, or both, providing at least 80% of trial participants had a diagnosis of asthma. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results for included trials, extracted numerical data and assessed risk of bias, all of which were cross-checked for accuracy. We resolved disagreements by discussion.We analysed dichotomous data as odds ratios (ORs) or risk differences (RDs) using study participants as the unit of analysis; we analysed continuous data as mean differences (MDs) or standardised mean differences (SMDs) using random-effects models. We rated all outcomes using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) and presented results in the 'Summary of findings' table. MAIN RESULTS Fifty-two studies met our inclusion criteria, randomly assigning 5077 participants to comparisons of interest. Most studies were double-blind and placebo-controlled, but studies varied in duration from one day to three years. Most participants had mild or intermittent asthma, often with co-morbid allergic rhinitis. Eighteen studies recruited only adults, 25 recruited only children and several recruited both or did not specify (n = 9).With the exception of adverse events, reporting of outcomes of interest to this review was infrequent, and selective reporting may have had a serious effect on the completeness of the evidence. Allocation procedures generally were not well described, about a quarter of the studies were at high risk of bias for performance or detection bias or both and participant attrition was high or unknown in around half of the studies.One short study reported exacerbations requiring a hospital visit and observed no adverse events. Five studies reported quality of life, but the data were not suitable for meta-analysis. Serious adverse events were infrequent, and analysis using risk differences suggests that no more than 1 in 100 are likely to suffer a serious adverse event as a result of treatment with SLIT (RD 0.0012, 95% confidence interval (CI) -0.0077 to 0.0102; participants = 2560; studies = 22; moderate-quality evidence).Within secondary outcomes, wide but varied reporting of largely unvalidated asthma symptom and medication scores precluded meaningful meta-analysis; a general trend suggested SLIT benefit over placebo, but variation in scales meant that results were difficult to interpret.Changes in inhaled corticosteroid use in micrograms per day (MD 35.10 mcg/d, 95% CI -50.21 to 120.42; low-quality evidence), exacerbations requiring oral steroids (studies = 2; no events) and bronchial provocation (SMD 0.69, 95% CI -0.04 to 1.43; very low-quality evidence) were not often reported. This led to many imprecise estimates with wide confidence intervals that included the possibility of both benefit and harm from SLIT.More people taking SLIT had adverse events of any kind compared with control (OR 1.70, 95% CI 1.21 to 2.38; low-quality evidence; participants = 1755; studies = 19), but events were usually reported to be transient and mild.Lack of data prevented most of the planned subgroup and sensitivity analyses. AUTHORS' CONCLUSIONS Lack of data for important outcomes such as exacerbations and quality of life and use of different unvalidated symptom and medication scores have limited our ability to draw a clinically useful conclusion. Further research using validated scales and important outcomes for patients and decision makers is needed so that SLIT can be properly assessed as clinical treatment for asthma. Very few serious adverse events have been reported, but most studies have included patients with intermittent or mild asthma, so we cannot comment on the safety of SLIT for those with moderate or severe asthma. SLIT is associated with increased risk of all adverse events.
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Affiliation(s)
- Rebecca Normansell
- St George's, University of LondonPopulation Health Research InstituteLondonUKSW17 0RE
| | - Kayleigh M Kew
- St George's, University of LondonPopulation Health Research InstituteLondonUKSW17 0RE
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23
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Leatherman BD, Khalid A, Lee S, McMains K, Peltier J, Platt MP, Stachler RJ, Toskala E, Tropper G, Venkatraman G, Lin SY. Dosing of sublingual immunotherapy for allergic rhinitis: evidence-based review with recommendations. Int Forum Allergy Rhinol 2015; 5:773-83. [PMID: 26097218 DOI: 10.1002/alr.21561] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/27/2015] [Accepted: 05/02/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Since the mid 1980s, the clinical use of sublingual immunotherapy (SLIT) has dramatically increased. However, 1 of the primary barriers to providing SLIT is lack of a published dosing recommendations. The purpose of this work is to provide a range of effective SLIT dosing based upon a rigorous review of the existing evidence base. An appendix with SLIT dosing recommendations is also included. METHODS A comprehensive search of the past 25 years of the medical literature using PubMed was performed for specific antigens. Inclusion criteria for articles included: randomized, placebo-controlled studies of SLIT, studies with clinical allergic rhinitis outcomes, and dosing units available to determine the micrograms per month of major allergen administered. The extracted data was used to compile a range of effective SLIT dosing for individual antigens. RESULTS Seventy-five articles met the inclusion criteria, providing a range of effective dosing for some allergens. There was commonly a wide range in doses for particular antigens between the individual studies. For some antigens, there was significant overlap in dosage amount between studies showing efficacy and lack of efficacy. Clinical trials meeting inclusion criteria are not available for many allergens. CONCLUSION This study provided a comprehensive review of the published sublingual dosing ranges for specific antigens. The review provided a range of effective sublingual doses for some allergens, whereas for other allergens there was insufficient published data to determine specific doses. Recommendations for SLIT dosing were produced based on the data revealed in the review and expert opinion.
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Affiliation(s)
- Bryan D Leatherman
- Coastal Sinus and Allergy Center, Gulfport, MS.,Coastal Ear Nose and Throat Associates, Gulfport, MS
| | | | - Stella Lee
- Department of Otolaryngology-Head and Neck Surgery, Division of Sinonasal Disorders and Allergy, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kevin McMains
- Otolaryngology, South Texas Veterans Health Care System, San Antonio, TX
| | | | - Michael P Platt
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, Boston, MA
| | | | - Elina Toskala
- Department of Otolaryngology-Head and Neck Surgery, Temple University, School of Medicine, Philadelphia, PA
| | - Guy Tropper
- Avant Garde Medical Care, Boucherville, QC, Canada
| | | | - Sandra Y Lin
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD
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Pfaar O, Gerth van Wijk R. Mite-Allergic Rhinitis: How to Evaluate Clinical Efficacy in Allergen-Specific Immunotherapy Trials? CURRENT TREATMENT OPTIONS IN ALLERGY 2015; 2:1-9. [PMID: 25798370 PMCID: PMC4361724 DOI: 10.1007/s40521-014-0040-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
House dust mite (HDM) allergen exposure is the most important cause of perennial allergic rhinitis and/or asthma. Although allergen-specific immunotherapy (AIT) with HDM is well established, published studies have been characterized by substantial heterogeneity in clinical endpoints. Standardization in measuring clinical efficacy is required. Moreover, when designing an AIT trial with HDM allergens, several considerations have to be taken into account. The history of HDM allergy is less clear cut than the typical history of pollen allergy. In addition, clinical features of HDM allergy may differ from those of pollen allergy. Moreover, although not easily measurable, fluctuation in allergen exposure may cause variation in symptom severity and determine the timing of assessment of clinical effects of HDM AIT. Key points 1. A combined symptom and medication score (CSMS) is recommended as standard for the primary endpoint in future house dust mite (HDM) allergen-specific immunotherapy trials. 2. The diagnosis of HDM allergy is based on a carefully taken history in combination with sensitization to HDM allergens. 3. Eye symptoms are less prominent in patients with HDM-induced allergic rhinitis. Nasal symptoms, but not eye symptoms, should be included in the CSMS and in symptom scores as well. 4. As methods to determine allergen exposure vary and the efficacy of environmental control is a matter of debate, a practical approach consists of restraining patients from implementing HDM-reducing measures, such as removing carpets and introducing anti-mite covers, after the start of the study. 5. Efficacy evaluation in the period with the highest exposure to mites is recommended.
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Affiliation(s)
- Oliver Pfaar
- Center for Rhinology and Allergology Wiesbaden, Germany, An den Quellen 10, 65189 Wiesbaden, Germany ; Department of Otorhinolaryngology, Head and Neck Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Roy Gerth van Wijk
- Section of Allergology, Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
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25
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Bahceciler NN, Babayigit Hocaoglu A, Galip N. A milestone in house dust-mite-allergen immunotherapy: the new sublingual tablet S-524101 (actair). Expert Rev Vaccines 2014; 13:1427-38. [PMID: 25345538 DOI: 10.1586/14760584.2014.972949] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Subcutaneous allergen-specific immunotherapy has long been used in the treatment of allergic rhinitis and/or asthma and its efficacy has been confirmed. However, due to the discomfort of injections and the risk of severe adverse reactions, alternative routes of allergen administration have emerged. Delivery of allergens through the mucosal route had been proposed and investigated thoroughly, confirming the sublingual route to be the most efficacious. Later, the efficacy and safety of this route have been documented by numerous controlled trials both for house dust mite (HDM) and pollens. Recently, sublingual orodispersable grass pollen allergen tablets were in use followed by the newly developed HDM allergen tablets with satisfactory clinical results: Moreover, very recently 1 year of HDM tablet treatment was demonstrated to exert its clinical efficacy 1 year after discontinuation of tablet IT. The persistence of efficacy after only 1 year of treatment is a new and promising era. Currently, Sublingual Immunotherapy is the most easily administered and safe treatment option until more immunogenic, less allergenic and more efficient allergen extracts are developed.
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Affiliation(s)
- Nerin N Bahceciler
- Department of Pediatrics, Division of Allergy and Clinical Immunology, Nicosia, North Cyprus, Turkey
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26
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Makatsori M, Scadding GW, Lombardo C, Bisoffi G, Ridolo E, Durham SR, Senna G. Dropouts in sublingual allergen immunotherapy trials - a systematic review. Allergy 2014; 69:571-80. [PMID: 24673502 DOI: 10.1111/all.12385] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2014] [Indexed: 11/27/2022]
Abstract
Participant dropouts can reduce the power of allergen immunotherapy clinical trials. Evaluation of the dropout rate and reasons for dropout are important not only in the planning of clinical studies but are also relevant for adherence to immunotherapy in daily clinical practice. A systematic review was carried out in order to establish the overall dropout rate among published double-blind, placebo-controlled randomized clinical trials of sublingual immunotherapy for respiratory allergic diseases. Dropouts were analysed in regards to allergen, formulation, treatment schedule, participant age, study size, number of centres and type of allergic disease. Relative dropout rates in placebo and active groups as well as reasons for dropout were also assessed. A total of 81 studies, comprising 9998 patients, were included. Dropout rates in sublingual immunotherapy controlled studies do not appear to be a major problem with a composite dropout percentage of 14% (95% CI:11.9-16). Furthermore, they are not different for active compared to placebo-treated participants. This lends support to the positive clinical outcomes seen in meta-analyses of these trials.
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Affiliation(s)
- M. Makatsori
- Allergy Department; Royal Brompton & Harefield NHS Foundation Trust; London UK
- National Heart & Lung Institute; Allergy & Clinical Immunology; Imperial College London; London UK
| | - G. W. Scadding
- Allergy Department; Royal Brompton & Harefield NHS Foundation Trust; London UK
- National Heart & Lung Institute; Allergy & Clinical Immunology; Imperial College London; London UK
| | - C. Lombardo
- Verona University Hospital; Allergy Unit; Verona Italy
| | - G. Bisoffi
- Verona University Hospital; Research Support Unit and Biostatistics; Verona
| | - E. Ridolo
- Department of Clinical and Experimental Medicine; University of Parma; Parma Italy
| | - S. R. Durham
- Allergy Department; Royal Brompton & Harefield NHS Foundation Trust; London UK
- National Heart & Lung Institute; Allergy & Clinical Immunology; Imperial College London; London UK
| | - G. Senna
- Verona University Hospital; Allergy Unit; Verona Italy
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27
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Wu YS, Chen S, Wang W, Lu CL, Liu CF, Chen SN. Oral Administration of MBG to Modulate Immune Responses and Suppress OVA-Sensitized Allergy in a Murine Model. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2014; 2014:567427. [PMID: 24723960 PMCID: PMC3960727 DOI: 10.1155/2014/567427] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 01/20/2014] [Indexed: 11/30/2022]
Abstract
Recently studies performed on mushroom isolated polysaccharides demonstrated that β -(1,3)-glucan may affect the balance of Th1/Th2 cell response. Using ovalbumin (OVA) as a hypersensitivity inducer, we evaluated the ability of mushroom beta-glucan (MBG) in modulating Th1/Th2 cell responses in B6 mice. As compared to the control group, administration of MBG resulted in an increase of phagocytic activities, Th1 cytokine productions, immunoglobulins including IgG2A and IgA, and a significant expression of the splenic surface markers including CD3, CD4, CD8, and F4/80. In contrast, administration of MBG has significantly suppressed IgE and IgG1 levels and Th2 cytokines including IL-4, IL-5, and IL-6. Histopathological observation of MBG-treated followed by OVA-treated mice showed less filtration of eosinophil in pulmonary tissue sections. Our data suggested that administration of MBG treatments alters the natural course of the IgE-mediated hypersensitivities. In this investigation, we realize the mushroom beta glucan alter the Th2 response toward the Th1 in the allergic, resulting in a reduction in IgE productions which played a substantive role in reducing the severity of IgE-mediated hypersensitivity.
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Affiliation(s)
- Yu-Sheng Wu
- College of Life Sciences, National Taiwan University, No. 1, Sec. 4, Roosevelt Road, Da'an District, Taipei City 10617, Taiwan
| | - Sherwin Chen
- Department of Research and Development, Super Beta Glucan Inc., Irvine, CA, USA
| | - William Wang
- Department of Research and Development, Super Beta Glucan Inc., Irvine, CA, USA
| | - Chung-Lun Lu
- College of Life Sciences, National Taiwan University, No. 1, Sec. 4, Roosevelt Road, Da'an District, Taipei City 10617, Taiwan
| | - Chi-Feng Liu
- Graduate Institute of Integration of Traditional Chinese Medicine with Western Nursing, National Taipei University of Nursing and Health Sciences, Taipei 11031, Taiwan
| | - Shiu-Nan Chen
- College of Life Sciences, National Taiwan University, No. 1, Sec. 4, Roosevelt Road, Da'an District, Taipei City 10617, Taiwan
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28
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Tao L, Shi B, Shi G, Wan H. Efficacy of sublingual immunotherapy for allergic asthma: retrospective meta-analysis of randomized, double-blind and placebo-controlled trials. CLINICAL RESPIRATORY JOURNAL 2014; 8:192-205. [PMID: 24118881 DOI: 10.1111/crj.12058] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 08/27/2013] [Accepted: 09/22/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND Allergen-specific immunotherapy (SIT) is the only available curative choice with a disease-modifying effect against respiratory allergies. The efficacy of SIT via the sublingual route was demonstrated by a number of clinical trials. This meta-analysis was performed to investigate the clinical efficacy and safety of sublingual-specific immunotherapy (SLIT) for allergic asthma. METHODS PubMed, EMBASE and the Cochrane Central Register of Controlled Trials were searched for randomized, double-blind and placebo-controlled (DBPC) trials evaluating the efficacy and safety of SLIT on allergic asthma. Subgroup analyses were performed according to age, type of allergen and duration of SLIT treatment. RESULTS Sixteen randomized DBPC trials comprising 794 patients in total met the inclusion criteria. The results suggest that SLIT significantly reduces both symptom [standardized mean difference (SMD), -0.74; P=0.006] and medication scores (SMD, -0.78; P=0.02) compared with placebo. SLIT offers a better clinical response in mite sensitive asthmatics but without confirmed proof from subgroup analyses. Prolonged duration of treatment for more than 12 months brings no additive effects. Improvement in the skin prick test was also observed following immunotherapy. There was no consistent effect on forced expiratory volume in 1 s, serum levels of antigen-specific immunoglobulin G4 and immunoglobulin E in the treated group. The risk of adverse effects was relative risk 2.23 (P=0.01). CONCLUSIONS SLIT is safe and clinically effective in reducing symptoms and medication use for allergic asthma. Our subgroup analyses failed to identify a disproportionate benefit of SLIT in any specific group of asthmatics, but some possible trends did emerge.
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Affiliation(s)
- Lianqin Tao
- Department of Pulmonary Medicine, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Shamji MH. Mechanisms of Allergen-Specific Sublingual Immunotherapy and the Use of Biological Markers in Allergic Rhinitis. CURRENT TREATMENT OPTIONS IN ALLERGY 2014. [DOI: 10.1007/s40521-013-0009-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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30
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Aryan Z, Compalati E, Comapalati E, Canonica GW, Rezaei N. Allergen-specific immunotherapy in asthmatic children: from the basis to clinical applications. Expert Rev Vaccines 2013; 12:639-59. [PMID: 23750794 DOI: 10.1586/erv.13.45] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Atopic asthma in childhood with the tendency to persist into adult life is an important issue in pediatrics. Allergen-specific immunotherapy (SIT) is the only curative treatment option for these children, being directed to the causes of the disease. The Th2 phenotype is a predominant immunological pattern in atopic asthma and SIT leads to apoptosis/anergy of T cells and induces immune-regulatory responses and immune deviation towards Th1. Many factors can affect the safety and efficacy of SIT, such as pattern of sensitization, allergy vaccine (allergen extracts, adjuvants and conjugated molecules), route of administration (subcutaneous or sublingual) and different treatment schedules. Overall, asthma symptoms and medication scores usually decrease following a SIT course and the most common observed side effects are restricted to local swelling, erythema and pruritus. Compared with conventional pharmacotherapy, SIT may be more cost effective, providing a benefit after discontinuation and a steroid-sparing effect. In addition, it can prevent new sensitizations in monosensitized asthmatic children. Microbial supplements such as probiotics, immunomodulatory substances like anti-IgE/leukotrienes, antibodies and newer allergen preparations such as recombinant forms have been tested to improve the efficacy and safety of SIT with inconclusive results. In conclusion, SIT provides an appropriate solution for childhood asthma that should be employed more often in clinical practice. Further studies are awaited to improve current knowledge regarding the mechanisms behind SIT and determine the most appropriate materials and schedule of immunotherapy for children with asthma.
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Affiliation(s)
- Zahra Aryan
- Molecular Immunology Research Center, Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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An evidence-based analysis of house dust mite allergen immunotherapy: a call for more rigorous clinical studies. J Allergy Clin Immunol 2013; 132:1322-36. [PMID: 24139829 DOI: 10.1016/j.jaci.2013.09.004] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 09/05/2013] [Accepted: 09/09/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND According to meta-analyses and reviews, subcutaneous allergen immunotherapy (SCIT) and sublingual allergen immunotherapy (SLIT) are beneficial in patients with allergic rhinitis (AR) and allergic asthma (AA) induced by house dust mites (HDMs). However, the reported effect sizes have varied greatly from one study to another. OBJECTIVE We sought to perform an evidence-based medicine assessment of commercially available SCIT and SLIT formulations in patients with HDM-induced AA and HDM-induced AR. METHODS We searched for double-blind, placebo-controlled randomized clinical trials and analyzed study designs, doses, regimens, patient-reported outcomes, safety reporting, and compliance. RESULTS Forty-four studies met our inclusion criteria. Some studies tested both SLIT and SCIT or scored both AA and AR outcomes; therefore we reviewed 35 treatment arms in patients with AA (20 for SCIT and 15 for SLIT) and 23 treatment arms in patients with AR (7 for SCIT and 16 for SLIT). The treatment duration ranged from 6 weeks to 3 years. For SCIT, the dose of Der p 1 major allergen (when reported) ranged from 7 to 30 μg for maintenance doses and 60 to 420 μg for cumulative doses. For SLIT, the doses of Der p 1 (when reported) were 0.8 to 70 μg for maintenance doses and 60 to 23,695 μg for cumulative doses. Safety data were often absent or poorly reported. A statistically significant active versus placebo symptom score was observed more frequently for SCIT than for SLIT. CONCLUSION There is no consensus on basic treatment parameters (eg, dose and duration) in HDM SCIT and SLIT. There is an urgent need for rigorous, long-term, double-blind, placebo-controlled randomized clinical trials with an efficacy criterion that reflects the particular features of HDM-induced allergic disease.
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32
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Eifan AO, Calderon MA, Durham SR. Allergen immunotherapy for house dust mite: clinical efficacy and immunological mechanisms in allergic rhinitis and asthma. Expert Opin Biol Ther 2013; 13:1543-56. [PMID: 24099116 DOI: 10.1517/14712598.2013.844226] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION There is an increasing prevalence of atopic diseases such as allergic rhinitis and asthma with house dust mite (HDM) being the common allergen that is highly associated with allergic rhinitis and asthma. Allergen avoidance and pharmacotherapy are part of treatment but it has proved difficult to change the course of HDM-related allergic diseases. Allergen immunotherapy (AIT) has been in use for the past century and has been shown to be effective in the treatment of allergic respiratory disease. AREAS COVERED This review exclusively focuses on HDM-AIT and discusses the differences in clinical efficacy and safety, long-term effect after discontinuation and immunological changes observed in both HDM-subcutaneous immunotherapy (SCIT) and HDM-sublingual immunotherapy (SLIT) in the treatment of allergic rhinitis and asthma in both pediatric and adult populations. EXPERT OPINION The majority of studies involved small numbers of patients, variable doses of major allergens and are of variable quality. There is good evidence for HDM-SCIT efficacy and its long-term effect in adults and children, whereas at the present time, evidence for HDM-SLIT is unconvincing, particularly in children. In carefully selected patients, HDM-SCIT is effective and safe. More definitive trials are needed before HDM-SLIT can be recommended in routine practice for rhinitis and/or asthma.
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Affiliation(s)
- Aarif O Eifan
- Imperial College London, Allergy and Clinical Immunology , NHLI, London, SW7 2AZ , UK
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Kim JM, Lin SY, Suarez-Cuervo C, Chelladurai Y, Ramanathan M, Segal JB, Erekosima N. Allergen-specific immunotherapy for pediatric asthma and rhinoconjunctivitis: a systematic review. Pediatrics 2013; 131:1155-67. [PMID: 23650298 PMCID: PMC4074663 DOI: 10.1542/peds.2013-0343] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Subcutaneous immunotherapy (SCIT) is approved in the United States for the treatment of pediatric asthma and rhinitis; sublingual immunotherapy (SLIT) does not have regulatory approval but is used in clinical practice. The objective of this study was to systematically review the evidence regarding the efficacy and safety of SCIT and SLIT for the treatment of pediatric asthma and allergic rhinoconjunctivitis. METHODS Two independent reviewers selected articles for inclusion, extracted data, and graded the strength of evidence for each clinical outcome. All studies were randomized controlled trials of children with allergic asthma or rhinoconjunctivitis treated with SCIT or an aqueous formulation of SLIT. Data sources were Medline, Embase, LILACS, CENTRAL, and the Cochrane Central Register of Controlled Trials through May 2012. RESULTS In 13 trials, 920 children received SCIT or usual care; in 18 studies, 1583 children received SLIT or usual care. Three studies compared SCIT with SLIT head-to-head in 135 children. The strength of evidence is moderate that SCIT improves asthma and rhinitis symptoms and low that SCIT improves conjunctivitis symptoms and asthma medication scores. Strength of evidence is high that SLIT improves asthma symptoms and moderate that SLIT improves rhinitis and conjunctivitis symptoms and decreases medication usage. The evidence is low to support SCIT over SLIT for improving asthma or rhinitis symptoms or medication usage. Local reactions were frequent with SCIT and SLIT. There was 1 report of anaphylaxis with SCIT. CONCLUSIONS Evidence supports the efficacy of both SCIT and SLIT for the treatment of asthma and rhinitis in children.
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Affiliation(s)
- Julia M. Kim
- Departments of Pediatrics, Division of General Pediatrics and Adolescent Medicine
| | | | | | | | | | - Jodi B. Segal
- Medicine, Division of General Internal Medicine, and
| | - Nkiruka Erekosima
- Medicine, Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Bonvalet M, Moussu H, Wambre E, Ricarte C, Horiot S, Rimaniol AC, Kwok WW, Horak F, de Beaumont O, Baron-Bodo V, Moingeon P. Allergen-specific CD4+ T cell responses in peripheral blood do not predict the early onset of clinical efficacy during grass pollen sublingual immunotherapy. Clin Exp Allergy 2013. [PMID: 23181790 DOI: 10.1111/cea.12015] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Surrogate biomarkers of efficacy are needed in support of allergen-specific immunotherapy. OBJECTIVE The aim of this study was to relate changes in peripheral CD4(+) T cell responses to clinical efficacy during sublingual immunotherapy (SLIT). METHODS Allergen-specific CD4(+) T cell responses were assessed in peripheral blood mononuclear cells (PBMCs) from 89 grass pollen-allergic individuals enrolled in a double-blind placebo-controlled SLIT study conducted in an allergen exposure chamber (ClinicalTrials.gov NCT00619827). Surface phenotype, proliferative responses, cytokine production and gene expression were analysed in coded samples at baseline, and after 2 and 4 months of SLIT, in PBMCs after in vitro allergen stimulation or among MHC class II/peptide (pMHCII)-tetramer-positive CD4(+) T cells. RESULTS SLIT induced a 29.3% improvement of the average rhinoconjunctivitis total symptom score in the active group, when compared to the placebo group. In parallel, only minor changes in proportions of CD4(+) T cells expressing Th1 (CCR5(+), CXCR3(+)), Th2 (CRTh2(+), CCR4(+)) and Treg (CD25(+), CD127(-), Foxp3(+)) markers were detected. A down-regulation of IL-4 and IL-10 gene expression and IL-10 secretion (P < 0.001) were observed, as well as a decrease in the frequency of potential "pro-allergic" CD27(-) Th2 cells from patients receiving active tablets (P < 0.001), but without any correlation with clinical benefit. pMHCII-tetramer analyses failed to document any major impact in both numbers and polarization of circulating Phl p 1- and Phl p 5-specific CD4(+) T cells, confirming that early clinical improvement during SLIT is not associated with dramatic alterations in T lymphocyte responses. CONCLUSION & CLINICAL RELEVANCE Changes in patterns of peripheral CD4(+) T cells are not markers for the early onset of efficacy during SLIT.
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Cappella A, Durham SR. Allergen immunotherapy for allergic respiratory diseases. Hum Vaccin Immunother 2012; 8:1499-512. [PMID: 23095870 PMCID: PMC3660772 DOI: 10.4161/hv.21629] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 07/18/2012] [Accepted: 07/26/2012] [Indexed: 01/27/2023] Open
Abstract
Allergen specific immunotherapy involves the repeated administration of allergen products in order to induce clinical and immunologic tolerance to the offending allergen. Immunotherapy is the only etiology-based treatment that has the potential for disease modification, as reflected by longterm remission following its discontinuation and possibly prevention of disease progression and onset of new allergic sensitizations. Whereas subcutaneous immunotherapy is of proven value in allergic rhinitis and asthma there is a risk of untoward side effects including rarely anaphylaxis. Recently the sublingual route has emerged as an effective and safer alternative. Whereas the efficacy of SLIT in seasonal allergy is now well-documented in adults and children, the available data for perennial allergies and asthma is less reliable and particularly lacking in children. This review evaluates the efficacy, safety and longterm benefits of SCIT and SLIT and highlights new findings regarding mechanisms, potential biomarkers and recent novel approaches for allergen immunotherapy.
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Affiliation(s)
- Antonio Cappella
- Section Allergy and Clinical Immunology, National Heart and Lung Institute; Imperial College; London UK
| | - Stephen R. Durham
- Section Allergy and Clinical Immunology, National Heart and Lung Institute; Imperial College; London UK
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Vichyanond P, Pensrichon R, Kurasirikul S. Progress in the management of childhood asthma. Asia Pac Allergy 2012; 2:15-25. [PMID: 22348203 PMCID: PMC3269597 DOI: 10.5415/apallergy.2012.2.1.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 01/17/2012] [Indexed: 12/16/2022] Open
Abstract
Asthma has become the most common chronic disease in childhood. Significant advances in epidemiological research as well as in therapy of pediatric asthma have been made over the past 2 decades. In this review, we look at certain aspects therapy of childhood asthma, both in the past and present. Literature review on allergen avoidance (including mites, cockroach and cat), intensive therapy with β(2)-agonists in acute asthma (administering via continuous nebulization and intravenous routes), a revisit of theophylline use and its action, the use of inhaled corticosteroids in various phases of childhood asthma and sublingual immunotherapy in asthma are examined. Recent facts and dilemmas of these treatments are identified along with expression of our opinions, particularly on points of childhood asthma in the Asia-Pacific, are made in this review.
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Affiliation(s)
- Pakit Vichyanond
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Rattana Pensrichon
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Suruthai Kurasirikul
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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La Rosa M, Lionetti E, Leonardi S, Salpietro A, Bianchi L, Salpietro C, Miraglia Del Giudice M, Ciprandi G, Marseglia GL. Specific immunotherapy in children: the evidence. Int J Immunopathol Pharmacol 2011; 24:69-78. [PMID: 22032790 DOI: 10.1177/03946320110240s413] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Specific immunotherapy (SIT) is the only treatment able to not only act on the symptoms of allergy but also act on the causes. At present, SIT may be administered in two forms: subcutaneous (SCIT) and sublingual immunotherapy (SLIT). SCIT represents the standard modality of treatment while SLIT has recently been introduced into clinical practice and today represents an accepted alternative to SCIT. The main advantages of SIT that are lacking with drug treatment are long-lasting clinical effects and alteration of the natural course of the disease. This prevents the new onset of asthma in patients with allergic rhinitis and the onset of new sensitizations. The mechanism of action of both routes is similar; they modify peripheral and mucosal Th2-responses into a prevalent Th1-polarization with subsequent reduction of the allergic inflammatory reaction. Both have long-term effects for years after they have been discontinued, although for SLIT these evidences are insufficient. To date several guidelines have defined indications, controindications, side-effects, and clinical aspect for SCIT and SLIT. New forms of immunotherapy, allergen products and approaches to food allergy and atopic eczema represents the future of SIT.
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Affiliation(s)
- M La Rosa
- Department of Pediatrics, University of Catania, Italy
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Han DH, Rhee CS. Sublingual immunotherapy in allergic rhinitis. Asia Pac Allergy 2011; 1:123-9. [PMID: 22053308 PMCID: PMC3206241 DOI: 10.5415/apallergy.2011.1.3.123] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Accepted: 09/17/2011] [Indexed: 12/31/2022] Open
Abstract
Current treatment options for allergic rhinitis (AR) include allergen avoidance and environmental control, pharmacotherapy, nasal surgery and immunotherapy. Among these, immunotherapy is the only therapeutic option that modifies fundamental immunologic mechanism by inducing desensitization. Specific allergen immunotherapy has been used for 1 century since 1911 and subcutaneous immunotherapy (SCIT) has been demonstrated to be effective in asthma and AR. However, SCIT has several disadvantages such as inconvenience, invasiveness and potentially severe systemic reactions. Thus, sublingual immunotherapy (SLIT) has recently received much attention around the world as a treatment for AR and is now widely used to replace the subcutaneous route. SLIT has recently been introduced in Korea and is now available for AR treatment in the Asia-Pacific region. This review offers better understanding of SLIT for AR by summarizing published articles and our previous works regarding proposed mechanisms, indication and efficacy, safety and adverse events, and compliance.
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Affiliation(s)
- Doo Hee Han
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul 110-799, Korea
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Abstract
Sublingual immunotherapy (SLIT) has been shown to be safe and efficacious in treating allergic rhinitis. It has been used in Europe for more than 20 years, and interest in the United States is increasing. SLIT has been shown to elicit immunologic changes similar to subcutaneous injection immunotherapy. SLIT may prevent new sensitizations, improve asthma control, and decrease asthma development in allergic individuals. Although differences in antigen quantification and standardization make European dosing schemes difficult to translate in the United States, several new studies suggest the range for effective dosing. Further studies will help clarify optimal dosing.
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Affiliation(s)
- Sandra Y Lin
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
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40
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Walker SM, Durham SR, Till SJ, Roberts G, Corrigan CJ, Leech SC, Krishna MT, Rajakulasingham RK, Williams A, Chantrell J, Dixon L, Frew AJ, Nasser SM. Immunotherapy for allergic rhinitis. Clin Exp Allergy 2011; 41:1177-200. [DOI: 10.1111/j.1365-2222.2011.03794.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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41
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Passalacqua G, Compalati E, Canonica GW. Sublingual immunotherapy: other indications. Immunol Allergy Clin North Am 2011; 31:279-87, ix. [PMID: 21530820 DOI: 10.1016/j.iac.2011.02.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sublingual immunotherapy (SLIT) represents a significant advance and it seems particularly suitable in pediatric patients. There are favorable results for food allergy in controlled trials. For latex allergy, the results of several trials are encouraging. For atopic dermatitis, previous experience with subcutaneous immunotherapy and some earlier trials suggest the possible application of SLIT in children with mild to moderate dermatitis and sensitization to dust mite, but this recommendation is considered insufficiently evidence based. In hymenoptera allergy, the only trial available is a proof-of-concept study in large local reactions that needs to be confirmed in well-controlled studies.
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Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases, Department of Internal Medicine, University of Genoa, Padiglione Maragliano, Largo R. Benzi 10, Genoa 16132, Italy
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Shamji MH, James LK, Durham SR. Serum immunologic markers for monitoring allergen-specific immunotherapy. Immunol Allergy Clin North Am 2011; 31:311-23, x. [PMID: 21530822 DOI: 10.1016/j.iac.2011.03.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Allergen immunotherapy is an effective treatment option in patients with IgE-mediated allergy, particularly in those who do not respond to usual antiallergic drugs. Successful immunotherapy has been associated with the suppression of allergic inflammation in target organs and increases in allergen-specific IgG antibodies, particularly the IgG(4) subclass. To date there are no biomarkers that are predictive of the clinical response to immunotherapy. This article explores the possibility that functional assays based on the ability of IgG to compete with IgE and inhibit IgE-allergen complex formation may be surrogate or predictive of the clinical response to immunotherapy.
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Affiliation(s)
- Mohamed H Shamji
- Allergy and Clinical Immunology Section, National Heart and Lung Institute, Medical Research Council and Asthma UK Centre for Allergic Mechanisms of Asthma, Imperial College London, Dovehouse Street, London, SW3 6LY, UK.
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Cox L, Wallace D. Specific Allergy Immunotherapy for Allergic Rhinitis: Subcutaneous and Sublingual. Immunol Allergy Clin North Am 2011; 31:561-99. [DOI: 10.1016/j.iac.2011.05.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Abstract
Allergen immunotherapy is allergen-specific, allergen dose- and time-dependent and is associated with long-term clinical and immunological tolerance that persists for years after discontinuation. Successful immunotherapy is accompanied by the suppression of numbers of T-helper 2 (Th2) effector cells, eosinophils, basophils, c-kit+mast cells and neutrophils infiltration in target organs, induction of IL-10 and/or TGF-β+Treg cells and increases in 'protective' non-inflammatory blocking antibodies, particularly IgG4 and IgA2 subclasses with inhibitory activity. These events are accompanied by a reduction and/or a redirection of underlying antigen-specific Th2-type T cell-driven hypersensitivity to the allergen(s) used for therapy. This suppression occurs within weeks or months as a consequence of the appearance of a population of regulatory T cells that exert their effects by mechanisms involving cell-cell contact, but also by the release of cytokines such as IL-10 (increases IgG4) and TGF-β (increases specific IgA). The more delayed-in-time appearance of antigen-specific T-helper 1 responses and alternative mechanisms such as Th2 cell anergy and/or apoptosis may also be involved. The mechanisms of sublingual immunotherapy are similar to those following a subcutaneous administration of allergen, whereas it is likely that additional events following antigen presentation in the sublingual mucosa and regional lymph nodes are involved. These insights have resulted in novel approaches and portend future biomarkers that may be surrogate or predictive of the clinical response to treatment.
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Affiliation(s)
- M H Shamji
- Allergy and Clinical Immunology Section, Medical Research Council and Asthma UK Centre for Allergic Mechanisms of Asthma, Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK.
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Calderon MA, Penagos M, Sheikh A, Canonica GW, Durham S. Sublingual immunotherapy for treating allergic conjunctivitis. Cochrane Database Syst Rev 2011:CD007685. [PMID: 21735416 DOI: 10.1002/14651858.cd007685.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Allergic ocular symptoms, although frequently trivialised, are common and represent an important comorbidity of allergic rhinitis. Sublingual Immunotherapy (SLIT) is an effective and well-tolerated treatment for allergic rhinitis, but its effects on symptoms of ocular allergy have not been well established. OBJECTIVES To evaluate the efficacy of SLIT compared with placebo for reductions in ocular symptoms, topical ocular medication requirements and conjunctival immediate allergen sensitivity. SEARCH STRATEGY We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 1), MEDLINE (January 1950 to January 2011), EMBASE (January 1980 to January 2011), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to January 2011), Web of Science (January 1970 to January 2011), Biosis Previews, (January 1979 to January 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (January 2011), ClinicalTrials.gov (www.clinicaltrials.gov) (January 2011), the Australian New Zealand Clinical Trials Registry (ANZCTR) (www.actr.org.au) (July 2010), SCOPUS (November 2008) and the UK Clinical Trials Gateway (January 2010). There were no language or date restrictions in the search for trials. All electronic databases except for SCOPUS, the UK Clinical Trials Gateway and ANZCTR were last searched on 19 January 2011. SELECTION CRITERIA Randomised controlled trials (RCTs), double-masked and placebo controlled, which evaluated the efficacy of SLIT in patients with symptoms of allergic rhinoconjunctivitis (ARC) or allergic conjunctivitis (AC). DATA COLLECTION AND ANALYSIS The primary outcome was the total ocular symptom scores. Secondary endpoints included individual ocular symptom scores (such as itchy eyes, red eyes, watery eyes, swollen eyes), ocular medication scores (eye drops) and conjunctival immediate allergen sensitivity (CIAS). Data were analysed and reported as standardised mean differences (SMDs) using Review Manager software. MAIN RESULTS Forty-two trials (n = 3958 total participants; n= 2011 SLIT and n = 1947 placebo) had available data to evaluate the efficacy of SLIT on AC and were included in the meta-analyses. Heterogeneity among studies (I(2) statistic) was around 50% or below for all endpoints. Sublingual immunotherapy induced a significant reduction in both total ocular symptom scores (SMD -0.41; 95% confidence interval (CI) -0.53 to -0.28; P < 0.00001; I(2) = 59%) and individual ocular symptom scores for red eyes (SMD -0.33; 95% CI -0.45 to -0.22; P < 0.00001; I(2) = 27%), itchy eyes (SMD -0.31; 95% CI -0.42 to -0.20; P < 0.00001; I(2) = 46%) and watery eyes (SMD -0.23; 95% CI -0.34 to -0.11; P < 0.0001; I(2) = 42%) compared to placebo. Those participants having active treatment showed an increase in the threshold dose for the conjunctival allergen provocation test (SMD 0.35; 95% CI 0.00 to 0.69; P = 0.05; I(2) = 43%). No significant reduction was observed in ocular eye drops use (SMD -0.10; 95% CI -0.22 to 0.03; P = 0.13; I(2) = 34%). AUTHORS' CONCLUSIONS Overall, SLIT is moderately effective in reducing total and individual ocular symptom scores in participants with ARC and AC. There were however some concerns about the overall quality of the evidence-base, this relating to inadequate descriptions of allocation concealment in some studies, statistical heterogeneity and the possibility of publication bias. There is a need for further large rigorously designed studies that study long-term effectiveness after discontinuation of treatment and establish the cost-effectiveness of SLIT.
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Affiliation(s)
- Moises A Calderon
- Department of Allergy and Respiratory Medicine, Royal Brompton Hospital, Imperial College School of Medicine at the National Heart and Lung Institute, London, UK, SW3 6LY
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Abstract
Allergic rhinitis is common worldwide, with significant morbidity and impact on quality of life. In patients who don't respond adequately to anti-allergic drugs. Subcutaneous allergen immunotherapy is effective although requires specialist administration. Sublingual immunotherapy may represent an effective and safer alternative. This Cochrane systematic review is an update of one published in 2003. We searched Cochrane ENT Group Trials Register, Central, PubMed, EMBASE, CINAHL, Web of Science, Biosis Previews, Cambridge Scientific Abstarcts, mRCT and additional sources. We included randomised, double-blind, placebo- controlled trials of sublingual immunotherapy in adults and children. Two authors selected studies and assessed them for quality. Data were put into RevMan 5.0 for a statistical analysis. We used standardised mean difference (SMD), with a random effect model to combine data. Sixty studies were included, with 49 suitable for meta-analysis. We found significant reductions in symptoms (SMD -0.49; 95%CI (-0.64 to -0.34, P < 0.00001)) and medication requirements (SMD -0.32; 95%CI (-0.43 to -0.21, P < 0.00001)) compared with placebo. None of the trials reported severe systemic reactions, anaphylaxis or use of Adrenaline. This updated review reinforces the conclusion of the original 2003 Cochrane Review that sublingual immunotherapy is effective for allergic rhinitis and appears a safe route of administration.
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MESH Headings
- Administration, Sublingual
- Adult
- Allergens/administration & dosage
- Allergens/therapeutic use
- Child
- Desensitization, Immunologic/methods
- Double-Blind Method
- Humans
- Randomized Controlled Trials as Topic
- Rhinitis, Allergic, Perennial/immunology
- Rhinitis, Allergic, Perennial/therapy
- Rhinitis, Allergic, Seasonal/immunology
- Rhinitis, Allergic, Seasonal/therapy
- Treatment Outcome
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Affiliation(s)
- S Radulovic
- Paediatric Allergy, King's College, London, UK
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Scadding G, Durham SR. Mechanisms of Sublingual Immunotherapy. Immunol Allergy Clin North Am 2011; 31:191-209, viii. [DOI: 10.1016/j.iac.2011.02.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Clinical practice: Allergen-specific immunotherapy in children: facts and FAQs. Eur J Pediatr 2011; 170:137-48. [PMID: 21153032 DOI: 10.1007/s00431-010-1348-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 11/04/2010] [Indexed: 10/18/2022]
Abstract
Allergen-specific immunotherapy (SIT) in its various application forms represents the main treatment approach of IgE-mediated allergic diseases in adults and children. Despite this clear recommendation, many particularities of products, patient characteristics, and product availability in different countries hamper the use of allergen-specific immunotherapy in particular in children. The frequently asked questions by parents, patients, and physicians are the backbone of this review. Thus, the potentials and limitations of allergen-specific immunotherapy in children and adolescents will be highlighted. IgE-mediated allergic diseases are affecting about 20% of the population. They manifest commonly early in life, and hence, the use of SIT should be considered also early in the course of the disease.
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Passalacqua G, Canonica GW. Specific immunotherapy in asthma: efficacy and safety. Clin Exp Allergy 2011; 41:1247-55. [PMID: 21255159 DOI: 10.1111/j.1365-2222.2010.03688.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The use of specific immunotherapy (SIT) to treat asthma has been, and still is, a matter of debate, and there are no clear or unequivocal indications in the official documents. This is partly due to the fact that there are few studies specifically designed to assess asthma, that none of such studies had a formal sample size calculation, and that objective parameters of pulmonary function have been assessed only sporadically. Nonetheless, there are good quality studies for both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) where asthma symptoms were evaluated, and showing positive results. Moreover, several favourable meta-analyses are available, although their validity is limited by the great heterogeneity of the trials included. The disease modifying effect of SIT, that is the capacity of preventing asthma onset should be also taken into account. Concerning the safety, fatalities seem to be an exceptional event and in Europe no fatality has been reported over the last two decades. Uncontrolled asthma is universally recognized as the most important risk factor for severe adverse events. In conclusion both SLIT and SCIT can be used in asthma associated with rhinitis (which is the most common condition), provided that asthma is adequately controlled by pharmacotherapy. In such case, a measurable clinical benefit on asthma symptoms can be expected. On the other hand, SIT cannot be presently recommended as single therapy when asthma is the unique manifestation of respiratory allergy.
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Affiliation(s)
- G Passalacqua
- Allergy and Respiratory Diseases, University Of Genoa, Genoa, Italy.
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Abstract
BACKGROUND This is an update of a Cochrane Review first published in The Cochrane Library in Issue 2, 2003.Allergic rhinitis is a common condition which can significantly impair quality of life. Immunotherapy by injection can significantly reduce symptoms and medication use but its use is limited by the possibility of severe systemic adverse reactions. Immunotherapy by the sublingual route is therefore of considerable interest. OBJECTIVES To evaluate the efficacy and safety of sublingual immunotherapy for allergic rhinitis in adults and children. SEARCH STRATEGY We searched the Cochrane ENT Group Trials Register; CENTRAL (2010, Issue 3); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 14 August 2009. SELECTION CRITERIA Randomised, double-blind, placebo-controlled trials of sublingual immunotherapy in adults or children. Primary outcome measures were symptom and medication scores. We also collected adverse event data. DATA COLLECTION AND ANALYSIS Two independent authors selected studies and assessed risk of bias. One author extracted data which was rechecked by two other authors. We used the standardised mean difference (SMD) with a random-effects model to combine data. MAIN RESULTS We included a total of 60 randomised controlled trials in the review. Forty-nine were suitable for pooling in meta-analyses (2333 SLIT, 2256 placebo participants). Overall, we found a significant reduction in symptoms (SMD -0.49; 95% confidence interval (CI) -0.64 to -0.34, P < 0.00001) and medication requirements (SMD -0.32; 95% CI -0.43 to -0.21, P < 0.00001) in participants receiving sublingual immunotherapy compared to placebo. None of the trials included in this review reported severe systemic reactions or anaphylaxis, and none of the systemic reactions reported required the use of adrenaline. AUTHORS' CONCLUSIONS This updated review reinforces the conclusion of the original 2003 Cochrane Review that sublingual immunotherapy is effective for allergic rhinitis and has been proven to be a safe route of administration.
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Affiliation(s)
- Suzana Radulovic
- Paediatric Allergy Research Department, King's CollegeLEAP Study TeamSt. Thomas' HospitalLambeth Palace RoadLondonUKSE1 7EH
| | - Moises A Calderon
- Royal Brompton HospitalDepartment of Allergy and Respiratory MedicineImperial College School of Medicine at the National Heart and Lung InstituteLondonUKSW3 6LY
| | - Duncan Wilson
- University Hospitals Birmingham NHS TrustSelly Oak HospitalRaddlebarn RoadBirminghamUK
| | - Stephen Durham
- Royal Brompton HospitalDepartment of Allergy and Respiratory MedicineImperial College School of Medicine at the National Heart and Lung InstituteLondonUKSW3 6LY
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