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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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Allergen immunotherapy for pediatric asthma: current evidence and knowledge gaps. Curr Opin Allergy Clin Immunol 2021; 20:162-167. [PMID: 31972602 DOI: 10.1097/aci.0000000000000618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The introduction of high-quality and standardized extracts for immunotherapy has renewed the interest in the treatment of pediatric allergic asthma that represents a high-prevalence disease. RECENT FINDINGS In addition to clinical trials, several systematic reviews and metaanalyses were published, confirming overall the clinical efficacy of allergen immunotherapy in pediatric asthma. In addition, new data on the preventive effect of the treatment on asthma onset were published. Despite this, many intriguing questions emerged, in parallel to the development of knowledge. SUMMARY Allergen immunotherapy is overall effective for the treatment of asthma in children, but a class-effect should not be claimed, rather the efficacy of each single product. According to the recent findings, the challenge for the future research will be to clarify: when to start immunotherapy in children, which are (if they exist) the predictive biomarkers for efficacy in the single individual, the magnitude of the preventive effect and the optimal duration of the treatment.
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Jiang Z, Xiao H, Liu S, Meng J. Changes in Immunologic Indicators During Allergen-Specific Immunotherapy for Allergic Rhinitis and Determinants of Variability: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Rhinol Allergy 2021; 35:910-922. [PMID: 33631946 DOI: 10.1177/1945892421999649] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND To date, there are no generally recognized biomarkers for allergen immunotherapy (AIT) and even the changes in immunological indicators during AIT are inconsistent in different publications. OBJECTIVE This study was conducted to quantify the immunological changes that occur during AIT and identify the determinants of heterogeneity. METHODS Randomized controlled trials of AIT published in the past 10 years were searched in Medline, Embase and Cochrane CENTRAL. Data on immunological indicators were extracted, and the characteristics of the included studies were collected. Meta-analysis and meta-regression were conducted for each indicator. The study was registered on the PROSPERO website (CRD42020176127). RESULTS We reviewed 1898 studies. Forty-six studies met the inclusion criteria, and 31 studies were included in the quantitative analyses. Subset analyses by time demonstrated that serum allergen-specific IgE (sIgE) of AIT patients increased in the first 12 months, then decreased and became slightly lower than that of control patients. Allergen-specific IgG4 (sIgG4) was elevated in the AIT group during and after treatment. IgE-blocking factor (IgE-BF) was increased and IgE-facilitated allergen binding (IgE-FAB) was reduced in AIT patients. Both of them of the 2 factors were associated with clinical efficacy in the multivariate regression analysis. sIgE/sIgG4 decreased in AIT patients, while there was no change in total IgE. CONCLUSION The levels of serum sIgE and sIgG4 during AIT showed a time-dependent pattern. IgE-BF and IgE-FAB should be further investigated as biomarkers for predicting and monitoring AIT efficacy.
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Affiliation(s)
- Zihan Jiang
- Department of Otorhinolaryngology, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Xiao
- Department of Otorhinolaryngology, West China Hospital, Sichuan University, Chengdu, China
| | - Shixi Liu
- Department of Otorhinolaryngology, West China Hospital, Sichuan University, Chengdu, China
| | - Juan Meng
- Department of Otorhinolaryngology, West China Hospital, Sichuan University, Chengdu, 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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Roger A, Malet A, Moreno V, Parra A, Gutiérrez D, Lleonart R, Moreno F, Valero A, Navarro B, Hinojosa B, Justicia JL. Real-life effect of a microcrystalline tyrosine adjuvanted mite immunotherapy in patients with allergic rhinitis. Immunotherapy 2020; 12:53-62. [PMID: 31910695 DOI: 10.2217/imt-2019-0205] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Aim: Evaluate the effectiveness and safety of immunotherapy with Acarovac Plus® in a 1-year prospective multicentered real-life study. Methods: A total of 118 adults with allergic rhinitis sensitized to Dermatophagoides received subcutaneous immunotherapy with Acarovac Plus. Treatment outcomes were evaluated at baseline, 6 months and 1 year after treatment initiation. Primary end point was the evolution of the combined symptom and medication score. Secondary end points included other effectiveness outcomes and measurement of product tolerability. Results: Acarovac Plus induced significant improvements in primary and secondary end points after 6 months compared with baseline. These differences persisted after 1 year of treatment (p < 0.001; baseline vs 1 year): combined symptom and medication score (1.60 vs 0.79). No serious adverse events were recorded. Conclusion: Acarovac Plus for 1 year was effective and well tolerated in a real-life setting.
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Affiliation(s)
- Albert Roger
- Allergy Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | | | | | - Antonio Parra
- Allergy Department, Hospital A Coruña, A Coruña, Spain
| | | | - Ramón Lleonart
- Allergy Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Antonio Valero
- Pneumology and Respiratory Allergy, Hospital Clínic de Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
| | - Begoña Navarro
- Allergy Department, Hospital Universitari Dexeus, Barcelona, Spain
| | - Belén Hinojosa
- Allergy Section, Hospital Juan Ramón Jiménez, Huelva, Spain
| | - José L Justicia
- Allergy Therapeutics Ibérica, Sant Joan Despí, Barcelona, Spain
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Porcaro F, Cutrera R, Pajno GB. Options of immunotherapeutic treatments for children with asthma. Expert Rev Respir Med 2019; 13:937-949. [PMID: 31414917 DOI: 10.1080/17476348.2019.1656533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Asthma is the most common chronic disease in children. Avoiding triggers, and pharmacologic treatment with short acting beta-agonist, inhaler corticosteroids and anti-leukotriene are often enough to obtain symptoms control. Nevertheless, there is a subset of children with severe asthma and poor symptom control despite maximal therapy. In these patients, anti-IgE and anti-IL5 monoclonal antibodies are suggested as the fifth step of Global Initiative for Asthma guidelines. Area covered: Immunotherapeutic treatments are now suggested for asthma management. This article will discuss the available evidence on allergen immunotherapy and biologic drugs in pediatric asthma treatment. Expert opinion: Previously published studies demonstrated a good efficacy and safety profile of Allergen Immunotherapy in patients with mild-moderate asthma and sensitization to one main allergen. New understanding of mechanisms underlying severe asthma inflammation has allowed the identifications of specific biomarkers guiding the clinician in the choice of patient specific drug. Among the suggested immunotherapeutic options, omalizumab (blocking IgE) remains the first choice for atopic 'early onset' asthma in patients aged over 6 years. Instead, mepolizumab (blocking the IL5 ligand) should be considered for 'eosinophilic' asthma. Other biologic drugs are under consideration but data on the pediatric population are still lacking.
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Affiliation(s)
- Federica Porcaro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Department of Pediatrics, Bambino Gesù Children's Hospital , Rome , Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Department of Pediatrics, Bambino Gesù Children's Hospital , Rome , Italy
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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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Blanco C, Bazire R, Argiz L, Hernández-Peña J. Sublingual allergen immunotherapy for respiratory allergy: a systematic review. Drugs Context 2018; 7:212552. [PMID: 30416528 PMCID: PMC6220898 DOI: 10.7573/dic.212552] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 01/01/2023] Open
Abstract
The objective of the systematic review is to provide complete and updated information on efficacy and safety of sublingual immunotherapy (SLIT) formulations for the treatment of allergic respiratory diseases (ARDs). The literature search was conducted on PubMed database, involving double-blind, randomized clinical trials published between January 1992 and 2018, written in English, and performed in humans. The number of articles finally selected for review was 112. Data from the majority of properly controlled clinical trials demonstrate that SLIT is effective not only with short-term use (first year) but also with long-term use (up to the third year of active therapy), for treating ARDs in children and adults. Both continuous and discontinuous schemes of administration showed significant reductions in symptom and medication scores. Moreover, a SLIT-induced disease-modifying effect has been documented mainly with grass pollen extracts, since improvement is maintained during at least 2 years of follow-up after a 3-year treatment period. Additionally, allergen immunotherapy should also be considered a preventive strategy, especially for decreasing bronchial asthma incidence in children and adolescents with allergic rhinitis treated with SLIT. This therapy is also safe, producing only a few mainly local and mild-to-moderate adverse events, and usually self-limited in time. The registration and authorization of allergen SLIT preparations (grasses and house-dust mite tablets) as drugs by regulatory agencies, such as the United States Food and Drug Administration (FDA) and the European Medicines Agency (EMA), has represented a landmark in allergy immunotherapy research. Further long-term studies, specially designed with allergens other than grass pollen or house-dust mites, not only in allergic rhinoconjunctivitis but also on asthmatic subjects, as well as studies comparing different administration schedules and/or routes, are required in order to continue the progress in the modern development of this particularly promising therapy.
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Affiliation(s)
- Carlos Blanco
- Allergy Service, University Hospital La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
- RETIC ARADYAL RD16/0006/0015, Instituto de Salud Carlos III, Madrid, Spain
| | - Raphaelle Bazire
- Allergy Service, University Hospital La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
| | - Laura Argiz
- Allergy Service, University Hospital La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
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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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13
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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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14
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Yang J, Zhang L, Zhao Z, Liao S. Sublingual immunotherapy for pediatric allergic conjunctivitis: a meta-analysis of randomized controlled trials. Int Forum Allergy Rhinol 2018; 8:1253-1259. [PMID: 29782067 DOI: 10.1002/alr.22149] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/09/2018] [Accepted: 05/04/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Allergic conjunctivitis (AC) is a common chronic condition, especially in children. Ocular symptoms are often overlooked during treatment of allergic rhinoconjunctivitis (ARC). Pediatric ARC can be effectively treated using sublingual immunotherapy (SLIT), which is a guideline-recommended safe treatment approach. However, the therapeutic efficacy of SLIT in terms of ameliorating eye symptoms has not been effectively evaluated. METHODS We performed a meta-analysis of randomized controlled trials (RCTs) evaluating the use of SLIT for infants, children, and adolescents (aged from 3 to 18 years) with AC or ARC. We searched the Cochrane Library database, EMBASE, and Medline from November 1990 to 2017 to find papers dealing with the effects of SLIT on pediatric AC or ARC. We used standardized mean differences (SMDs) to assess therapeutic effects, employing a random effects model. Subgroup and sensitivity analyses were also conducted. The I2 metric was used to evaluate heterogeneity. RESULTS In total, 13 clinical RCTs were included in our meta-analysis. SLIT reduced ocular symptoms to a level below that of controls (SMD = -0.21; 95% confidence interval [CI], -0.41 to -0.01; p = 0.04; I2 = 55%). Notably, on subgroup analysis, SLIT clearly reduced pollen-induced pediatric AC (SMD = -0.36; 95% CI, -0.53 to -0.19; p < 0.0001; I2 = 25%) but not mite-induced AC (SMD = 0.20; 95% CI, -0.20 to 0.60; p = 0.34; I2 = 46%). CONCLUSION SLIT relieved ocular symptoms in children with ARC or AC. To confirm these results, future meta-analyses should evaluate high-quality, large-scale population-based trials.
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Affiliation(s)
- Jie Yang
- Department of Ophthalmology, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Li Zhang
- Department of Ophthalmology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhixiang Zhao
- Department of Otorhinolaryngology, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Shiyu Liao
- Department of Otorhinolaryngology, Zhejiang Hospital, Hangzhou, Zhejiang, China
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15
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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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Mirra V, Montella S, Santamaria F. Pediatric severe asthma: a case series report and perspectives on anti-IgE treatment. BMC Pediatr 2018; 18:73. [PMID: 29466963 PMCID: PMC5820802 DOI: 10.1186/s12887-018-1019-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 01/29/2018] [Indexed: 12/22/2022] Open
Abstract
Background The primary goal of asthma management is to achieve disease control for reducing the risk of future exacerbations and progressive loss of lung function. Asthma not responding to treatment may result in significant morbidity. In many children with uncontrolled symptoms, the diagnosis of asthma may be wrong or adherence to treatment may be poor. It is then crucial to distinguish these cases from the truly “severe therapy-resistant” asthmatics by a proper filtering process. Herein we report on four cases diagnosed as difficult asthma, detail the workup that resulted in the ultimate diagnosis, and provide the process that led to the prescription of omalizumab. Case presentation All children had been initially referred because of asthma not responding to long-term treatment with high-dose inhaled steroids, long-acting β2-agonists and leukotriene receptor antagonists. Definitive diagnosis was severe asthma. Three out four patients were treated with omalizumab, which improved asthma control and patients’ quality of life. We reviewed the current literature on the diagnostic approach to the disease and on the comorbidities associated with difficult asthma and presented the perspectives on omalizumab treatment in children and adolescents. Based on the evidence from the literature review, we also proposed an algorithm for the diagnosis of pediatric difficult-to-treat and severe asthma. Conclusions The management of asthma is becoming much more patient-specific, as more and more is learned about the biology behind the development and progression of asthma. The addition of omalizumab, the first targeted biological treatment approved for asthma, has led to renewed optimism in the management of children and adolescents with atopic severe asthma.
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Affiliation(s)
- Virginia Mirra
- Department of Translational Medical Sciences, Federico II University, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Silvia Montella
- Department of Translational Medical Sciences, Federico II University, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Via Sergio Pansini 5, 80131, Naples, Italy.
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17
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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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Djuric-Filipovic I, Caminati M, Filipovic D, Salvottini C, Zivkovic Z. Effects of specific allergen immunotherapy on biological markers and clinical parameters in asthmatic children: a controlled-real life study. Clin Mol Allergy 2017; 15:7. [PMID: 28392751 PMCID: PMC5376712 DOI: 10.1186/s12948-017-0064-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 03/08/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Allergen-specific immunotherapy (AIT) is the only treatment able to change the natural course of allergic diseases. We aimed at investigating the clinical efficacy of SLITOR (Serbian registered vaccine for sublingual allergen specific immunotherapy). METHODS 7-18 years old children with allergic asthma and rhinitis were enrolled and addressed to the active (AIT plus pharmacological treatment) or control (standard pharmacological treatment only) group. Clinical and medications scores, lung function and exhaled FeNO were measured at baseline and at every follow-up. RESULTS There was a significant improvement in both nasal and asthma symptom scores as well as in medication score in SLIT group. SLIT showed an important influence on lung function and airway inflammation. CONCLUSIONS Our data showed that SLITOR was effective not only in terms of patient reported outcomes but an improvement of pulmonary function and decrease of lower airway inflammation were also observed.
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Affiliation(s)
- I Djuric-Filipovic
- Faculty of Medical Science, University of Kragujevac, Svetozara Markovica 64, 34000 Kragujevac, Serbia
| | - Marco Caminati
- Allergy Unit and Asthma Center, Verona University and General Hospital, Piazzale Stefani 1, 37126 Verona, Italy
| | - D Filipovic
- Institution for Emergency Medical Care, Bulevar Franša Depera 5, 11000 Belgrade, Serbia
| | - C Salvottini
- Department of Internal Medicine and Therapeutics, University of Pavia, Strada Nuova 65, Pavia, Italy
| | - Z Zivkovic
- Children's Hospital for Lung Diseases and Tuberculosis, Medical Center "Dr. Dragiša Mišović", Belgrade, Pilota Mihajla Tepica 1, 11000 Belgrade, Serbia.,Faculty of Pharmacy, University Business Academy in Novi Sad, Trg Mladenca 5, 2100, Novi Sad, Serbia
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19
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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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Tortajada-Girbés M, Mesa Del Castillo M, Larramona H, Lucas JM, Álvaro M, Tabar AI, Jerez MJ, Martínez-Cañavate A. Evidence in immunotherapy for paediatric respiratory allergy: Advances and recommendations. Allergol Immunopathol (Madr) 2016; 44 Suppl 1:1-32. [PMID: 27776895 DOI: 10.1016/j.aller.2016.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 09/05/2016] [Indexed: 01/26/2023]
Abstract
Allergic respiratory diseases are major health problems in paediatric population due their high level of prevalence and chronicity, and to their relevance in the costs and quality of life. One of the most important risk factors for the development of airway diseases in children and adolescents is atopy. The mainstays for the treatment of these diseases are avoiding allergens, controlling symptoms, and preventing them through sustained desensitization by allergen immunotherapy (AIT). AIT is a treatment option that consists in the administration of increasing amounts of allergens to modify the biological response to them, inducing long-term tolerance even after treatment has ended. This treatment approach has shown to decrease symptoms and improve quality of life, becoming cost effective for a large number of patients. In addition, it is considered the only treatment that can influence the natural course of the disease by targeting the cause of the allergic inflammatory response. The aim of this publication is to reflect the advances of AIT in the diagnosis and treatment of allergic respiratory diseases in children and adolescents reviewing articles published since 2000, establishing evidence categories to support the strength of the recommendations based on evidence. The first part of the article covers the prerequisite issues to understand how AIT is effective, such as the correct etiologic and clinical diagnosis of allergic respiratory diseases. Following this, the article outlines the advancements in understanding the mechanisms by which AIT achieve immune tolerance to allergens. Administration routes, treatment regimens, dose and duration, efficacy, safety, and factors associated with adherence are also reviewed. Finally, the article reviews future advances in the research of AIT.
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Affiliation(s)
- M Tortajada-Girbés
- Paediatric Allergology and Pulmonology Unit, Dr. Peset University Hospital, Valencia, Spain; Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, Valencia, Spain.
| | - M Mesa Del Castillo
- Paediatric Allergology and Neumology Unit, Hospital El Escorial, Madrid, Spain
| | - H Larramona
- Paediatric Allergology and Pulmonology Unit, Department of Paediatrics, University Autonoma of Barcelona, and Corporacio Sanitaria Parc Tauli, Hospital of Sabadell, Barcelona, Spain
| | - J M Lucas
- Pediatric Allergy and Immunology Unit, Virgen Arrixaca Clinic Universitary Hospital, Murcia, Spain
| | - M Álvaro
- Allergy and Clinical Immunology Section, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - A I Tabar
- Servicio de Alergología. Complejo Hospitalario de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), RETIC de Asma, Reacciones adversas y Alérgicas (ARADYAL), Pamplona, Spain
| | - M J Jerez
- Publications Office of the European Union, Luxembourg
| | - A Martínez-Cañavate
- Paediatric Allergology and Neumology Unit, Complejo Hospitalario Universitario de Granada, Spain
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21
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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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Yukselen A. Allergen-specific immunotherapy in pediatric allergic asthma. Asia Pac Allergy 2016; 6:139-48. [PMID: 27489785 PMCID: PMC4967613 DOI: 10.5415/apallergy.2016.6.3.139] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 06/10/2016] [Indexed: 12/12/2022] Open
Abstract
Allergen-specific immunotherapy (AIT) is the only curative way that can change the immunologic response to allergens and thus can modify the natural progression of allergic diseases. There are some important criteria which contributes significantly on efficacy of AIT, such as the allergen extract used for treatment, the dose and protocol, patient selection in addition to the severity and control of asthma. The initiation of AIT in allergic asthma should be considered in intermittent, mild and moderate cases which coexisting with other allergic diseases such as allergic rhinitis, and in case of unacceptable adverse effects of medications. Two important impact of AIT; steroid sparing effect and preventing from progression to asthma should be taken into account in pediatric asthma when making a decision on starting of AIT. Uncontrolled asthma remains a significant risk factor for adverse events and asthma should be controlled both before and during administration of AIT. The evidence concerning the efficacy of subcutaneous (SCIT) and sublingual immunotherapy (SLIT) for treatment of pediatric asthma suggested that SCIT decreases asthma symptoms and medication scores, whereas SLIT can ameliorate asthma symptoms. Although the effectiveness of SCIT has been shown for both seasonal and perennial allergens, the data for SLIT is less convincing for perennial allergies in pediatric asthma.
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Affiliation(s)
- Ayfer Yukselen
- Division of Pediatric Allergy & Immunology, Department of Pediatrics, Baskent University Istanbul Hospital, Istanbul 34662, Turkey
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23
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Larenas-Linnemann D. How does the efficacy and safety of Oralair(®) compare to other products on the market? Ther Clin Risk Manag 2016; 12:831-50. [PMID: 27313458 PMCID: PMC4892828 DOI: 10.2147/tcrm.s70363] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Due to differences between allergen immunotherapy (AIT) trials in patient populations, trial design (including primary efficacy variables), the definition of a pollen season, data analysis, and comparisons between AIT products with existing data, is not possible nor valid. The efficacy of two grass pollen AIT tablets, Oralair® and Grazax®/Grastek®, should not be compared by looking at the percentage of score improvement in their respective trials. However, the evidence available concerning the efficacy and safety in trials can be compared by paying close attention to the scientific quality of the trials, details in the administration schedules, and safety issues. It can be concluded due to the high level of evidence available, that Oralair® is effective in a pre (2-months)-coseasonal schedule to reduce symptoms and medication use, and improve a patients’ quality of life during the treatment season. For the long-term, where the quality of efficacy evidence is moderate at 2-year posttreatment due to a high dropout rate, the pre (4-months)-coseasonal schedule should be used. No clinical efficacy data exists for starting treatment in-season, but the clinical onset of action of Oralair® is detectable after only 1 month of treatment. In the pivotal trials in Europe and the USA, no tablet-related epinephrine was needed, though some rare severe local reactions have been reported. Research for Grazax®/Grastek® showed that the long-term efficacy needs a continuous 3-year administration (moderate-low quality evidence available), and in two patients, tablet-related epinephrine was given. Further details on the comparative efficacy of both tablets would only be possible if both were evaluated in the same, adequately powered trial.
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Affiliation(s)
- Désirée Larenas-Linnemann
- Pediatric Allergy and Asthma Clinic, Department of Investigation, Hospital Médica Sur, México City, México
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Arasi S, Passalacqua G, Caminiti L, Crisafulli G, Fiamingo C, Pajno GB. Efficacy and safety of sublingual immunotherapy in children. Expert Rev Clin Immunol 2015; 12:49-56. [PMID: 26496537 DOI: 10.1586/1744666x.2016.1102058] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Allergen immunotherapy (AIT) is currently the only available disease-modifying and aetiological treatment of IgE-mediated diseases. Sublingual allergen immunotherapy (SLIT) constitutes the preferred route of administration of AIT for respiratory allergies in Europe. Recently it has also been approved in the US. Further applications are currently under evaluation, such as IgE-mediated food allergy and IgE-mediated atopic dermatitis. The SLIT safety profile is overall favourable, although local adverse events, usually mild, are described. Most of the meta-analyses confirmed the efficacy of SLIT in reducing symptoms and medication intake in children with allergic diseases. AIT, as an immune-modulating treatment, can modify the natural history of the allergic diseases: reduction of the risk of development of asthma and bronchial hyperreactivity in patients with allergic rhinitis, and reduction of the onset of new sensitizations. A great interest is now devoted to the preventive effects of AIT and, consequently, to the optimal time of initiation.
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Affiliation(s)
- Stefania Arasi
- a Department of Pediatrics- Allergy Unit , University of Messina , Messina , Italy
| | - Giovanni Passalacqua
- b Allergy and Respiratory Diseases, IRCCS San Martino IST , University of Genoa , Genova , Italy
| | - Lucia Caminiti
- a Department of Pediatrics- Allergy Unit , University of Messina , Messina , Italy
| | - Giuseppe Crisafulli
- a Department of Pediatrics- Allergy Unit , University of Messina , Messina , Italy
| | - Chiara Fiamingo
- a Department of Pediatrics- Allergy Unit , University of Messina , Messina , Italy
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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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Passalacqua G, Rogkakou A, Mincarini M, Canonica GW. Allergen immunotherapy in asthma; what is new? Asthma Res Pract 2015; 1:6. [PMID: 27965760 PMCID: PMC4970380 DOI: 10.1186/s40733-015-0006-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/27/2015] [Indexed: 12/29/2022] Open
Abstract
The use and role of allergen immunotherapy (AIT) in asthma is still a matter of debate, and no definite recommendation about this is made in guidelines, both for the subcutaneous and sublingual routes. This is essentially due to the fact that most controlled randomised trials were not specifically designed for asthma, and that objective measures of pulmonary function were only occasionally considered. Nonetheless, in many trials, favourable results in asthma (symptoms, medication usage, bronchial reactivity) were consistently reported. There are also several meta analyses in favour of AIT, although their validity is limited by a relevant methodological heterogeneity. In addition to the crude clinical effect, a disease modifying action of AIT (prevention of asthma onset and long-lasting effects) have been reported. The safety is an important aspect to consider in asthma. Fatalities were rare: in Europe no fatality was reported in the last three decades, as in the United States in the last 4 years. Based on previous surveys, and common sense, uncontrolled asthma is still recognized as the most important risk factor for severe adverse events. On the contrary, there is no evidence that AIT can worsen or induce asthma. According to the available evidence, AIT can be safely used as add-on treatment when asthma is associated with rhinitis (a frequent condition), provided that asthma is adequately controlled by pharmacotherapy. AIT cannot be recommended or suggested as single therapy. When asthma is the unique manifestation of respiratory allergy, its use should be evaluated case by case.
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Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital-IST-University of Genoa, Padiglione Maragliano, L.go R.Benzi 10, Genoa, 16133 Italy
| | - Anthi Rogkakou
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital-IST-University of Genoa, Padiglione Maragliano, L.go R.Benzi 10, Genoa, 16133 Italy
| | - Marcello Mincarini
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital-IST-University of Genoa, Padiglione Maragliano, L.go R.Benzi 10, Genoa, 16133 Italy
| | - Giorgio Walter Canonica
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital-IST-University of Genoa, Padiglione Maragliano, L.go R.Benzi 10, Genoa, 16133 Italy
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Bozek A, Kolodziejczyk K, Warkocka-Szoltysek B, Jarzab J. Grass pollen sublingual immunotherapy: a double-blind, placebo-controlled study in elderly patients with seasonal allergic rhinitis. Am J Rhinol Allergy 2015; 28:423-7. [PMID: 25198030 DOI: 10.2500/ajra.2014.28.4091] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND This study evaluates the safety and efficacy of specific sublingual immunotherapy (SLIT) against grass pollen allergens in patients >60 years of age with seasonal allergic rhinitis (SAR) and/or asthma. This study sought to assess nasal symptoms during the grass pollen season, reduce medication use, and monitor adverse reactions during immunotherapy. METHODS Seventy-eight 60- to 70-year-old patients with SAR and a confirmed grass pollen allergy according to skin-prick tests, nasal provocation, and measurement of serum IgE were included in the study. The patients were individually randomized to the active or placebo groups using a double-blind method. A total of 41 subjects in the SLIT group (5 grass pollen mixture) and 37 subjects in the placebo group were monitored for 3 years. The patients were required to record each use of an antiallergy medication on a diary card. RESULTS Thirty-eight patients completed 3 years (preseasonal) of SLIT, and 34 subjects finished the placebo treatment in the same time period. The total nasal symptom score decreased by 64% in the active group and 7% in the placebo group after SLIT. This difference was only significant in the active group (p < 0.05). At the end of therapy, the total medication score of the active group decreased significantly by a maximum of 51% (p < 0.05), whereas the total medication score of the placebo group had an insignificant decrease. None of the study participants had systemic adverse reactions during the study period. CONCLUSIONS SLIT in elderly patients with a grass pollen allergy generated a significant clinical improvement in the active group compared with the placebo group for grass pollen season. This therapy was well tolerated.
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Affiliation(s)
- Andrzej Bozek
- Clinical Department of Internal Disease, Dermatology, and Allergology, Medical University School of Silesia, Zabrze, Poland
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Network Meta-analysis Shows Commercialized Subcutaneous and Sublingual Grass Products Have Comparable Efficacy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:256-266.e3. [DOI: 10.1016/j.jaip.2014.09.018] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 09/12/2014] [Accepted: 09/16/2014] [Indexed: 01/29/2023]
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Standardized sublingual allergen extract solution (Staloral®): a guide to its use as allergen-specific immunotherapy. DRUGS & THERAPY PERSPECTIVES 2014. [DOI: 10.1007/s40267-014-0165-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Calderon MA, Bernstein DI, Blaiss M, Andersen JS, Nolte H. A comparative analysis of symptom and medication scoring methods used in clinical trials of sublingual immunotherapy for seasonal allergic rhinitis. Clin Exp Allergy 2014; 44:1228-39. [DOI: 10.1111/cea.12331] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- M. A. Calderon
- Imperial College London - National Heart and Lung Institute; Royal Brompton Hospital NHS; London UK
| | - D. I. Bernstein
- Bernstein Clinical Research Center and University of Cincinnati College of Medicine; Cincinnati OH USA
| | - M. Blaiss
- University of Tennessee Health Science Center; Memphis TN USA
| | | | - H. Nolte
- Merck & Co., Inc.; Whitehouse Station NJ USA
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Abstract
PURPOSE OF REVIEW The aim is to review recent literature up to July 2013 concerning the effect of allergen-specific immunotherapy (AIT) on asthma. AIT, effective in combined allergic rhinitis and asthma, was previously described as a convenient approach able to improve clinical outcomes and reduce bronchial hyperresponsiveness. In addition, long-term and preventive effects on the onset of new sensitizations and progression from allergic rhinitis to asthma have been shown. RECENT FINDINGS Recent investigations, mainly based on observational or small open trials, confirmed previous findings, showing improvement in asthma control, symptoms and medication usage and steroid-sparing effects, sometimes inconsistent with changes in lung function. Some meta-analyses support the clinical benefit on adult and paediatric asthma. Only few trials, however, were specifically designed to explore asthma endpoints. SUMMARY Clinical studies primarily have focused on AIT, and research on asthma endpoints is scarce; however, the evidence of beneficial effect of AIT for the treatment of adults and children affected by allergic rhinitis with or without asthma suggests that this treatment can favourably affect asthma. In children, sublingual AIT has been more extensively investigated than injective. Confirmatory, adequately powered trials are needed to reinforce the evidence of efficacy for individual AIT products. The main drawback in using injective AIT for asthma is the risk of serious adverse reactions and uncontrolled asthma. The sublingual route is better tolerated and does not appear inferior. As standard controller pharmacotherapy seems unable to affect the natural course of asthma, the potentially disease-modifying effect of AIT represents an appealing perspective that requires further investigation.
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Quiralte J, Justicia JL, Cardona V, Dávila I, Moreno E, Ruiz B, García MA. Is faster safer? Cluster versus short conventional subcutaneous allergen immunotherapy. Immunotherapy 2014; 5:1295-303. [PMID: 24283840 DOI: 10.2217/imt.13.133] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Few studies have compared cluster immunotherapy and conventional administration regimens. The aim of this study was to establish the safety profile of these different regimens in patients with allergic respiratory diseases who received index-of-reactivity (IR)-standardized allergen extracts by the subcutaneous route. MATERIALS & METHODS The safety of subcutaneous immunotherapy (SCIT), administered by means of a 4-week cluster titration schedule (cluster-SCIT) or by an 8-week short conventional titration schedule (SC-SCIT), both with a target dose of 8 IR, was assessed in a retrospective, observational, multicenter study. RESULTS A total of 658 patients (339 cluster-SCIT and 319 SC-SCIT) were recruited from 92 sites in Spain. Injection site reactions occurred in 25.1 and 27.3% of patients treated with cluster-SCIT and SC-SCIT, respectively. Systemic reactions (European Academy of Allergy and Clinical Immunology criteria) were reported for 0.2% of doses and 1.5% of patients with cluster-SCIT, and 0.7% of doses and 4.4% of patients with SC-SCIT. Most reactions were mild and there were no grade 3 or 4 systemic reactions. No life-threatening systemic reactions, anaphylactic shock, or adverse events leading to therapy discontinuation were reported. CONCLUSION The safety profile of the cluster regimen supports the use of accelerated SCIT schedules with IR-standardized allergen extracts compared with short conventional schedules, particularly if similar extracts and application methods are used.
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Affiliation(s)
- Joaquín Quiralte
- Allergology Service, University Hospital Virgen del Rocío, Sevilla, Spain.
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Frati F, Ridolo E, Fuiano N, Barberi S, Dell’Albani I, Landi M, Ricciardi L, Scala G, Incorvaia C. Safety of sublingual immunotherapy in children. Expert Opin Drug Saf 2014; 13:947-53. [DOI: 10.1517/14740338.2014.918949] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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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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Balaji R, Parasuramalu BG, Chandregowda BV, Gangaboraiah. Safety, tolerability and clinical efficacy of ultra-rush sublingual immunotherapy among patients suffering from allergic rhinitis. Allergol Immunopathol (Madr) 2014; 42:216-23. [PMID: 23481554 DOI: 10.1016/j.aller.2012.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 11/20/2012] [Accepted: 12/06/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Conventional immunotherapy for allergy with 3-5 years of treatment period has poor compliance. Ultra-rush sublingual immunotherapy with a shorter period of treatment can have better compliance. There are very few studies on ultra-rush sublingual immunotherapy all over the world. OBJECTIVES (1) To determine allergen sensitivity among allergic rhinitis patients. (2) To assess safety, tolerability and clinical efficacy of ultra-rush sublingual immunotherapy. METHODS The present study was conducted in Allergy clinic, KIMS Hospital & Research Centre, Bangalore, India from January 2010 to June 2011. After obtaining Institutional Ethics Committee approval, 40 allergic rhinitis patients (according to ARIA guidelines) in the 18-60 years age group who were positive for aeroallergens in skin prick test were recruited for ultra-rush sublingual immunotherapy (20min initial phase and 4-month maintenance phase) and followed for 8 months with symptom and treatment diary. RESULTS Out of 40 patients, the majority, 36 (90.00%) patients were sensitive to house dust mites. Six patients had seven immediate adverse reactions and seven patients had eight delayed adverse reactions. All subsided without medication or with symptomatic oral medications. All patients tolerated ultra-rush SLIT and there was significant decrease in both symptom-score and treatment received in these patients. CONCLUSION Ultra-rush SLIT regimen has excellent safety, tolerability and clinical efficacy among allergic rhinitis patients.
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Affiliation(s)
- R Balaji
- Department of Community Medicine, SRM Medical College and Research Centre, Kancheepuram, India.
| | - B G Parasuramalu
- I/c Allergy Clinic, Kempegowda Institute of Medical Sciences and Research Centre, Bangalore, India
| | - B V Chandregowda
- Department of ENT, Kempegowda Institute of Medical Sciences and Research Centre, Bangalore, India
| | - Gangaboraiah
- Department of Community Medicine, Kempegowda Institute of Medical Sciences (KIMS), Bangalore, India
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Canonica GW, Cox L, Pawankar R, Baena-Cagnani CE, Blaiss M, Bonini S, Bousquet J, Calderón M, Compalati E, Durham SR, van Wijk RG, Larenas-Linnemann D, Nelson H, Passalacqua G, Pfaar O, Rosário N, Ryan D, Rosenwasser L, Schmid-Grendelmeier P, Senna G, Valovirta E, Van Bever H, Vichyanond P, Wahn U, Yusuf O. Sublingual immunotherapy: World Allergy Organization position paper 2013 update. World Allergy Organ J 2014; 7:6. [PMID: 24679069 PMCID: PMC3983904 DOI: 10.1186/1939-4551-7-6] [Citation(s) in RCA: 317] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 02/07/2014] [Indexed: 02/07/2023] Open
Abstract
We have prepared this document, "Sublingual Immunotherapy: World Allergy Organization Position Paper 2013 Update", according to the evidence-based criteria, revising and updating chapters of the originally published paper, "Sublingual Immunotherapy: World Allergy Organization Position Paper 2009", available at http://www.waojournal.org. Namely, these comprise: "Mechanisms of sublingual immunotherapy;" "Clinical efficacy of sublingual immunotherapy" - reporting all the data of all controlled trials published after 2009; "Safety of sublingual immunotherapy" - with the recently published Grading System for adverse reactions; "Impact of sublingual immunotherapy on the natural history of respiratory allergy" - with the relevant evidences published since 2009; "Efficacy of SLIT in children" - with detailed analysis of all the studies; "Definition of SLIT patient selection" - reporting the criteria for eligibility to sublingual immunotherapy; "The future of immunotherapy in the community care setting"; "Methodology of clinical trials according to the current scientific and regulatory standards"; and "Guideline development: from evidence-based medicine to patients' views" - including the evolution of the methods to make clinical recommendations.Additionally, we have added new chapters to cover a few emerging crucial topics: "Practical aspects of schedules and dosages and counseling for adherence" - which is crucial in clinical practice for all treatments; "Perspectives and new approaches" - including recombinant allergens, adjuvants, modified allergens, and the concept of validity of the single products. Furthermore, "Raising public awareness about sublingual immunotherapy", as a need for our patients, and strategies to increase awareness of allergen immunotherapy (AIT) among patients, the medical community, all healthcare stakeholders, and public opinion, are also reported in detail.
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Affiliation(s)
- Giorgio Walter Canonica
- Respiratory and Allergy Clinic, DIMI—Department of Internal Medicine, University of Genoa, IRCCS Aou San Martino, Largo Rosanna Benzi 10, Genoa 1-16132, Italy
| | - Linda Cox
- Department of Medicine, Nova Southeastern University, College of Osteopathic Medicine, Davie Florida, USA
| | - Ruby Pawankar
- Division of Allergy, Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Carlos E Baena-Cagnani
- Research Center for Respiratory Medicine (CIMER), Catholic University, Fundación LIBRA, Córdoba, Argentina
| | - Michael Blaiss
- Department of Pediatrics and Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sergio Bonini
- Department of Medicine, Second University of Naples, Institute of Translational Pharmacology, Italian National Research Council, Rome, Italy
| | - Jean Bousquet
- Centre Hospitalier Regional Universitaire de Montpellier, Université de Montpellier, Montpellier, France
| | - Moises Calderón
- Section of Allergy and Clinical Immunology, Imperial College of London, National Heart and Lung Institute, Royal Brompton Hospital, London, UK
| | - Enrico Compalati
- Allergy and Respiratory Diseases Clinic, Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Stephen R Durham
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College of London, London, UK
| | - Roy Gerth van Wijk
- Department of Allergology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Harold Nelson
- National Jewish Health, University of Colorado – Denver School of Medicine, Denver, Colorado, USA
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino IST, University of Genoa, Genova, Italy
| | - Oliver Pfaar
- Center for Rhinology and Allergology Wiesbaden, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Nelson Rosário
- Pediatric Allergy and Immunology Division, Hospital de Clínicas, Federal University of Parana, Curitiba, Brazil
| | - Dermot Ryan
- Academic Centre of Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Lanny Rosenwasser
- Children’s Mercy Hospital, University of Missouri – Kansas City School of Medicine, Kansas City, Missouri
| | | | | | - Erkka Valovirta
- Department of Clinical Allergology and Pulmonary Diseases, University of Turku, Finland, and Allergy Clinic, Terveystalo, Turku, Finland
| | - Hugo Van Bever
- Department of Paediatrics, University Children’s Medical Institute, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Pakit Vichyanond
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ulrich Wahn
- Department of Pediatric Pneumology and Immunology, Charité, Humboldt University, Berlin, Germany
| | - Osman Yusuf
- The Allergy and Asthma Institute, Islamabad, Pakistan
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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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Baena-Cagnani CE, Larenas-Linnemann D, Teijeiro A, Canonica GW, Passalacqua G. Will sublingual immunotherapy offer benefit for asthma? Curr Allergy Asthma Rep 2014; 13:571-9. [PMID: 24022465 DOI: 10.1007/s11882-013-0385-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Evidence shows that sublingual immunotherapy (SLIT) is indicated in patients with allergic rhinitis (AR). In this article we discuss whether SLIT could offer benefit for children and adults with asthma.We reviewed individual trials on SLIT in asthmatic patients, but also asthma data reported in some SLIT trials conducted in AR patients. Findings were complemented with data from systematic reviews and metaanalysis on the subject since 2000 and some guidelines that mention immunotherapy for asthma treatment. In AR patients with concomitant persistent asthma, SLIT reduces medication needs while maintaining symptom control. This holds especially true for house dust mite SLIT. Data on pollen SLIT and lung symptom improvement with SLIT, however, are less convincing. Therefore, we suggest SLIT should be added as an optional add-on therapy for patients with asthma whenever a causative allergen has been demonstrated and AR is associated with asthma. For the future, SLIT should be studied in specifically designed asthma studies in allergic asthmatics without AR.
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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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Abstract
BACKGROUND The prescription of allergen immunotherapy (SIT) in asthma remains a matter of debate and official guidelines often do not provide clear recommendations in this regard. METHODS An extensive review of the literature was untaken. RESULTS There are many robust studies with SCIT and SLIT showing positive results related to improving asthma symptoms, in particular when asthma was associated with rhinitis. In addition, there are several favourable meta-analyses, although their validity is limited by the heterogeneity of the trials included. The disease modifying effect of SIT (prevention of asthma onset and long-lasting effects) should be considered when prescribing this treatment. Regarding safety, fatalities seem to be rare: in Europe no fatality has been reported over the last two decades, and the same has been observed in USA in the last 4 years. Uncontrolled asthma is universally recognized as the most important risk factor for severe adverse events, but there is no clear demonstration that SIT can worsen or induce asthma. In contrast, of the few studies specifically designed to evaluate asthma, none had a formal sample size calculation, and pulmonary function was assessed as primary outcome only sporadically. CONCLUSIONS According to the presently available evidence, SLIT and SCIT can be used in asthma associated with rhinitis (the most common condition), provided that asthma is adequately controlled by pharmacotherapy. In such cases, a measurable clinical benefit on asthma symptoms can be expected. SIT cannot be presently recommended as single therapy when asthma is the unique manifestation of respiratory allergy.
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Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino, IST, University of Genoa , Genoa , Italy
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Pediatric sublingual immunotherapy efficacy: evidence analysis, 2009-2012. Ann Allergy Asthma Immunol 2013; 110:402-415.e9. [PMID: 23706708 DOI: 10.1016/j.anai.2013.02.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 02/19/2013] [Accepted: 02/20/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To perform a structured analysis of the latest scientific evidence obtained for the clinical efficacy of sublingual immunotherapy (SLIT) in children. DATA SOURCES PubMed, Embase, reference lists from reviews, and personal databases were reviewed for original articles on clinical trials with SLIT in patients younger than 18 years published from January 1, 2009, through December 31, 2012, using broad search and medical subject heading terms. STUDY SELECTIONS Clinical trials, irrespective of their design, of SLIT in the treatment of respiratory and food allergy in patients 18 years or younger were selected. Clinical outcomes (symptom scores, medication use, provocation tests, pulmonary function tests, skin prick tests, and adverse events) and immunologic changes were tabulated. Quality of each trial and total quality of compounded evidence was analyzed with the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS Of 56 articles, 29 met the inclusion criteria. New evidence is robust for the precoseasonal tablet and drop grass pollen SLIT efficacy in allergic rhinitis and scarce for seasonal asthma. Some evidence for Alternaria SLIT efficacy is appearing. For house dust mite (HDM) SLIT in asthma, there is high-quality evidence for medication reduction while maintaining symptom control; evidence for HDM SLIT efficacy in allergic rhinitis is of moderate-low quality. There is moderate evidence for efficacy of dual grass pollen-HDM SLIT after 12 months of treatment and 1 year after discontinuation. Specific provocation test results (nasal, skin) improve with grass pollen and HDM SLIT but nonspecific bronchial provocation testing does not. Food oral immunotherapy is more promising than food SLIT. Possible new surrogate markers have been reported. No anaphylaxis was found among 2469 treated children. CONCLUSION Evidence for efficacy of SLIT in children with respiratory or food allergy is growing.
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Mucosal immunity and sublingual immunotherapy in respiratory disorders. J Allergy (Cairo) 2012; 2012:725719. [PMID: 23028392 PMCID: PMC3457632 DOI: 10.1155/2012/725719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 07/25/2012] [Indexed: 11/17/2022] Open
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Therapeutic effects and biomarkers in sublingual immunotherapy: a review. J Allergy (Cairo) 2012; 2012:381737. [PMID: 22500184 PMCID: PMC3303629 DOI: 10.1155/2012/381737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 11/15/2011] [Indexed: 02/08/2023] Open
Abstract
Immunotherapy is considered to be the only curative treatment for allergic diseases such as pollinosis, perennial rhinitis, asthma, and food allergy. The sublingual route is widely applied for immunotherapy for allergy, instead of the conventional administration by subcutaneous route. A recent meta-analysis of sublingual immunotherapy (SLIT) has shown that this approach is safe, has positive clinical effects, and provides prolonged therapeutic effects after discontinuation of treatment. However, the mechanism of SLIT and associated biomarkers are not fully understood. Biomarkers that change after or during SLIT have been reported and may be useful for response monitoring or as prognostic indicators for SLIT. In this review, we focus on the safety, therapeutic effects, including prolonged effects after treatment, and new methods of SLIT. We also discuss response monitoring and prognostic biomarkers for SLIT. Finally, we discuss immunological mechanisms of SLIT with a focus on oral dendritic cells and facilitated antigen presentation.
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Stelmach I, Kaluzińska-Parzyszek I, Jerzynska J, Stelmach P, Stelmach W, Majak P. Comparative effect of pre-coseasonal and continuous grass sublingual immunotherapy in children. Allergy 2012; 67:312-20. [PMID: 22142341 DOI: 10.1111/j.1398-9995.2011.02758.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND One of the most important aspects of sublingual immunotherapy (SLIT) is the regimen of administration. The aim of the study was to compare the efficacy and the safety of SLIT given pre-coseasonally (starting before the pollen season and continuing until the end of it) and continuously (all year round, independent of the pollen season) in children allergic to grass pollen. METHODS Sixty children aged 6-18, sensitive only to grass pollen, with rhinitis (20 patients had concomitant asthma) participated in the 2-year prospective, randomized, double-blind, placebo-controlled trial. RESULTS Both pre-coseasonal and continuous SLIT were associated with a substantial reduction in the combined symptoms/medication score when compared with placebo; there were no significant differences between the regimens (mean difference: 18.1 ± 12.4, P > 0.05). Similar changes were observed in the total symptoms score. Pre-coseasonal therapy, compared with continuous, was more effective in the reduction of nasal symptoms (mean difference: -18.0 ± 2.5, P = 0.006). We did not observe significant differences in medication, ocular, and asthma scores between the regimens. We did not observe changes in morning PEF, FEV1, and PD20 in any of the three groups nor between the groups throughout the study. We showed a significant decrease in FeNO level comparable in both active groups. There were no differences between groups in the induction of CD4CD25Foxp3-positive cells in peripheral blood during the study. CONCLUSION Both protocols were effective compared with placebo and showed similar decreases for combined symptoms/medication score and all secondary endpoints, with the exception of nasal symptoms that were lower in the pre-coseasonal group.
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MESH Headings
- Administration, Sublingual
- Adolescent
- Allergens/administration & dosage
- Allergens/immunology
- Child
- Child, Preschool
- Conjunctivitis, Allergic/etiology
- Conjunctivitis, Allergic/immunology
- Conjunctivitis, Allergic/therapy
- Desensitization, Immunologic/methods
- Double-Blind Method
- Female
- Humans
- Male
- Poaceae/adverse effects
- Poaceae/immunology
- Pollen/adverse effects
- Pollen/immunology
- Prospective Studies
- Rhinitis, Allergic, Seasonal/etiology
- Rhinitis, Allergic, Seasonal/immunology
- Rhinitis, Allergic, Seasonal/therapy
- Seasons
- Treatment Outcome
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Affiliation(s)
- I Stelmach
- Department of Pediatrics and Allergy, Medical University of Lodz, N Copernicus Hospital, Poland.
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Bahceciler NN, Cobanoglu N. Subcutaneous versus sublingual immunotherapy for allergic rhinitis and/or asthma. Immunotherapy 2012; 3:747-56. [PMID: 21668312 DOI: 10.2217/imt.11.48] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Subcutaneous allergen-specific immunotherapy has long been used in allergic rhinitis and/or asthma and has been recognized to be efficacious. However, owing to the inconvenience of injection and the risk of serious side effects, alternative concepts inspiring the search for effective noninjective routes, namely sublingual administration of allergens, have emerged. Sublingual immunotherapy (SLIT) appears to be associated with a lower incidence of systemic reactions. The clinical efficacy of subcutaneous immunotherapy (SCIT) is well established for both rhinitis and asthma. Meta-analyses relating to its efficacy on asthma and rhinitis are available. SLIT has also been validated in this respect. Comparative clinical studies of SLIT versus SCIT are scarce demonstrating both routes to be clinically efficient. Knowledge of the exact mechanism of action of SLIT has been increasing in the last decade. In addition, recent studies have proved similarities of the immunological changes with the treatment of both routes. Further comparative clinical and immunological studies of SLIT versus SCIT are needed to confirm the long-term efficacy and to complete the knowledge of immunological mechanisms of both routes. Moreover, better understanding of the interaction of allergen and oral mucosal dendritic cells during SLIT may allow improved targeting of SLIT vaccines.
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Hong J, Bielory L. Oralair®: sublingual immunotherapy for the treatment of grass pollen allergic rhinoconjunctivitis. Expert Rev Clin Immunol 2011; 7:437-44. [PMID: 21790286 DOI: 10.1586/eci.11.36] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Oralair(®) is a sublingual grass pollen immunotherapy tablet that was authorized for use in Europe on 26 November 2009 and is currently in Phase III clinical trials in the USA. It is indicated for the management of grass pollen allergic rhinitis with or without conjunctivitis in adults, adolescents and children (above the age of 5) with clinically relevant symptoms, confirmed by a positive cutaneous test and/or a positive titer of the specific IgE to the grass pollen. Treatment is composed of an initiation phase (3-day dose escalation: 100 IR [index of reactivity] on day 1, 200 IR on day 2 and 300 IR on day 3) and a continuation phase at a dosage of 300 IR/day. Treatment is scheduled to start approximately 4 months before the actual start of the pollen season and should be continued throughout the season. The treatment should be prescribed and initiated by an experienced allergy specialist.
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Affiliation(s)
- Jison Hong
- UMDNJ New Jersey Medical School, 90 Bergen Street, Newark, NJ 07103, USA.
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de Bot CMA, Moed H, Berger MY, Röder E, van Wijk RG, van der Wouden JC. Sublingual immunotherapy in children with allergic rhinitis: quality of systematic reviews. Pediatr Allergy Immunol 2011; 22:548-58. [PMID: 21919934 DOI: 10.1111/j.1399-3038.2011.01165.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Systematic reviews have gained popularity as a way to combine the increasing amount of research information. This study assessed the quality of systematic reviews and meta-analyses of sublingual immunotherapy (SLIT) for allergic rhinitis in children, published since 2000. Eligible reviews were identified by searching Medline/Pubmed, Embase, and the Cochrane Library, from 2000 through 2008. Methodological quality was assessed using the assessment of multiple systematic reviews instrument. Ten systematic reviews were included, one of which was published in the Cochrane Library. Eight reviews gave some details about the search strategy. None of the reviews included measures to avoid selection bias. In 60% of the reviews, the methodological quality of the included studies was (partly) assessed. Four reviews pooled the results of individual studies, neglecting clinical heterogeneity. Three of the 10 reviews provided information about sources of funding or grants from industry. Of the 10 reviews, the six reviews with the highest overall score scored 5-8 points, indicating moderate quality. Systematic reviews are useful to evaluate the efficacy of SLIT in children. Although more reviews have become available, the methodological quality could be improved. SLIT for children could be promising, but methodological flaws in the reviews and individual studies are too serious to draw definite conclusions.
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Affiliation(s)
- Cindy M A de Bot
- Department of General Practice, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
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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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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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Passalacqua G, Canonica GW. Sublingual immunotherapy for allergic respiratory diseases: efficacy and safety. Immunol Allergy Clin North Am 2011; 31:265-77, ix. [PMID: 21530819 DOI: 10.1016/j.iac.2011.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Subcutaneous immunotherapy (SCIT) is effective and safe when properly prescribed and administered. However, a certain risk of severe side effects exists, even when the reaction is managed correctly. These potential adverse effects stimulated the search for new administration routes (nasal, bronchial, oral, sublingual), which were expected to be safer. Not all of these alternative routes provided an improved benefit-safety profile compared with SCIT. The sublingual route (SLIT) seemed to be a good candidate for the clinical practice because of its satisfactory safety profile and is now considered an acceptable alternative to SCIT in adults and children.
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Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases, Department of Internal Medicine, University of Genoa, Padiglione Maragliano, Largo Rosanna Benzio 10, 16132 Genoa, Italy.
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