Intralymphatic immunotherapy with tyrosine-adsorbed allergens: a double-blind, placebo-controlled trial

Immunotherapy and new treatments

PURPOSE OF REVIEW

This review comes at a time where new techniques in immunotherapy administration are being developed, new innovations are being incorporated to standard techniques, and new regulations are being adopted regarding the creation and storage of allergen extracts. Prior to the release of updated practice parameters regarding allergic rhinitis and immunotherapies, this review article provides a synopsis of current recommendations, a comparison of the practices in the United States and those of Europe, and an examination of experimental methods that are being studied.

RECENT FINDINGS

This article seeks to review and discuss the various methods of administration, build up schedules, efficacy, effect on other atopic symptoms, and safety associated with allergen immunotherapy.

SUMMARY

Innovations in standard techniques, such as new allergoids for SCIT, appear to be effective in improving symptoms and increasing IgG levels for grass allergens. Data for newer techniques is less clear. There appears to be increased treatment-related adverse events for ILIT, worse symptom scores compared with placebo for IDIT, and insufficient studies regarding the effectiveness of EPIT for aeroallergens. New regulations seek to standardize the documentation, storage, and creation of allergen extracts.

Is intralymphatic immunotherapy effective and safe for allergic rhinitis?: A meta-analysis

BACKGROUND

As there is much controversy in using intralymphatic immunotherapy (ILIT) as a therapeutic means for allergic rhinitis (AR), its efficacy and safety for AR were investigated based on a systematic review and meta-analysis.

METHODS

Databases PubMed, Embase, Cochrane library, and Web of Science were employed to retrieve relevant randomized control studies on ILIT for AR. The search deadline was September 15, 2023. Meta-analysis was performed on the data of the included literature using Stata 15.0.

RESULTS

Eleven randomized control studies were included involving a total of 406 patients. Meta-analysis results revealed that ILIT improved patients' quality of life [standardized mean difference (SMD) = -0.53, 95% confidence interval (CI) = (-1.00, -0.050)], and reduced the adverse events of nasal symptoms [risk ratio (RR) = 0.16, 95% CI = (0.06, 0.45)] as compared to control, whereas no significant difference was discovered in symptom score [SMD = 0.14, 95% CI = (-0.34, 0.62)], IgE [SMD = 0.93, 95% CI = (-0.44, 2.30)], medication scores [SMD = 1.37, 95% CI = (-0.45, 3.18)], comprehensive symptom and medication scores [SMD = 0.93, 95% CI = (-0.62, 2.47)], nasal symptoms [RR = 0.16, 95% CI = (0.06, 0.45)], and lymphadenectasis [RR = 2.27, 95% CI = (0.37, 6.73)] versus control.

CONCLUSION

After the application of the ILIT strategy against AR, the quality of life of patients was improved and the incidence of adverse events associated with nasal symptoms was reduced, but the conclusion needed further verification with more high-quality research.

Efficacy and safety of intratonsillar immunotherapy for allergic rhinitis: A randomized, double-blind, placebo-controlled clinical trial

BACKGROUND

A lower adherence rate existed in patients receiving allergen-specific immunotherapy due to its lengthy period and adverse effects even though it is the only curative treatment for IgE-mediated allergies. Therefore, exploring innovative allergen-specific immunotherapy routes is necessary.

OBJECTIVE

To explore the efficacy and safety of the intratonsillar injection of house dust mite (HDM) extract in patients with HDM-induced allergic rhinitis (AR).

METHODS

A randomized, double-blind, placebo-controlled clinical trial was conducted. A total of 80 patients with HDM-induced AR were randomized to receive 6 intratonsillar injections with HDM extract or placebo in 3 months. The total nasal symptom score (TNSS), visual analogue scale of nasal symptoms, combined symptom and medication score, mini rhinoconjunctivitis quality of life questionnaire, and serum allergen-specific IgG4 to Dermatophagoides pteronyssinus were all monitored at baseline and 3 months, 6 months, and 12 months after the treatment was finished. The intent-to-treat and per-protocol set (PPS) are both analyzed.

RESULTS

The primary end points TNSS and ΔTNSS were improved significantly at 3 months after the patients with AR finished a 3-month 6-injection intratonsillar immunotherapy compared with those in the placebo treatment in both intent-to-treat and PPS. Results of visual analogue scale, combined symptom and medication score, and mini rhinoconjunctivitis quality of life questionnaire were also improved significantly at 3 months after the treatment in PPS. However, the improvement effect of intratonsillar immunotherapy at 6 and 12 months was limited and uncertain based on the data. The increase of serum Der p IgG4 in the active group was significantly higher than that in the placebo group at 3, 6, and 12 months after the treatment was finished. Adverse events were monitored, and no systemic adverse reactions were observed.

CONCLUSION

The clinical trial revealed that intratonsillar injection with HDM extract was safe and effective in patients with AR. Optimizing the protocol and allergen formulations is expected to increase and maintain the efficacy of this novel approach.

TRIAL REGISTRATION

https://www.chictr.org.cn/index.html, identifier: ChiCTR-TRC-13003600.

Investigating Experimental Treatments for Rhinitis: A State-of-the-Art Systematic Review

Background: Rhinitis is a common inflammatory condition that affects the nasal passages, significantly impacting quality of life and placing a considerable burden on healthcare systems. While traditional treatments offer limited relief, there is a growing interest in novel therapies. This systematic review aims to analyze investigational new treatments for rhinitis. Methods: A search was conducted in ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and the European Union Clinical Trials Register, as well as PubMed, Web of Science, and the Cochrane Library. Both ongoing and completed clinical trials exploring innovative therapies for rhinitis, including immunotherapy, probiotics, and stem cell therapy, were included. Results: This systematic review compiled information from 74 clinical trials-51 completed and 23 ongoing-focused on new treatments for rhinitis. A significant portion of the completed studies (44) focused on various forms of immunotherapy, which showed potential for long-term effectiveness and had a high safety profile. Another seven completed trials investigated probiotics as a treatment method, yielding mixed results, though they did show promise in managing symptoms, particularly when combined with other treatments. The ongoing trials are primarily investigating immunotherapy, with a smaller number looking at probiotics and stem cell therapy. This shows a continued exploration of innovative and diverse therapies for managing rhinitis. Conclusion: This study highlights the potential of emerging rhinitis therapies to improve patient outcomes and enhance quality of life. Continued research is recommended for developing more effective, personalized, and targeted therapeutic strategies for rhinitis.

A Review on Novel Therapeutic Modalities and Evidence-based Drug Treatments against Allergic Rhinitis

Allergic rhinitis (AR) is an IgE-mediated atopic disease that occurs due to inhaled antigens in the immediate phase. Misdiagnosis, insufficient treatment, or no treatment at all are frequent problems associated with the widespread condition known as chronic allergic rhinitis. AR symptoms include runny, itchy, stuffy, and sneezing noses. Asthma and nasal polyps, for example, sometimes occur simultaneously in patients. In order for people living with AR to be as comfortable and productive as possible, treatment should center on reducing their symptoms. The online sources and literature, such as Pubmed, ScienceDirect, and Medline, were reviewed to gather information regarding therapeutic modalities of AR and evidence-based treatments for the disease as the objectives of the present study. An increasing number of people are suffering from AR, resulting in a heavy financial and medical burden on healthcare systems around the world. Undertreating AR frequently results in a decline in quality of life. Treatment compliance is a critical challenge in the administration of AR. Innovative therapies are needed for RA to provide patients with symptom alleviation that is less expensive, more effective, and longer duration of action. Evidence-based guidelines are helpful for managing AR illness. Treating AR according to evidence-based standards can help in disease management. AR treatment includes allergen avoidance, drug therapy, immunotherapy, patient education, and follow-up. However, AR treatment with intranasal corticosteroids is more popular. Hence, in this review article, treatment options for AR are discussed in depth. We also discussed the incidence, causes, and new treatments for this clinical condition.

Future Directions of Allergen Immunotherapy for Allergic Rhinitis: Experts' Perspective

Allergen immunotherapy (AIT) is broadly used all over the world as the only available disease-modifying treatment option. The aim of this experts' perspective is to address 7 important unmet needs for the further direction of AIT and to provide the readership with the authors' positions on these topics. An international group of experts in the field of AIT have formulated 7 important aspects for the future position of AIT, performed a current literature review, and proposed a consented position on these topics. The aspects discussed and consented by the authors include: (1) alternative routes of allergen application in AIT, (2) potential of recombinant vaccines, (3) the role of allergy diagnosis based on component-resolved diagnosis for AIT composition, (4) the impact of COVID-19 vaccination for further innovations in AIT, (5) potential of combining biologics to AIT, (6) future innovations in high-risk children/adolescents, and (7) the future regulatory position on AIT. Important unmet needs and topics for AIT have been addressed in this expert review. The authors' views and personal position on these 7 aspects have also been elaborated.

Effect of intralymphatic allergen-specific immunotherapy on house dust mite in a murine model of allergic rhinitis

BACKGROUND

Intralymphatic immunotherapy (ILIT) is a promising alternative for the treatment of patients with allergic rhinitis, providing similar therapeutic efficacy to conventional allergen-specific immunotherapy (AIT). However, the allergic mechanism of ILIT is not completely known.

AIM

The aim of this study was to determine the efficacy of ILIT in a house dust mite (HDM) mouse model of allergic rhinitis.

METHODS

BALB/c mice were divided into four groups: G1, control without allergy; G2, allergy sensitized with HDM; G3, allergy with ILIT (starting with HDM 1.25 μg/mL); and G4, allergy with ILIT (starting with HDM 2.5 μg/mL). After the murine model of allergic rhinitis with HDM was established, mice were administered an intralymphatic injection through the inguinal lymph nodes with HDM.

RESULTS

ILIT decreased serum total IgE level and eosinophil infiltration in the nasal mucosa. ILIT also decreased the expression levels of IL-13, IL-25, IL-33, IFN-γ, IL-6, and IL-17, and increased the expression of FoxP3(+) T reg cells.

CONCLUSIONS AND SIGNIFICANCE

Our results suggest that ILIT regulates the specific immunotherapy immunologic mechanism by downregulating Th1, Th2, and Th17 cytokines and upregulating FoxP3(+) T reg cells in the HDM allergic mouse model.

Intra-cervical lymphatic immunotherapy for dust mite-induced allergic rhinoconjunctivitis in children: a 3-year prospective randomized controlled trial

Background

Pediatric allergic rhinoconjunctivitis has become a public concern with an increasing incidence year by year. Conventional subcutaneous immunotherapy (SCIT) has long treatment time, high cost and poor compliance. The novel immunotherapy significantly shortens the course of treatment by directly injecting allergens into cervical lymph nodes, which can perform faster clinical benefits to children.

Objective

By comparing with SCIT, this study aimed to evaluate the long-term efficacy and safety of intra-cervical lymphatic immunotherapy (ICLIT).

Methods

This is a prospective randomized controlled study. A total of 50 allergic rhinoconjunctivitis children with dust mite allergy was randomly divided into ICLIT group and SCIT group, receiving three cervical intralymphatic injections of dust mite allergen or three years of subcutaneous injection, separately. Primary outcomes included total nasal symptom scores (TNSS), total ocular symptom scores (TOSS), total symptom scores (TSS), total medication scores (TMS), and total quality of life score. Secondary outcomes included pain perception and adverse reactions during treatment. Other secondary outcome was change in Dermatophagoides pteronyssinus (Derp) and Dermatophagoides farina (Derf) -specific IgE level.

Results

Both groups had significantly decreased TNSS, TOSS, TSS, TMS, and total quality of life score after 36 months of treatment (p<0.0001). Compared with SCIT, ICLIT could rapidly improve allergic symptoms (p<0.0001). The short-term efficacy was consistent between the two groups (p=0.07), while the long-term efficacy was better in SCIT group (p<0.0001). The pain perception in ICLIT group was lower than that in SCIT group (p<0.0001). ICLIT group was safer. Specifically, the children had only 3 mild local adverse reactions without systemic adverse reactions. The SCIT group had 14 systemic adverse reactions. At last, the serum Derp and Derf-specific IgE levels in ICLIT and SCIT groups decreased 3 years later (p<0.0001).

Conclusion

ICLIT could ameliorate significantly the allergic symptoms in pediatric patients with an advantage in effectiveness and safety, besides an improved life quality including shortened period of treatment, frequency of drug use and pain perception.

Clinical trial registration

https://www.chictr.org.cn/, identifier ChiCTR1800017130.

Evaluation of Intralymphatic Immunotherapy in Allergic Rhinitis Patients: A Systematic Review and Meta-analysis

Background

Intralymphatic immunotherapy (ILIT) is short-course administration of allergen-specific immunotherapy (AIT). This study is aimed at assessing the clinical efficacy and safety of ILIT in patients with allergic rhinitis (AR).

Methods

MEDLINE, PUBMED, and Cochrane Library were used to conduct electronic searches for clinical trials comparing ILIT and placebo in patients with AR. The final search took place on August 24, 2022. Cochrane Handbook for Systematic Reviews of Interventions was used to assess the risk of bias in the included studies. The outcomes included combined symptom and medication scores (CSMS), visual analog scale (VAS), allergic rhinoconjunctivitis quality of life (RQLQ), Skin-prick test (SPT), and adverse events (AEs). Data were synthesized as mean difference (MD)/standard mean difference (SMD) or risk difference (RD) and 95% confidence interval (CI).

Results

Thirteen studies (454 participants) were included in this study. The ILIT group had better clinical improvement on the CSMS (random effects model, SMD-0.85, 95% CI [-1.58, -0.11], P = 0.02) and RQLQ (fixed-effects model, MD-0.42, 95% CI [0.69, 0.15], P = 0.003) than the placebo group. The booster injection was beneficial for CSMS (P < 0.0001), and the 4-week injection interval was superior to the 2-week injection period for improving VAS (P < 0.0001). Local swelling or erythema was the main AE following injection (random effects model, RD 0.16, 95% CI [0.05, 0.27], P = 0.005). Discussion. For individuals with AR, ILIT is safe and effective. ILIT alleviates clinical symptoms and reduces pharmaceutical consumption without causing severe AEs. However, the validity of this study is compromised by the substantial heterogeneity and risk of bias in the included researches. RegistrationCRD42022355329.

Evaluation of Safety, Efficacy, and Compliance of Intralymphatic Immunotherapy for Allergic Rhinoconjunctivitis: A Systematic Review and Meta-Analysis

INTRODUCTION

Intralymphatic immunotherapy (ILIT) is an emerging type of allergen immunotherapy with fewer injections and shorter course for allergic rhinoconjunctivitis (ARC). The efficacy and safety have not been confirmed by informative and powerful evidence yet.

METHODS

A systematic review and meta-analysis were conducted through electronic searching with PubMed, Web of Science, Embase, Scopus, and China National Knowledge Infrastructure (CNKI). The safety (incidence of adverse events [AEs]), compliance (percent of patients completing treatment), and clinical efficacy of ILIT were evaluated. Clinical efficacy could be assessed by improvement of subjective symptom and rescue medication use or the nasal tolerance to specific allergen. This study is registered with PROSPERO (CRD42022353562).

RESULTS

12 randomized controlled trials (RCTs) comparing ILIT with placebo and 3 trials (2 RCTs and one case-control study) comparing ILIT and SCIT were included in this review. Totally, 582 patients diagnosed as AR or ARC were enrolled. Almost all the AEs were mild-to-moderate reactions except 2 patients developed anaphylactic reactions at the intralymphatic injection dose 5,000 SQ-U in one study. ILIT got higher incidence of local AEs than placebo, but their incidence of systemic AEs was similar. ILIT was safer than SCIT (p < 0.05). Almost all the patients could complete ILIT treatment, and the most common reason for discontinuation of ILIT was AEs. The compliance of patients receiving ILIT seemed higher than patients receiving SCIT. ILIT could significantly ameliorate subjective allergic symptoms, especially for seasonal ARC, and increase nasal tolerance, similar to SCIT.

CONCLUSION

ILIT was a safe and effective treatment for ARC and could achieve comparable clinical improvement with SCIT with shorter duration and higher compliance. Moreover, ILIT was safer than SCIT.

Current advances in house dust mite allergen immunotherapy (AIT): Routes of administration, biomarkers and molecular allergen profiling

Allergy to house dust mites (HDM) is a perennial respiratory disease that affect more than half a billion people worldwide. Dermatophagoides pteronyssinus and D. farinae, two HDM species, are major sources of indoor allergens triggering allergic inflammation. Although symptomatic drugs are widely used to block the allergic reaction, allergen immunotherapy is the only curative treatment of IgE-mediated type I respiratory allergies. In this article, we review recent advances in various routes of allergen immunotherapy. We particularly focus on subcutaneous (SCIT) and sublingual (SLIT) immunotherapy, used as a reference therapy since they have transformed allergic treatments by improving symptoms (asthma and rhinitis) as well as the quality of life of patients. We also highlight recent data in more exploratory routes (i.e., oral, intralymphatic, epicutaneous and intradermal) and discuss respective advantages of various route, as well as their foreseen modes of action. Finally, we provide an update on biomarkers as well as on the relevance of the molecular profiling of allergic individuals related to treatment efficacy or asthma prediction.

Quality of life in allergic rhinitis patients treated with intralymphatic immunotherapy (ILIT): A 19-year follow-up

Background

In 2002-2005, we conducted a phase I/II clinical trial where a new allergy immunotherapy (AIT) route was introduced: intralymphatic immunotherapy (ILIT). Ultrasound guidance allowed injection of allergen directly into inguinal lymph nodes. Grass pollen-allergic patients received 3 injections with 1-month intervals. The short ILIT was more patient-friendly, required lower dosing, and was comparable with SCIT regarding short-term efficacy, which was used as a reference.

Objective

Nineteen years after ILIT, the same patients were followed up to assess the long-term effect on quality of life and efficacy of the treatment.

Methods

Patients who received ILIT and SCIT in 2002-2005 and an additional group of patients, who completed SCIT in 2015-2018, were recruited. All participants received a trial-specific in-house questionnaire and a standardized Rhinoconjunctivitis Quality of Life Questionnaire. Data were recorded off- (February 2021) and on- (May-June 2021) season. Descriptive statistics were applied.

Results

Of 58 and 54 patients who originally received ILIT or SCIT, 25 (43%) and 29 (54%) patients, respectively, returned the questionnaires for analysis. Four (16%) and 3 (11%) of the ILIT and SCIT patients, respectively, developed complete protection against grass pollen-mediated rhinitis, whereas another 15 (60%) and 20 (69%) expressed satisfaction with the received AIT. In both groups, any persistent symptoms were reported as mild. Medication usage in the ILIT and SCIT groups was comparable. Nineteen (76%) and 23 (79%) patients, respectively, expressed satisfaction with their AIT.

Conclusions

Grass pollen ILIT leads to long-term significant improvement in rhinitis-associated quality of life 19 years after treatment, and the ILIT quality-of-life effect was not inferior to that of SCIT.

Nonallergic Rhinitis, Allergic Rhinitis, and Immunotherapy: Advances in the Last Decade

Chronic rhinitis encompassing both allergic and nonallergic rhinitis affects a significant portion of the population worldwide, having a great impact on patient quality of life, and associated comorbid conditions, with an important societal economic burden. Allergists are often the first to evaluate and treat allergic and nonallergic rhinitis, addressing the individual triggers of the disease as well as the patient-specific responses to these triggers. This review focuses on the advances that have been made in the diagnosis, management, and treatment of nonallergic and allergic rhinitis over the past 10 years, including specific allergen immunotherapy, care pathways, and digital health.

Strengthening the case for intralymphatic immunotherapy

PURPOSE OF REVIEW

Intralymphatic immunotherapy (ILIT) is a promising novel method of immunotherapy, that is short and convenient, and may be very effective. Results have been varied, and efforts to unravel the real value of the treatment are ongoing. Methods used to assess the effect in clinical trials have been so varied that it is difficult to compare studies with each other.

RECENT FINDINGS

Some advances have been made; the importance of injecting into the lymph node has been illustrated, and treatment with a range of medicines has proven to be successful. In meta-analyses the treatment has been shown to have no serious side effects and to be an effective short term desensitizing agent. Now it remains to be shown that ILIT also has long-term effects of tolerance. Preliminary data suggest that there is a long-term effect.

SUMMARY

Injecting allergen directly into a lymph node strengthens the protective immune response. ILIT is safe and induces desensitization and very likely also induces tolerance. Compliance will improve compared with other treatment forms. If ILIT holds its promise, it will become an attractive option for patients with allergy.

Immunology of allergen immunotherapy

Allergen immunotherapy (AIT) is the only disease-modifying therapy for allergic disease. Through repeated inoculations of low doses of allergen-either as whole proteins or peptides-patients can achieve a homeostatic balance between inflammatory effectors induced and/or associated with allergen contact, and mediators of immunologic non-responsiveness, potentially leading to sustained clinical improvements. AIT for airborne/respiratory tract allergens and insect venoms have traditionally been supplied subcutaneously, but other routes and modalities of administration can also be effective. Despite differences of allergen administration, there are some similarities of immunologic responses across platforms, with a general theme involving the restructuring and polarization of adaptive and innate immune effector cells. Here we review the immunology of AIT across various delivery platforms, including subcutaneous, sublingual, epicutaneous, intradermal, and intralymphatic approaches, emphasizing shared mechanisms associated with achieving immunologic non-responsiveness to allergen.

Chinese Guideline on Allergen Immunotherapy for Allergic Rhinitis: The 2022 Update

In the last few decades, there has been a progressive increase in the prevalence of allergic rhinitis (AR) in China, where it now affects approximately 250 million people. AR prevention and treatment include allergen avoidance, pharmacotherapy, allergen immunotherapy (AIT), and patient education, among which AIT is the only curative intervention. AIT targets the disease etiology and may potentially modify the immune system as well as induce allergen-specific immune tolerance in patients with AR. In 2017, a team of experts from the Chinese Society of Allergy (CSA) and the Chinese Allergic Rhinitis Collaborative Research Group (C2AR2G) produced the first English version of Chinese AIT guidelines for AR. Since then, there has been considerable progress in basic research of and clinical practice for AIT, especially regarding the role of follicular regulatory T (TFR) cells in the pathogenesis of AR and the use of allergen-specific immunoglobulin E (sIgE) in nasal secretions for the diagnosis of AR. Additionally, potential biomarkers, including TFR cells, sIgG4, and sIgE, have been used to monitor the incidence and progression of AR. Moreover, there has been a novel understanding of AIT during the coronavirus disease 2019 pandemic. Hence, there was an urgent need to update the AIT guideline for AR by a team of experts from CSA and C2AR2G. This document aims to serve as professional reference material on AIT for AR treatment in China, thus improving the development of AIT across the world.

Update on pathomechanisms and treatments in allergic rhinitis

Allergic rhinitis (AR) is a global health problem with increasing prevalence and association with an enormous medical and socioeconomic burden. New recognition of immune cells such as type 2 innate lymphocytes (ILC2s), T helper (Th2) 2 cells, follicular helper T cells, follicular regulatory T cells, regulatory T cells, B cells, dendritic cells, and epithelial cells in AR pathogenesis has been updated in this review paper. An in-depth understanding of the mechanisms underlying AR will aid the identification of biomarkers associated with disease and ultimately provide valuable parameters critical to guide personalized targeted therapy. As the only etiological treatment option for AR, allergen-specific immunotherapy (AIT) has attracted increasing attention, with evidence for effectiveness of AIT recently demonstrated in several randomized controlled trials and long-term real-life studies. The exploration of biologics as therapeutic options has only involved anti-IgE and anti-type 2 inflammatory agents; however, the cost-effectiveness of these agents remains to be elucidated precisely. In the midst of the currently on-going COVID-19 pandemic, a global life-threatening disease, although some studies have indicated that AR is not a risk factor for severity and mortality of COVID-19, this needs to be confirmed in multi-centre, real-life studies of AR patients from different parts of the world.

Recent Advances in Allergen-Specific Immunotherapy in Humans: A Systematic Review

Allergen-specific immunotherapy (AIT) is presumed to modulate the natural course of allergic disease by inducing immune tolerance. However, conventional AITs, such as subcutaneous immunotherapy and sublingual immunotherapy, require long treatment durations and often provoke local or systemic hypersensitivity reactions. Therefore, only <5% of allergy patients receive AIT as second-line therapy. Novel administration routes, such as intralymphatic, intradermal and epicutaneous immunotherapies, and synthetic recombinant allergen preparations have been evaluated to overcome these limitations. We will review the updated views of diverse AIT methods, and discuss the limitations and opportunities of the AITs for the treatment of allergic diseases in humans.