Early compliance and efficacy of sublingual immunotherapy in patients with allergic rhinitis for house dust mites

Retrospective Observational Study on Telemedicine in Sublingual Immunotherapy for Patients with Japanese Cedar Pollinosis and House Dust Mite Allergic Rhinitis

Introduction: In Japan, telemedicine has gradually expanded due to deregulation in response to the COVID-19 pandemic. However, its current status remains unclear, as it is primarily provided by general practitioners. This study aims to examine the use of telemedicine in sublingual immunotherapy (SLIT) for patients with Japanese cedar pollen allergy and/or house dust mite allergic rhinitis. Methods: We conducted a retrospective analysis of medical record data from seven otorhinolaryngology clinics and performed an exploratory evaluation between a group that combined telemedicine and in-person visits during the initial 6 months of SLIT and another group with only in-person visits. Results: Following propensity score matching, 51 and 82 patients were eligible for the telemedicine and in-person groups, respectively, with 33 cases in both groups. Both groups had similar characteristics after matching. No significant difference was found in the withdrawal rate at 6 months from the start of SLIT (6.1% and 9.1% in each group; p = 1.00), side effects, or treatment efficacy between the two groups. The average copayment for patients tended to be significantly higher in the telemedicine group after one, three, and 6 months following SLIT initiation. Discussion: The situation of patients who receive an appropriate combination of telemedicine and in-person visits is not significantly different from patients who receive in-person visits alone. This study may help indicate the actual status of telemedicine in Japan. Further investigation at more facilities is necessary in the future to dispel concerns in the practice setting.

An Overview of Adherence-What It Is and Why It Is Important

Asthma, allergic rhinitis, and food allergy are common allergic diseases, yet adherence to many management options remains poor, leading to worse health outcomes and financial implications for society and health systems. The underlying causes of nonadherence are numerous, ranging from patient-specific factors to broader socioeconomic and systems-based factors. In this review, we aim to discuss the definition of adherence, which can be divided into 3 components: initiation, implementation, and persistence, as well as to review various methods of measuring adherence. Subsequently, we will review the epidemiology of adherence to asthma and allergic rhinitis medications, allergen immunotherapy, and oral immunotherapy. Finally, we will discuss the multifaceted etiology of poor adherence and its subsequent impact on patients and society.

Adherence in allergen immunotherapy: Current situation and future implications

Allergen immunotherapy (AIT) is the only disease-modifying treatment in allergy. However clinical trials as well as real-life studies revealed poor treatment adherence. This article is intended to provide an overview of the current literature of the last 10 years, to outline reasons for poor treatment adherence in AIT and to provide possible solutions for improving adherence.

Sublingual immunotherapy persistence and adherence in real-world settings: a systematic review

BACKGROUND

Sublingual immunotherapy (SLIT) adherence in the literature is often evaluated in closely monitored trials that may impact patient behavior; real-world SLIT adherence is relatively unknown. This systematic review intends to assess SLIT adherence in studies that reflect real-world settings.

METHODS

A literature search of PubMed, Embase, Cochrane, Web of Science, and Scopus for real-world studies examining SLIT adherence was performed. Monitored clinical trials were excluded. Paired investigators independently reviewed all articles. For this review, "persistence" was defined as continuing therapy and not being lost to follow-up and "adherence" as persistence in accordance with prescribed SLIT dose, dosing schedule, and duration. Article quality was assessed using a modified Newcastle-Ottawa scale and then converted to AHRQ standards (good, fair, and poor).

RESULTS

The search yielded 1596 nonduplicate abstracts, from which 32 articles (n = 63,683 patients) met criteria. Twenty-six (81%) studies reported persistence rates ranging from 7.0% to 88.7%, and 18 (56%) reported adherence rates ranging from 9.6% to 97.0%. Twenty-one (66%) studies surveyed reasons for discontinuing SLIT. All studies were Oxford level of evidence 2b and of good (n = 12) to fair (n = 20) quality.

CONCLUSION

Reported rates of real-world SLIT persistence and adherence varied widely by study methodology (e.g., follow-up duration, objective vs subjective assessment). Studies with longer follow-up generally reported lower rates; 3-year persistence ranged from 7% to 59.0% and 3-year adherence from 9.6% to 49.0%. Future studies of SLIT adherence would benefit from following concordant definitions of persistence/adherence and standardized reporting metrics. This article is protected by copyright. All rights reserved.

Abatacept (Cytotoxic T Lymphocyte Antigen 4-Fragment Crystallizable) Reduces Allergic Inflammation of Ovalbumin-Sensitized Mice

BACKGROUND

Abatacept (Aba) is a cytotoxic T-lymphocyte antigen-4 and fragment crystallizable fusion protein. Aba blocks B7/Cluster of differentiation 28 - cytotoxic T-lymphocyte antigen-4 costimulatory pathway, inhibits cluster of differentiation 4+ T-cell activation, and is used as an anti-inflammatory drug.

OBJECTIVES

We conducted this study to assess the effectiveness of Aba in the treatment of allergic rhinitis (AR) in a mouse model.

METHODS

We divided 40 four-week-old BALB/c mice into four groups: control group (n = 10), positive control group (AR, n = 10), Aba group (AR + Aba, n = 10), and dexamethasone group (AR + Dex, n = 10). Mice in each group were challenged intranasally with daily ovalbumin (OVA) administration. Episodes of sneezing and nose rubbing were counted. Mice were sacrificed on day 42 and cytokines were measured in nasal lavage fluid. Nasal mucosae of five mice from each group were used for reverse transcriptase-polymerase chain reaction and western blot assay. Samples were collected from five mice from each group for histological analysis.

RESULTS

Symptoms of AR significantly improved in the AR + Aba and AR + Dex groups compared with the AR group. Fewer eosinophils and goblet cells were seen in the AR + Aba and AR + Dex groups compared with the AR group. Both the AR + Aba and AR + Dex groups showed a significant decrease in nasal T helper 2 cytokine levels, including interleukin (IL)-4, IL-5, IL-13 and T cell activation related IL-17A, and interferon gamma (IFN- γ). Total immunoglobulin (Ig) E and OVA-specific IgG1 levels were also significantly lower in the AR + Aba and AR + Dex groups. OVA-specific IgE level was also significantly lower in the AR + Aba than AR group.

CONCLUSIONS

Aba suppresses allergic inflammation and appears to be a good treatment for AR.

International consensus statement on allergy and rhinology: Olfaction

BACKGROUND

The literature regarding clinical olfaction, olfactory loss, and olfactory dysfunction has expanded rapidly over the past two decades, with an exponential rise in the past year. There is substantial variability in the quality of this literature and a need to consolidate and critically review the evidence. It is with that aim that we have gathered experts from around the world to produce this International Consensus on Allergy and Rhinology: Olfaction (ICAR:O).

METHODS

Using previously described methodology, specific topics were developed relating to olfaction. Each topic was assigned a literature review, evidence-based review, or evidence-based review with recommendations format as dictated by available evidence and scope within the ICAR:O document. Following iterative reviews of each topic, the ICAR:O document was integrated and reviewed by all authors for final consensus.

RESULTS

The ICAR:O document reviews nearly 100 separate topics within the realm of olfaction, including diagnosis, epidemiology, disease burden, diagnosis, testing, etiology, treatment, and associated pathologies.

CONCLUSION

This critical review of the existing clinical olfaction literature provides much needed insight and clarity into the evaluation, diagnosis, and treatment of patients with olfactory dysfunction, while also clearly delineating gaps in our knowledge and evidence base that we should investigate further.

The role of house dust mite immunotherapy in Indonesian children with chronic rhinosinusitis allergy: A randomized control trial

Background

Chronic rhinosinusitis allergy (CRA) is a disease that is commonly found in children and is mostly caused by allergy to house dust mites (HDM). The use of HDM immunotherapy can be considered in children with allergies.

Objectives

Analyzing the impact of mite immunotherapy on disease burden in Indonesian children with CRA.

Methods

A randomized control trial study was conducted to participants in 2 groups, namely the immunotherapy group (n = 25) and the non-immunotherapy group (n = 25). Participants were given HDM immunotherapy for 14 weeks, which was given once per week. Participants during therapy were evaluated for rhinosinusitis symptoms and measured their immunity status (specific IgE), sleep quality (SDSC), quality of life (SN5), and family coping (F-COPES) pre-post therapy. Statistical analysis used in this study included paired t-test, Wilcoxon test, independent t-test, or Mann Whitney test with p < 0.05.

Results

The value of specific IgE in the immunotherapy group was 4.12 ± 7.75 kU/l (pre-test) and 1.52 ± 2.42 kU/l (post-test; p < 0.001), while in the non-immunotherapy group was 1.47 ± 3.28 kU/l (pre-test) and 1.18 ± 2.81 kU/l (post-test; p = 0.317). The SDSC value in the immunotherapy group was 42.16 ± 2.75 (pre-test) and 30.32 ± 3.22 (post-test; p < 0.001), while in the non-immunotherapy group was 41.92 ± 2.75 (pre-test) and 41.84 ± 2.87 (post-test; p = 0.987). The F-COPES value in the immunotherapy group was 101.56 ± 5.78 (pre-test) and 105.20 ± 4.31 (post-test; p = 0.015), while in the non-immunotherapy group was 100.36 ± 9.63 (pre-test) and 99.96 ± 9.98 (post-test; p = 0.224). The SN-5 value in the immunotherapy group was 30.04 ± 2.78 (pre-test) and 11.00 ± 2.33 (post-test; p < 0.001), while in the non-immunotherapy group was 30.04 ± 2.78 (pre-test) and 30.04 ± 2.78 (post-test; p = 0.767). There was a significant comparison between the immunotherapy group and the non-immunotherapy group on the specific IgE (p = 0.013), SDSC (p < 0.001), and SN-5 (p < 0.001) values. Meanwhile, there was no significant difference in the F-COPES value (p = 0.129).

Conclusions

The administration of HDM immunotherapy can improve the participant's immunity, quality of life, and sleep disorder.

A Retrospective Nationwide Non-Interventional Study of an Aqueous Sublingual Immunotherapy Formulation Administered with a 200-µL Dosing Pump

Background

Convenient dosing is a key component of treatment adherence and thus efficacy and safety. Aqueous sublingual immunotherapy (SLIT) formulations can be administered with a dosing pump that delivers 200 µL of volume per actuation.

Objective

The objective of this study was to describe the use of Staloral^® 300 Rapid in its new dosing pump presentation and to evaluate the safety and satisfaction from both the patient and doctor.

Patients and Methods

We performed a retrospective non-interventional study in a population (aged 5 years or over) of individuals with allergic rhinitis or allergic asthma who were being treated with aqueous 300 index of reactivity SLIT formulations of various allergens (grass pollen, tree pollen, house dust mites). Based on a detailed, SLIT-specific, patient self-questionnaire (Quartis^®) and the inspection of medical records, we assessed the characteristics of the SLIT, safety, patient satisfaction and willingness to continue SLIT. The physician’s satisfaction with the treatment was measured on a 0–100 visual analogue scale. Adverse events were coded with the Medical Dictionary for Regulatory Activities.

Results

A total of 801 valid patients were included (52.4% male; mean ± standard deviation age: 25.9 ± 17.2 years; mean time since diagnosis: 4.56 ± 4.68 years; mean time using the previous dosing pump: 19.2 ± 13.0 months; time using the 200-µL dosing pump: 14.95 ± 3.80 months). Among the study population, 317 subjects comprised the paediatric subgroup (57%: male; mean age: 9.8 ± 2.5 years). Overall, 54 patients (6.7%) reported a total of 68 adverse events (including 51 gastrointestinal adverse events). The large majority of adverse events were mild, local and transient and did not require treatment. There were no severe adverse events. The level of patient satisfaction with the ease of SLIT administration was high (84.3% overall, and 82.6% in the paediatric subgroup). The mean ± standard deviation visual analogue scale score for physician satisfaction with the treatment was 70.6 ± 25.1 out of 100.

Conclusions

Administration of 300 index of reactivity SLIT with a 200-µL dosing pump is safe, well tolerated and associated with good levels of patient satisfaction.

Sublingual immunotherapy for treating adult patients with allergic rhinitis induced by house dust mite among Chinese Han population: A retrospective study

The objective of this retrospective study was to evaluate the efficacy and safety of sublingual immunotherapy (SLIT) for treating adult patients with allergic rhinitis (AR) induced by house dust mite (HDM) among Chinese Han population.A total of 201 adult patients with AR induced by HDM were included. All of them received SLIT treatment. The outcomes consisted of AR symptoms, and quality of life. In addition, any adverse events were also recorded in this study.Compared with the AR symptoms and quality of life before the treatment, significant differences were found after 1-year treatment (P < .01), and 2-year treatment (P < .01). Additionally, only mild and acceptable adverse events were observed in this study.This study demonstrated that SLIT may be efficacious and safety for adult patients with HDM induced by AR among Chinese Han population.

Quality-of-life outcomes in patients who underwent subcutaneous immunotherapy and sublingual immunotherapy in a real-world clinical setting

OBJECTIVE

To compare changes in quality of life (QOL) that resulted from sublingual immunotherapy (SLIT) and subcutaneous immunotherapy (SCIT) in a real-world clinical setting.

BACKGROUND

SLIT is established as a viable alternative to SCIT for the treatment of allergic rhinitis. Although comparative trials are increasingly available, few studies have examined QOL outcomes between these two treatments.

METHODS

One hundred and five participants who underwent immunotherapy for airborne allergies were enrolled in this prospective, single-center study. Forty participants completed the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) at initiation of therapy, after 6 months, and after 1 year of therapy. Only patients with complete time points were included in the ultimate analysis. Twenty-nine of these participants underwent SCIT and 11 underwent SLIT. The effects of age, sex, and asthma history were also examined.

RESULTS

The participants in both groups demonstrated improvements in QOL regarding allergic rhinoconjunctivitis over the study period. However, the change in the RQLQ score from both baseline to 6 months and baseline to 1 year was only statistically significant in the SCIT group (p = 0.002, 6 months and 1 year). The participants in the SCIT group also demonstrated statistically significant improvement from baseline to 1 year in the specific domains of practical and emotional functioning, nasal symptoms, non-nasal/eye symptoms, and sleep. After 1 year, both SCIT and SLIT demonstrated a minimally important difference from baseline in the overall RQLQ score. Age <35 years in the SCIT group had a significant positive impact on QOL improvement (p = 0.038).

CONCLUSION

Although improvements in QOL were noted in both groups, changes in overall scores and the majority of domains only achieved statistical significance in the SCIT group. A small study population and difficulties adhering to immunotherapy dosing schedules in the SLIT group may be contributing factors.

Allergy genuflection? It's surmount with special focus on ear, nose and throat

The system that protects body from infectious agents is immune system. On occasions, the system seldom reacts with some foreign particles and causes allergy. Allergies of the ear, nose and throat (ENT) often have serious consequences, including impairment and emotional strain that lowers the quality of life of patients. This is further responsible for the common cold, cough, tonsillitis, dermal infection, chest pain and asthma-like conditions which disturb one's day to day life. The present review enlightens some common ENT allergies which one can suffer more frequently in one's lifetime, and ignorance leads to making the condition chronic. Information regarding pathophysiology and the management of ENT allergy by this review could help clinicians and common people to better understand the circumstances and treatment of ENT allergy.

Allergen Immunotherapy Clinical Trial Outcomes and Design: Working Toward Harmonization of Methods and Principles

Progress has been made in the harmonization of efficacy and safety outcome measures for allergen immunotherapy (AIT) trials, but unresolved issues still remain. Furthermore, there are discrepancies in recommendations from professional medical societies and regulatory agencies regarding requirements for AIT trials. In this article, we reviewed published recommendations and current data from recent clinical trials, as well as the criteria applied by regulatory authorities for approval of AIT products, to provide updated considerations for conducting phase 3 AIT trials. Topics discussed include analysis of outcomes and trial designs for pediatric and asthma indications, as well as trial designs for perennial allergic rhinoconjunctivitis. In addition, the need for harmonization of safety reporting is emphasized. Considerations presented in this article may further effort to find common ground among professional medical societies and government agencies in developing future recommendations for AIT trial design.

Evidence in immunotherapy for paediatric respiratory allergy: Advances and recommendations

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.

Comprehensive Study of Patients' Compliance with Sublingual Immunotherapy in House Dust Mite Perennial Allergic Rhinitis

INTRODUCTION

Allergen immunotherapy is a long-term treatment that has been associated with patient adherence issues. The aim of the study was to increase the knowledge on compliance of patients allergic to house dust mites, receiving sublingual immunotherapy (SLIT).

METHODS

A retrospective observational study was performed in 53 Spanish allergy units. We enrolled patients undergoing the SLIT treatment for house dust mites including a scheduled control visit 12 months after initiating the therapy. We conducted a comprehensive assessment of compliance using three methods. In the first step, an allergist evaluated the patients according to the results of an interview and the existing medical records. The subjects taking more than 80% of the overall prescription were defined as compliant. The remaining noncompliant patients were divided into groups taking less than 25%, 25-50%, and 50-80% of the prescribed SLIT. In the second stage, we conducted the Morisky-Green test. Finally, the noncompliant patients were asked to fill a self-report assessment form. Data were stratified into age groups. The potential factors affecting compliance were also investigated.

RESULTS

Overall, 380 subjects participated in the study. The compliance rate was 79.7%, and the treatment discontinuation rate was 22.5%, while 66.8% of patients were adherent (both compliant and continuing with the treatment). The results showed that children were the most compliant and adolescents the least compliant (86.6% and 60.9%, respectively). The main reason for noncompliance was "forgetting some doses" in 31.0% of the children, 48.0% of the adolescents, and 53.2% of the adults. Compliance was associated with the following factors: age, number of annual control visits, and reduction in symptomatic medication.

CONCLUSION

Our results showed that two out of three patients with house dust mite-induced allergic rhinitis adhered to the SLIT treatment. Multidisciplinary and integral solutions are needed to improve the compliance, with special attention paid to adolescents.

FUNDING

Stallergenes Greer Spain.

Sublingual Immunotherapy: A Useful Tool for the Allergist in Private Practice

This is a review of the author's experience with Sublingual Immunotherapy in a private office setting. Sublingual Immunotherapy should be considered by any allergy practitioner as a useful tool. Sublingual Immunotherapy is safe while at the same time it is effective. It enables the practitioner to treat asthmatics and young children without the concerns implicit with allergy injections.

Immunotherapy compliance: comparison of subcutaneous versus sublingual immunotherapy

BACKGROUND

Patient compliance is critical for successful allergen immunotherapy (AIT). Previous studies suggest that AIT compliance is worse outside of controlled clinical trials, with reported subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) noncompliance at 11% to 50% and 3% to 25%, respectively.

METHODS

A retrospective review of 384 AIT patients at a single, tertiary care otolaryngic allergy practice evaluated SCIT and SLIT compliance, based on treatment stage. SCIT compliance was defined as the number of 2-week breaks per year or in compliance with their defined schedule: excellent = 2 or fewer; good = 3 to 4; fair = 5 to 6; and poor = 7 or more. Compliance with SLIT was defined as the number of days vials were refilled within the defined expiration date: excellent = 10 days or fewer; good = 11 to 15 days, fair = 16 to 20 days; and poor = 25 or more days. Fisher exact and chi square tests were used for statistical analysis.

RESULTS

Seventy-four SCIT and 200 SLIT patients had data appropriate for analysis. Compliance rates were excellent (62%) or good (22%) in 62 SCIT patients and excellent (31%) or good (35%) in 131 SLIT patients. Comparing excellent compliance rates, SCIT patients had a higher rate of excellent compliance at all stages of treatment compared to SLIT patients (p < 0.05). For SCIT patients there was no significant difference in excellent compliance rates between escalation, first year of maintenance, and greater than 1 year of maintenance (p > 0.05).

CONCLUSION

The results of this study showed higher rates of patient adherence to treatment protocols among SCIT patients. There was no decrease in SCIT compliance rates across treatment stages.

Olfaction in allergic rhinitis: A systematic review

Olfactory dysfunction is a key symptom in patients with allergic rhinitis (AR). Despite the implications for quality of life, relatively few articles have tested olfactory function in their investigations. The current systematic review aimed to investigate the following 2 questions: (1) What does AR do to human olfaction? (2) How effective is the treatment of AR in restoring the sense of smell? A comprehensive literature search was performed, and human studies of any design were included. A total of 420 articles were identified, and 36 articles were considered relevant. Data indicate that the frequency of olfactory dysfunction increases with the duration of the disorder, and most studies report a frequency in the range of 20% to 40%. Although olfactory dysfunction does not appear to be very severe in patients with AR, its presence seems to increase with the severity of the disease. There is very limited evidence that antihistamines improve olfactory function. In addition, there is limited evidence that topical steroids improve the sense of smell, especially in patients with seasonal AR. This is also the case for specific immunotherapy. However, many questions remain unanswered because randomized controlled trials are infrequent and only a few studies rely on quantitative measurement of olfactory function.

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

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

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

BACKGROUND

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

METHOD/DESIGN

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

DISCUSSION

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

Three-Year Follow-up Results of Sublingual Immunotherapy in Patients With Allergic Rhinitis Sensitized to House Dust Mites

Purpose

This study investigated the long-term efficacy, safety, and compliance associated with sublingual immunotherapy (SLIT) in Korean patients with allergic rhinitis sensitized to house dust mites.

Methods

This is a retrospective cohort study. A total of 164 patients who were sensitized to Dermatophagoides pteronyssinus and Dermatophagoides farinae and who received SLIT were enrolled between November 2007 and January 2010. Each patient was followed up using a diary card, on which a symptom score, rescue medication score, and adverse events (AEs) were recorded.

Results

All allergic rhinitis symptoms improved after 3 years of SLIT (P<0.05), and the rescue medication score decreased with time (P<0.05). The incidence of AEs associated with SLIT was 31% (51 of 164 patients) during the first month of therapy, and there were no severe AEs. The dropout rate was 19.5% (32 of 164 patients) during the first month, 34% (56 of 164 patients) after 6 months, and 41% (68 of 164 patients) after 1 year of SLIT. The 3-year compliance rate was approximately 40% (65 of 164 patients). The most common causes of dropout during the first month of SLIT were high cost and inconvenience. The improvement in allergic symptoms was the most common cause of dropout after 6 months.

Conclusions

Allergic symptoms significantly decreased after 1 year of SLIT treatment, and this effect was sustained after 2 or 3 years of treatment. By increasing compliance through patient education, the 3-year use of SLIT for house dust mite allergies may be effective in the management of allergic rhinitis.

Patient adherence to allergy immunotherapy

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Balancing efficacy against safety in sublingual immunotherapy with inhalant allergens: what is the best approach?

Over the last 20 years, studies and clinical trials have demonstrated efficacy, safety and cost-effectiveness of sublingual immunotherapy (SLIT) for respiratory allergic diseases. Nevertheless, it seems to be mostly used as a second-line therapeutic option, and adherence to treatment is not always optimal. Selective literature research was done in Medline and PubMed, including guidelines, position papers and Cochrane meta-analyses concerning SLIT in adult patients. The most recent reviews confirm SLIT as viable and efficacious treatment especially for allergic rhinitis, even if the optimal dosage, duration, schedule are not clearly established for most of the products. Despite an optimal safety profile, tolerability and patient-reported outcomes concerning SLIT have received poor attention until now. Recently, new tools have been specifically developed in order to investigate these aspects. Regular assessment of tolerability profile and SLIT-related patient-reported outcomes will allow balancing efficacy with tolerability and all the other patient-related variables that may affect treatment effectiveness beyond its efficacy.

Patient knowledge, perceptions, expectations and satisfaction on allergen-specific immunotherapy: a survey

BACKGROUND

Assessing patient's perspective provides useful information enabling a customized approach which has been advocated by current guidelines. In this multicentre cross-sectional study we evaluated personal viewpoints on allergen-specific immunotherapy (SIT) in patients treated with subcutaneous (SCIT) or sublingual (SLIT) immunotherapy.

METHODS

A survey of 28 questions assessing patient's knowledge, perceptions, expectations and satisfaction was developed by an expert panel and was applied by physicians from allergology centres in patients with respiratory allergy treated with SIT. Treating physicians independently reported their satisfaction level regarding SIT for each patient.

RESULTS

Fully completed surveys from 434 patients (55.3% male; 66.7% poly-sensitized, 74% SLIT) were analysed. Mean duration of SIT was 2.5 years with different allergens. Most patients acquired their SIT knowledge from their physician (95%) and consequently, their physicians' opinion in their choice to start with SIT was important. Most patients perceived SIT to be safe and easy to integrate into their daily routine. The main motivations for SIT were its supposed potential to alter the course of the disease (45.7%), less need of (28.2%), or dissatisfaction with current pharmacotherapy (19.3%). Both patients' and physicians' satisfaction was high (VAS-scores 74/100 and 78/100, respectively) and showed a significant correlation (SCIT: r=0.612; SLIT: r=0.608). No major difference was found in patients' answers based on the level of education.

CONCLUSION

In this real life study evaluating different aspects of patient's perspective on SIT, the majority of patients had an adequate level of knowledge, perceptions, expectations and satisfaction about SIT, which corresponded well with the physician's perceptions and satisfaction. Our data warrant the use of patient's perspectives on chronic SIT treatment.

Efficacy and safety of a once-daily sublingual immunotherapy without escalation regimen in house dust mite-induced allergic rhinitis

BACKGROUND

The conventional escalation regimen for sublingual immunotherapy (SLIT) in patients with allergic rhinitis has been proven to be safe and successful in reducing allergic symptoms. However, few studies compared the efficacy and safety between a conventional escalation regimen for SLIT and once-daily SLIT. The aim of the present study was to compare the efficacy and safety of once-daily SLIT without escalation (SLITsE) to conventional escalation therapy (SLITwE).

METHODS

This study was a nonrandomized open label observational study. In total, 153 patients suffering from allergic rhinitis symptoms and sensitized to the perennial house dust mite allergens Dermatophagoides pteronyssinus and Dermatophagoides farinae, were enrolled in this study from July 2008 to December 2009. The patients were divided into 2 groups, SLITwE and SLITsE. Each patient was followed with a diary card on which a symptom score, a rescue medication score, and adverse events were recorded.

RESULTS

All of the nasal symptoms, including rhinorrhea, sneezing, nasal obstruction, itching, and olfactory symptoms, defined as a total nasal symptom score, were reduced after 6 months in both groups (p < 0.05). The rescue medication score, defined as the sum of all of the allergy medications used, also decreased in both groups. Adverse events were similar in both groups, and no major adverse events, such as anaphylaxis, were reported.

CONCLUSION

Once-daily SLITsE was well tolerated and showed safe and comparable efficacy compared with a conventional SLITwE regimen.

Clinical efficacy of sublingual immunotherapy in pediatric patients with allergic rhinitis sensitized to house dust mites: comparison to adult patients

CONCLUSION

Sublingual immunotherapy (SLIT) with house dust mite (HDM) extracts in school-age children and adolescents seems to be as effective as in adults. SLIT could be recommended as a therapeutic modality in pediatric allergic rhinitis (AR) patients sensitized to HDMs.

OBJECTIVES

To investigate the efficacy of HDM SLIT in pediatric patients with AR.

MATERIALS AND METHODS

Seventy-six patients treated with HDM SLIT for at least 1 year between November 2007 and February 2010 were enrolled in this study. A young age group (n = 54) between 6 and 18 years old was compared with an adult group (n = 22). Standardized extract of HDM (Pangramin® SLIT) was used. Total symptom scores (TSS) and anti-allergic medication scores (AMS) were evaluated before and 1 year after SLIT.

RESULTS

TSS improved in both groups, and the change was comparable in the 2 groups (ΔTSS, 5.1 vs 5.3; p = 0.538). Also among the young age group, ΔTSS did not significantly differ between school-age children and adolescents (5.2 vs 4.9, p = 0.429). Thirty-five out of 54 youngsters (64.8%) and 11 out of 22 adults (50.0%) showed improvement in TSS over 30%. AMS were significantly decreased in both groups. ΔAMS tended to be higher in the young age group, but the difference did not reach statistical significance (57.2 vs 35.7, p = 0.060).

Medical management and sublingual immunotherapy practices in patients with house dust mite-induced respiratory allergy: a retrospective, observational study

The primary objective of this study is to retrospectively describe the treatment regimens (initiation, maintenance, dosage and duration) in sublingual immunotherapy (SLIT) with house dust mite (HDM) extracts in routine practice in France. The secondary objectives include a description of the respiratory allergies that led to treatment and an evaluation of the treatment's efficacy and safety, patient satisfaction and compliance (as assessed by the physician) and patient management practices. Randomly-selected allergy specialists each included ten patients over the age of five with a respiratory allergy and proven sensitization to HDM (positive skin test and/or specific IgE >0.7 kUI) and in whom SLIT had been initiated in 2002 or 2005. The participants were monitored for at least two years. A total of 139 physicians participated in the study and contributed data from 1,289 patients (57% of whom were under the age of 18). More than 70% of the patients suffered from moderate-to-severe allergic rhinitis and 50% also suffered from asthma. More than 60% of the patients were polysensitized. A shift to shorter SLIT protocols was observed over time. Longer protocols tended to be used in children. Compliance was deemed good or very good in 84% of the patients. Treatment was deemed effective or very effective in 82% of the patients. Symptoms of rhinitis and/or asthma improved in 66% and 63% of the patients respectively, with a concomitant reduction in symptomatic medication intake. The majority of the patients were satisfied with their treatment, which was well tolerated. The results of this large, retrospective, observational study confirm the efficacy and tolerability of HDM SLIT in routine French practice in a real-world setting.

Sublingual immunotherapy in allergic rhinitis

Current treatment options for allergic rhinitis (AR) include allergen avoidance and environmental control, pharmacotherapy, nasal surgery and immunotherapy. Among these, immunotherapy is the only therapeutic option that modifies fundamental immunologic mechanism by inducing desensitization. Specific allergen immunotherapy has been used for 1 century since 1911 and subcutaneous immunotherapy (SCIT) has been demonstrated to be effective in asthma and AR. However, SCIT has several disadvantages such as inconvenience, invasiveness and potentially severe systemic reactions. Thus, sublingual immunotherapy (SLIT) has recently received much attention around the world as a treatment for AR and is now widely used to replace the subcutaneous route. SLIT has recently been introduced in Korea and is now available for AR treatment in the Asia-Pacific region. This review offers better understanding of SLIT for AR by summarizing published articles and our previous works regarding proposed mechanisms, indication and efficacy, safety and adverse events, and compliance.

Determinants of patient compliance in allergic rhinoconjunctivitis

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Aspergillus infections in the head and neck

Aspergillus is a chronic colonizer as well as a nidus of infection in the sinuses and ears. In the sinuses, the severity of the disease is classified by the invasiveness of the infection. Invasive fungal sinusitis varies in its presentation based upon the infective organism and shows reduced morbidity if identified early, which requires a high index of suspicion. Allergic fungal sinusitis was recently further classified using a radiologic staging system and was proven to have symptomatic improvement with the concomitant use of surgery and immunotherapy. Finally, fungal ball appears to be a chronic problem that is usually cured with surgery. Aspergillus in the ear is a relatively common problem often related to prolonged antibiotic use and almost always successfully treated with topical antifungals.

Management of rhinitis: allergic and non-allergic

RHINITIS IS A GLOBAL PROBLEM AND IS DEFINED AS THE PRESENCE OF AT LEAST ONE OF THE FOLLOWING: congestion, rhinorrhea, sneezing, nasal itching, and nasal obstruction. The two major classifications are allergic and nonallergic rhinitis (NAR). Allergic rhinitis occurs when an allergen is the trigger for the nasal symptoms. NAR is when obstruction and rhinorrhea occurs in relation to nonallergic, noninfectious triggers such as change in the weather, exposure to caustic odors or cigarette smoke, barometric pressure differences, etc. There is a lack of concomitant allergic disease, determined by negative skin prick test for relevant allergens and/or negative allergen-specific antibody tests. Both are highly prevalent diseases that have a significant economic burden on society and negative impact on patient quality of life. Treatment of allergic rhinitis includes allergen avoidance, antihistamines (oral and intranasal), intranasal corticosteroids, intranasal cromones, leukotriene receptor antagonists, and immunotherapy. Occasional systemic corticosteroids and decongestants (oral and topical) are also used. NAR has 8 major subtypes which includes nonallergic rhinopathy (previously known as vasomotor rhinitis), nonallergic rhinitis with eosinophilia, atrophic rhinitis, senile rhinitis, gustatory rhinitis, drug-induced rhinitis, hormonal-induced rhinitis, and cerebral spinal fluid leak. The mainstay of treatment for NAR are intranasal corticosteroids. Topical antihistamines have also been found to be efficacious. Topical anticholinergics such as ipratropium bromide (0.03%) nasal spray are effective in treating rhinorrhea symptoms. Adjunct therapy includes decongestants and nasal saline. Investigational therapies in the treatment of NAR discussed include capsaicin, silver nitrate, and acupuncture.

Efficacy of sublingual immunotherapy with house dust mite extract in polyallergen sensitized patients with allergic rhinitis

BACKGROUND

It is suggested that polysensitized patients might not benefit from specific allergic rhinitis immunotherapy as much as monosensitized patients, although further research on this subject is needed.

OBJECTIVE

To compare the efficacy of sublingual immunotherapy (SLIT) with standardized house dust mite extract in monosensitized and polysensitized patients with allergic rhinitis.

METHODS

Patients who were sensitized to house dust mites and treated with SLIT for house dust mites for at least 1 year between November 2007 and March 2010 were studied. The monoallergen sensitized group was defined as patients who were sensitized to Dermatophagoides pteronyssinus and/or Dermatophagoides farinae (n = 70). The polyallergen sensitized group was defined as patients who were simultaneously sensitized to house dust mites and other allergens (n = 64). A standardized extract of house dust mites was used for immunotherapy. Antiallergic medication and the total nasal symptom score (TNSS), including rhinorrhea, sneezing, nasal obstruction, and itchy nose, were evaluated before and 1 year after SLIT.

RESULTS

This study enrolled 134 patients. The TNSS improved significantly after SLIT in both groups, whereas the change in the TNSS did not differ significantly between the groups. The antiallergic medication scores also decreased significantly in both groups, but there was no significant difference between the groups.

CONCLUSIONS

In polysensitized allergic rhinitis patients, SLIT for D pteronyssinus and/or D farinae produced improvements in both nasal symptoms and rescue medication scores comparable to those in monosensitized patients, regardless of other positive allergens. SLIT for D pteronyssinus and/or D farinae should be considered in polysensitized allergic rhinitis patients.

Clinical and immunologic effects of sublingual immunotherapy on patients with allergic rhinitis to house-dust mites: 1-year follow-up results

BACKGROUND

There have been no data on sublingual immunotherapy (SLIT) in Asian patients with allergic rhinitis (AR) sensitized to house-dust mites (HDMs). This study aimed to investigate the efficacy and immunologic change after 12 months of SLIT in Korean patients.

METHODS

Fifty-eight patients, who had AR caused by Dermatophagoides pteronyssinus and Dermatophagoides farinae and who completed 12 months of SLIT were included. Symptom scores were evaluated before and after 12 months of SLIT, and medication scores were assessed throughout the study. Peripheral blood eosinophil counts, eosinophil cationic protein (ECP), total IgE, and specific IgE were also evaluated.

RESULTS

All of the symptoms of AR were significantly improved with reduced medication scores. In addition, there were significant decrements in peripheral blood eosinophil counts and ECP (p = 0.025 and p = 0.048, respectively). Specific IgE for D. farinae slightly increased (p = 0.019), whereas specific IgE for D. pteronyssinus and total IgE did not change significantly. Thirty-six (62%) of 58 patients were in the effective response group. Although not statistically significant, findings in the study showed that the effective response group had a tendency to have higher ECP levels before SLIT than the ineffective response group (p = 0.056).

CONCLUSION

SLIT improved the symptoms and medication scores in Korean patients with AR from HDM. Laboratory parameters including eosinophil counts, ECP, and specific IgE for D. farinae seemed to be modified after 1-year SLIT. A high ECP level may be a useful parameter to predict the effectiveness of SLIT and select the patient for the treatment.

Patient satisfaction with the benefits of overactive bladder treatment: exploration of influencing factors and development of a satisfaction assessment instrument

INTRODUCTION

Patient-reported outcome (PRO) instruments are useful for assessing treatment success in patients with overactive bladder (OAB). PROs such as the OAB Questionnaire (OAB-q) and Patient Perception of Bladder Condition (PPBC) focus more on OAB symptoms than satisfaction. We describe the development of the Patient Satisfaction with Treatment Benefit (PSTB) questionnaire, and examine the face, content and criterion validity of this tool in a study of darifenacin treatment in OAB patients who expressed dissatisfaction with prior antimuscarinic therapy.

METHODS

The PSTB questionnaire was created based on treatment-related items identified as relevant to OAB patients in exploratory interviews, then refined to comprise an Overall Satisfaction question and 23 items addressing specific treatment benefits using a 5-point Likert scale. The PSTB questionnaire was completed at last visit by 473 patients participating in an open-label, 12-week study of darifenacin treatment. Factors driving Overall Satisfaction were explored by investigating its relationship to PPBC, bladder symptom diaries and specific benefits assessed by the PSTB.

RESULTS

At study end, mean Overall Satisfaction score was 3.1, corresponding to "satisfied." Overall Satisfaction correlated strongly with each specific benefit in the PSTB, and with PPBC and OAB symptoms at last visit, but more weakly with change from baseline PPBC/symptoms. Satisfaction at last visit was higher for patients with mild/moderate versus severe problems on baseline PPBC.

CONCLUSIONS

Patients' reported satisfaction appears to reflect their current status rather than improvement over time. The PSTB tool may have a place alongside other symptom-based instruments. Further testing is required to validate these findings.

The pathophysiology, diagnosis and treatment of allergic rhinitis

Treatment of AR requires a stepwise approach depending on the severity and duration of symptoms. Treatment options for AR consist of allergen avoidance, pharmacotherapy, immunotherapy and surgery. For the mechanisms of AR, anti-IgE antibody and specific antibody to cytokines such as IL-4 or IL-5 that correlate with allergic inflammation have recently emerged. SLIT is currently widely used due to its efficacy, safety and convenience, which replaces subcutaneous immunotherapy. Although allergen avoidance and immunotherapy are theoretically ideal, antihistamines and intranasal corticosteroids will play the main role in the management of AR until an innovative treatment develops. However, patients' main symptom, the duration and severity of AR, patients' compliance, safety of medication and cost-effectiveness should be considered when treatment options are chosen. In conclusion, physicians should be aware of etiology, pathophysiology, symptoms, signs and diseases related to AR in order to make a correct diagnosis and choose a proper treatment option for each patient.