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Larenas-Linnemann D, Rodríguez-Pérez N, Luna-Pech JA, Rodríguez-González M, Blandón-Vijil MV, Del-Río-Navarro BE, Costa-Domínguez MDC, Navarrete-Rodríguez EM, Macouzet-Sánchez C, Ortega-Martell JA, Pozo-Beltrán CF, Estrada-Cardona A, Arias-Cruz A, Rodríguez Galván KG, Brito-Díaz H, Canseco-Raymundo MDR, Castelán-Chávez EE, Escalante-Domínguez AJ, Gálvez-Romero JL, Gómez-Vera J, González-Díaz SN, Guerrero-Núñez MGB, Hernández-Colín DD, Macías-Weinmann A, Mendoza-Hernández DA, Meneses-Sánchez NA, Mogica-Martínez MD, Moncayo-Coello CV, Montiel-Herrera JM, O'Farril-Romanillos PM, Onuma-Takane E, Ortega-Cisneros M, Rangel-Garza L, Stone-Aguilar H, Torres-Lozano C, Venegas-Montoya E, Wakida-Kusunoki G, Partida-Gaytán A, López-García AI, Macías-Robles AP, Ambriz-Moreno MDJ, Azamar-Jácome AA, Beltrán-De Paz CY, Caballero-López C, Fernández de Córdova-Aguirre JC, Fernández-Soto JR, Lozano-Sáenz JS, Oyoqui-Flores JJ, Osorio-Escamilla RE, Ramírez-Jiménez F, Rivero-Yeverino D, Martínez Infante E, Medina-Ávalos MA. Compromising between European and US allergen immunotherapy schools: Discussions from GUIMIT, the Mexican immunotherapy guidelines. World Allergy Organ J 2020; 13:100444. [PMID: 32884611 PMCID: PMC7451623 DOI: 10.1016/j.waojou.2020.100444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/15/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background Allergen immunotherapy (AIT) has a longstanding history and still remains the only disease-changing treatment for allergic rhinitis and asthma. Over the years 2 different schools have developed their strategies: the United States (US) and the European. Allergen extracts available in these regions are adapted to local practice. In other parts of the world, extracts from both regions and local ones are commercialized, as in Mexico. Here, local experts developed a national AIT guideline (GUIMIT 2019) searching for compromises between both schools. Methods Using ADAPTE methodology for transculturizing guidelines and AGREE-II for evaluating guideline quality, GUIMIT selected 3 high-quality Main Reference Guidelines (MRGs): the European Academy of Allergy, Asthma and Immunology (EAACI) guideines, the S2k guideline of various German-speaking medical societies (2014), and the US Practice Parameters on Allergen Immunotherapy 2011. We formulated clinical questions and based responses on the fused evidence available in the MRGs, combined with local possibilities, patient's preference, and costs. We came across several issues on which the MRGs disagreed. These are presented here along with arguments of GUIMIT members to resolve them. GUIMIT (for a complete English version, Supplementary data) concluded the following. Results Related to the diagnosis of IgE-mediated respiratory allergy, apart from skin prick testing complementary tests (challenges, in vitro testing and molecular such as species-specific allergens) might be useful in selected cases to inform AIT composition. AIT is indicated in allergic rhinitis and suggested in allergic asthma (once controlled) and IgE-mediated atopic dermatitis. Concerning the correct subcutaneous AIT dose for compounding vials according to the US school: dosing tables and formula are given; up to 4 non-related allergens can be mixed, refraining from mixing high with low protease extracts. When using European extracts: the manufacturer's indications should be followed; in multi-allergic patients 2 simultaneous injections can be given (100% consensus); mixing is discouraged. In Mexico only allergoid tablets are available; based on doses used in all sublingual immunotherapy (SLIT) publications referenced in MRGs, GUIMIT suggests a probable effective dose related to subcutaneous immunotherapy (SCIT) might be: 50-200% of the monthly SCIT dose given daily, maximum mixing 4 allergens. Also, a table with practical suggestions on non-evidence-existing issues, developed with a simplified Delphi method, is added. Finally, dissemination and implementation of guidelines is briefly discussed, explaining how we used online tools for this in Mexico. Conclusions Countries where European and American AIT extracts are available should adjust AIT according to which school is followed.
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Key Words
- AGREE-II, Appraisal of Guidelines for Research & Evaluation Instrument
- AIT, Allergen immunotherapy
- Allergen extract
- Allergen immunotherapy
- Asthma and Immunology, DBPC
- CMICA, Colegio Mexicano de Inmunología Clínica y Alergia
- COMPEDIA, Colegio Mexicano de Pediatras Especialistas in Inmunología Clínica y Alergia
- EAACI, European Academy of Allergy
- FASIT, Future of the Allergists and Specific Immunotherapy
- GIN, Guidelines International Network
- GINA, Global Initiative for Asthma
- GP, grass pollen
- GRADE, grading of recommendations assessment development and evaluation
- GUIMIT, by its Spanish initials of Guía Mexicana de Inmunoterapia
- Guideline
- HDM, house dust mite
- Ig, immunoglobulin
- MRG, main reference guidelines
- PICO, Patient-Intervention-Comparator-Outcome
- SCIT, subcutaneous allergen immunotherapy
- SLIT, sublingual allergen immunotherapy
- Subcutaneous immunotherapy
- Sublingual immunotherapy
- US, United States of North America
- double-blind, placebo controlled
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Affiliation(s)
- Désirée Larenas-Linnemann
- Médica Sur, Clinical Foundation and Hospital, Mexico City, Mexico
- Corresponding author. Médica Sur, Fundación clínica y hospital, Puente de piedra 150, T2Toriello Guerra, Tlalpan, 14050, Ciudad de México, Mexico
| | | | - Jorge A. Luna-Pech
- Departamento de Disciplinas Filosóficas, Metodológicas e Instrumentales (CUCS), Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | | | | | | | | | | | - Carlos Macouzet-Sánchez
- State University of Nuevo León, School of Medicine and University Hospital “Dr. José Eleuterio González”, Monterrey, Nuevo León, Mexico
| | | | | | | | - Alfredo Arias-Cruz
- State University of Nuevo León, School of Medicine and University Hospital “Dr. José Eleuterio González”, Monterrey, Nuevo León, Mexico
| | | | | | | | | | | | | | - Javier Gómez-Vera
- Institute of Security and Social Services of State Workers, López Mateos Regional Hospital, Mexico City, Mexico
| | - Sandra Nora González-Díaz
- State University of Nuevo León, School of Medicine and University Hospital “Dr. José Eleuterio González”, Monterrey, Nuevo León, Mexico
| | | | | | - Alejandra Macías-Weinmann
- State University of Nuevo León, School of Medicine and University Hospital “Dr. José Eleuterio González”, Monterrey, Nuevo León, Mexico
| | | | - Néstor Alejandro Meneses-Sánchez
- Centro Médico Nacional Siglo Xxi. Unidad Médica De Alta Especialidad. Hospital De Pediatria Dr. Silvestre Frenk Freund., Mexico City, Mexico
| | | | | | | | | | | | | | | | | | | | - Edna Venegas-Montoya
- Mexican Social Security Institute, High Specialty Medical Unit 25, Department of Clinical Immunology and Allergy, Monterrey, Nuevo León, Mexico
| | | | | | | | - Ana Paola Macías-Robles
- Instituto Mexicano del Seguro Social, Centro Medico Nacional de Occidente Unidad de Alta Especialidad Hospital de Pediatria, Guadalajara, Jalisco, Mexico
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Castro-Almarales RL, Ronquillo-Díaz M, Álvarez-Castelló M, Rodríguez-Canosa J, González-León M, Enríquez-Domínguez I, Navarro-Viltre BI, Mateo-Morejón M, Oliva-Díaz Y, Ramírez-González W, Cox L, Labrada-Rosado A. Subcutaneous allergen immunotherapy for asthma: A randomized, double-blind, placebo-controlled study with a standardized Blomia tropicalis vaccine. World Allergy Organ J 2020; 13:100098. [PMID: 32308779 PMCID: PMC7155230 DOI: 10.1016/j.waojou.2020.100098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 11/14/2019] [Accepted: 11/22/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Sensitization to Blomia tropicalis (Bt) is very frequent in the tropics, and particularly in Cuba, being a significant cause of allergic asthma. Allergen immunotherapy (AIT) with Bt can be a therapeutic option, however, placebo-controlled clinical trials have not been reported. OBJECTIVE To assess the therapeutic effect and safety of AIT for asthma using a standardized allergen vaccine of B. tropicalis by subcutaneous route, in allergic asthmatic patients exposed and sensitized to this mite species. METHODS A double-blind, placebo-controlled Phase II trial was conducted in 35 adults (18 with treatment and 17 with placebo), with mild to moderate asthma, predominantly sensitized to Bt. AIT was administered subcutaneously in increasing doses from 4 to 6000 Biological Units using a locally manufactured standardized extract (BIOCEN, Cuba). Patient assessment was performed using symptom-medication score (SMS), peak expiratory flow and skin reactivity relative to Histamine as measured by skin prick test (SPT). RESULTS The 12-month treatment achieved a significant (p < 0.001) decrease of SMS. Symptom score showed only 41% (CI: 26-61) of placebo values, whereas medication was 34.5% (22.4%-63.3%). Treatment was regarded clinically effective in 67% of patients (OR 32; 95%CI: 17 to 102). The effect size on symptoms and medication was higher than has been reported with equivalent allergen dosages of D. pteronyssinus and D. siboney in Cuban asthmatic patients. Skin reactivity to Bt was also significantly reduced (p = 0.0001), increasing 148-fold the allergen threshold to elicit a positive skin test. This desensitization effect was specific to Bt and did not modify the reactivity to Dermatophagoides. The change of specific skin reactivity was significantly (p < 0.05) correlated to clinical improvement. All adverse events were local with a frequency of 2.4% of injections. CONCLUSIONS Subcutaneous AIT with Blomia tropicalis was effective and safe in asthmatic adults exposed and sensitized to this mite species in a tropical environment. TRIAL REGISTRATION Cuban Public Registry of Clinical Trials: RPCEC00000026 (WHO International Clinical Trial Registry Platform ICTRP).
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Key Words
- AIT, Allergen immunotherapy
- ALK, Denmark-based pharmaceutical company
- BIOCEN, National Center of Bioproducts
- BU, Biological Units
- BU/mL, Biological units per milliliter
- Blo t, Mayor allegen of Blomia tropicalis
- Blomia tropicalis
- Bt, Blomia tropicalis or B. tropicalis
- CECMED, Center for State Control of Drugs, Equipment and Medical Devices
- Ch10, Allergen specific reactivity calculated relative to the Histamine HC 10 mg/mL
- Clinical trial
- Dp or D, pteronyssinus: Dermatophagoides pteronyssinus
- Ds or D, siboney: Dermatophagoides siboney
- HDM SCIT, Immunotherpy Subcutaneous with allergens of House Dust Mite
- HDM, House Dust Mite
- OCI, Overall clinical improvement
- PEF, Peak Expiratory Flow
- SM, Symptom and Medication
- SMD, Standard Mean Difference
- Standardized allergen extract
- Subcutaneous immunotherapy
- VALERGEN-BT, Standardized allergen extract of Blomia tropicalis
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Affiliation(s)
- Raúl Lázaro Castro-Almarales
- Second Degree Specialist in Allergy and Integral General Medicine, Master in Transmissible Diseases, Auxiliary Professor, “General Calixto García” University Hospital, Havana University of Medical Science. Auxiliary Researcher, National Center of Bioproducts, Bejucal, Mayabeque, Cuba
| | - Mercedes Ronquillo-Díaz
- Second Degree Specialist in Allergy, Master in Occupational Health, Auxiliary Professor, “General Calixto García” University Hospital, Allergy and Immunology Service, Havana University of Medical Science, Cuba
| | - Mirta Álvarez-Castelló
- Second Degree Specialist in Allergy, Auxiliary Professor and Researcher, “General Calixto García” University Hospital, Allergy and Immunology Service, Havana University of Medical Science, Cuba
| | - José Rodríguez-Canosa
- Second Degree Specialist in Allergy, Master in Transmissible Diseases, Auxiliary Professor, “General Calixto García” University Hospital, Allergy and Immunology Service, Havana University of Medical Science, Cuba
| | - Mayda González-León
- Second Degree Specialist in Integral General Medicine, Master in Natural and Traditional Medicine, Teaching Polyclinic “Pedro Fonseca Álvarez”, Havana, Cuba
| | - Irene Enríquez-Domínguez
- First Degree Specialist in Allergy and Integral General Medicine, Master in Child Integral Care, “General Calixto García” University Hospital, Allergy and Immunology Service, Havana, Cuba
| | | | - Maytee Mateo-Morejón
- Master in Biotechnology, National Center of Bioproducts, Allergens Department, Bejucal, Mayabeque, Cuba
| | - Yunia Oliva-Díaz
- National Center of Bioproducts, Allergen Department, Bejucal, Mayabeque, Cuba
| | - Wendy Ramírez-González
- Master in Biochemistry, National Center of Bioproducts, Allergens Department, Bejucal, Mayabeque, Cuba
| | - Linda Cox
- Allergy & Asthma Center, Fort Lauderdale, Florida, USA
| | - Alexis Labrada-Rosado
- Full Researcher, Research and Development Director, National Center of Bioproducts, Bejucal, Mayabeque, Cuba
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