[Allergen-specific immunotherapy : A brief overview in association with allergic conjunctivitis]

Allergen-specific immunotherapy (AIT) is the only causal and disease-modifying treatment for immunoglobulin E (IgE)-mediated type I allergies. Regular exposure to the causative allergen results in an immunomodulatory effect by which the predominant T‑helper (Th) 2 lymphocyte response is shifted to a Th1 lymphocyte response and more allergen-specific blocking immunoglobulins are produced. The approval of substances for AIT is regulated by the Therapy Allergens Ordinance (TAV). There are subcutaneous and/or sublingual AITs for the following indications: allergic rhinitis, allergic conjunctivitis, allergic asthma and insect venom allergy. In this article the indications for allergic conjunctivitis are discussed in particular. Clinical symptoms and a relevant type 1 sensitization are the prerequisites for the indications for AIT. The assessment of the indications and carrying out an AIT should only be carried out by physicians who have been trained in allergology.

Sublingual immunotherapy tablets in monosensitized and polysensitized adults with allergic rhinoconjunctivitis

Background: Most patients with allergic rhinitis/conjunctivitis (AR/C) are sensitized to more than one allergen. An ongoing question is the efficacy of single-allergen immunotherapy in patients who are polysensitized. Objective: To evaluate the efficacy and safety of grass, ragweed, tree, and house-dust mite (HDM) sublingual immunotherapy (SLIT) tablets in adults with AR/C who are mono- or polysensitized. Methods: Data from adults (ages ≥ 18 years) with AR/C who participated in phase III double-blind, placebo controlled field trials (four grass, two ragweed, two HDM, one tree) were included in the post hoc analyses. Efficacy was assessed by the total combined score (TCS) (sum of AR/C daily symptom and medication scores) during the entire pollen season for grass and tree trials, and peak pollen season for ragweed trials versus placebo. Efficacy for the HDM SLIT-tablet was assessed by the total combined rhinitis score (TCRS) (sum of rhinitis daily symptom and medication scores) during the last 8 weeks of treatment versus placebo. Results: For the grass SLIT-tablet, TCS improved by 20% (mean difference 1.33 [95% confidence interval {CI}, 0.44-2.22]) in the subjects who were monosensitized (n = 442) and 20% (mean difference 1.28 [95% CI, 0.90-1.67]) in the subjects who were polysensitized (n = 1857). For the ragweed SLIT-tablet, TCS improved by 19% (mean difference 1.72 [95% CI, -0.20 to 3.63]) in the subjects who were monosensitized (n = 115) and 27% (mean difference 2.27 [95% CI, 1.28-3.27]) in the subjects who were polysensitized (n = 528). For the tree SLIT-tablet, TCS improved by 54% (mean difference 4.65 [95% CI, 2.48-6.82]) in the subjects who were monosensitized (n = 138) and 34% (mean difference 2.51 [95% CI, 1.34-3.69]) in the subjects who were polysensitized (n = 437). For the HDM SLIT-tablet, TCRS improved by 20% (mean difference 1.24 [95% CI, 0.48-1.99]) in the subjects who were monosensitized (n = 468) and 17% (mean difference 0.85 [95% CI, 0.43-1.28]) in the subjects who were polysensitized (n = 1294). The overall safety profile was not qualitatively different between the subjects who were monosensitized and the subjects who were polysensitized. Conclusion: Grass, ragweed, tree, or HDM SLIT-tablet treatment is effective for the specific allergen in question in adults with AR/C and who are monosensitized or polysensitized. Targeting one relevant allergen with SLIT-tablets induces a clinical effect for that allergen in patients who were polysensitized.

Efficacy and safety of Artemisia annua sublingual immunotherapy in patients with seasonal allergic rhinoconjunctivitis over two pollen seasons

OBJECTIVE

This study investigates the efficacy and safety of sublingual immunotherapy (SLIT) with A. annua allergens in patients with seasonal allergic rhinoconjunctivitis over two pollen seasons.

METHODS

Seventy patients with moderate-severe seasonal allergic rhinoconjunctivitis were divided evenly into the SLIT and control groups. The SLIT last from 3 months before the summer-autumn pollen season in 2021 till the end of the summer-autumn pollen season in 2022. The daily individual symptom score, total rhinoconjunctivitis symptom score (dTRSS), total medication score (dTMS), combined score of medication and rhinoconjunctivitis symptom (dCSMRS), visual analog scale (VAS) score, and adverse events (AEs) were evaluated.

RESULTS

The average pollen concentration in 2022 was twice that previous two-year during the pollen season. Fifty-six patients completed treatments (SLIT group: 29, control group: 27). Compared with baseline, the individual symptoms, dTRSS, dTMS, dCSMRS, and VAS scores of SLIT group declined in 2021. After 16 months of SLIT, all efficacy indexes in 2022 were still lower than baseline and equivalent to those in 2021. In control group, the efficacy indexes in 2022 were higher than that in 2020 and 2021. The efficacy indexes of SLIT group were lower than those of control group in 2021 and 2022. SLIT is effective for both mono- and poly-sensitized patients. AEs incidence in SLIT group was 82.7% without severe AEs.

CONCLUSIONS

The A. annua-SLIT can obtain efficacy and safety over two pollen seasons for patients with moderate-severe seasonal allergic rhinoconjunctivitis.

The use of environmental exposure chambers in studies related to ocular surface effects

PURPOSE OF REVIEW

The potential of allergen challenges using environmental exposure facilities in allergic conjunctivitis drug development and more recently its implication on the diagnosis of the united airways concept have been emphasized in the recent literature. This study aims to present an overview of new and important data in this field.

RECENT FINDINGS

Standardized methodologies for ocular surface assessment during allergen challenges were described. The Total Ocular Symptom Score (TOSS) is the main validated questionnaire used for the assessment of ocular surface during allergen challenges. It combines patient and investigator assessments for more accurate conjunctival response and was extensively used in clinical research and daily practice. Environmental Exposure Chambers (EECs) studies aim to conduct tight-controlled challenges to a stable and well defined allergen airborne concentration, closer to natural exposure to evaluate the efficacy of nonpharmaceutical and antiallergic treatments. Recent studies showed a good correlation between ocular symptoms elicited by EEC and those assessed during natural exposure. These validated methods allow to investigate the efficacy of novel pharmacotherapies for allergic conjunctivitis and allergen immunotherapy (AIT) in a real-world model of allergen exposure.

SUMMARY

This study aims to summarize novel data regarding the impact of EECs in studying pathophysiology and drug efficacy in the context of existing clinical protocols related to ocular surface effects. In this regard, studies comparing conjunctival response during natural and EEC exposures in patients with pollen-induced conjunctivitis aimed to demonstrate better outcomes in tight-controlled exposures mimicking natural exposure. Because allergen challenges are widely implemented in allergy treatment, this article will focus on the most important outcomes and the evolution of treatments for allergic conjunctivitis.

Clinical efficacy and safety of coseasonal initiation of Artemisia annua sublingual immunotherapy on patients with Artemisia-induced rhinoconjunctivitis

PURPOSE

Patients with seasonal allergic rhinoconjunctivitis (SARC) might seek evaluation and treatment when symptoms appear during the pollen season. It is unclear whether coseasonal-initiated sublingual immunotherapy (SLIT) would be effective and safe for SARC. This study aims to identify the feasibility of initiating Artemisia annua SLIT during the pollen season.

MATERIALS AND METHODS

Sixty patients with Artemisia-induced SARC were equally recruited into the SLIT and control groups during the pollen season in 2021. The SLIT group was treated with standardized Artemisia annua SLIT drops using a modified dosing schedule combined with pharmacotherapy, while the control group only received pharmacotherapy. Diary cards for clinical symptoms, rescue medication use, and adverse events (AEs) were recorded during the pollen seasons. Objective measures, including average daily combined scores of medication and rhinoconjunctivitis symptoms (CSMRS), total rhinoconjunctivitis symptom score (TRSS), total medication score (TMS), and the score of visual analog scale (VAS) were calculated to evaluate the efficacy of SLIT. Safety was assessed through the occurrence and severity of AEs.

RESULTS

In total, 80.0 % (24/30) patients in the SLIT group and 86.67 % (26/30) patients in the control group completed the study. The severity of SARC, which was assessed by objective measures including CSMRS, TRSS, TMS, and VAS of the SLIT group and the control group, was generally at the same level during the 2021 pollen season, except for the medical consumption, which the score of TMS was slightly higher in the SLIT group. After one year of treatment, the scores of CSMRS, TRSS, and VAS in the SLIT group were significantly improved compared with the control group (all P < 0.001), and the difference in the TMS between the two groups disappeared (P > 0.05). Moreover, clinical improvement of the four objective measures was also observed in the SLIT group compared with the baseline value (P < 0.001). Overall, 9/24 patients in the SLIT group experienced mild local AEs, and two patients experienced mild systemic AEs during the SLIT period.

CONCLUSIONS

This controlled preliminary study identified that coseasonal-initiated Artemisia annua SLIT treatment for one year was generally safe and effective in improving the symptoms of SARC patients induced by Artemisia annua pollen.

Vernal Keratoconjunctivitis: A Systematic Review

Vernal keratoconjunctivitis (VKC) is a chronic, bilateral corneal and conjunctival problem which typically presents in young individuals. VKC is characterized by itching, photophobia, white mucous discharge, lacrimation, foreign body sensation, and pain due to corneal involvement of shield ulcers. Vernal keratoconjunctivitis is categorized within ocular diseases. The diagnosis is clinical, as no sure biomarkers pathognomonic of the disease have yet been identified. The VKC therapy relies on different types of drugs, from antihistamines and topical steroids to cyclosporine or tacrolimus eye drops. In extremely rare cases, there is also the need for surgical treatment for the debridement of ulcers, as well as for advanced glaucoma and cataracts, caused by excessive prolonged use of steroid eye drops. We performed a systematic review of the literature, according to PRISMA guideline recommendations. We searched the PubMed database from January 2016 to June 2023. Search terms were Vernal, Vernal keratoconjunctivitis, and VKC. We initially identified 211 articles. After the screening process, 168 studies were eligible according to our criteria and were included in the review. In this study, we performed a systematic literature review to provide a comprehensive overview of currently available diagnostic methods, management of VKC, and its treatments.

Management of Vernal Keratoconjunctivitis in Children in the United Kingdom: A Review of the Literature and Current Best Practice Across Six Large United Kingdom Centers

Vernal keratoconjunctivitis (VKC) is a form of ocular allergy primarily affecting children. Considered a rare disease in Europe, its prevalence varies by geographic region and is poorly studied in the United Kingdom. There is considerable national variation in the management of VKC within the United Kingdom, risking misdiagnosis and delays to treatment for some children. This can significantly impact their quality of life, with the potential for lasting negative consequences. Based on discussions between experienced clinicians from six large centers across the United Kingdom, this article describes best practice recommendations for United Kingdom settings, including principles for diagnosis, referral, initial and long-term management, and supportive care. Recommendations include guidance on referral timing, which should depend on VKC severity, and a stepwise approach to treatment. Joint management by primary care and secondary care is recommended and the importance of supportive care, including emotional support and outreach to schools, is highlighted. Because frequent flareups are common in VKC, it is essential that families have access to the information they need to manage the disease and routes to access rapid care if needed. A thorough understanding of the nature of VKC, its triggers, and how best to manage it, by both patients and their families, is critical to ensuring appropriate management and to improving patient outcomes. [J Pediatr Ophthalmol Strabismus. 2023;60(1):6-17.].

The effects of the COVID-19 pandemic on the treatment of allergic eye diseases

PURPOSE OF REVIEW

To analyze if recommendations given before and during the COVID-19 pandemic are still a valid option for patients suffering of ocular allergy (OA).

RECENT FINDINGS

During the last year many doctors and patients requested suggestions for the treatment of OA patients in COVID-19 time. Most of them were given by phone calls and emails following the recommendations given by Scientific Societies.

SUMMARY

Considering the current multiple problems related to the COVID-19 pandemic, OA has not been considered a priority, even though patients need treatments. Topical antiallergic drugs are still the first option to treat all kind of OA, with the addition of topical corticosteroids in the severe forms of vernal and atopic keratoconjunctivitis (VKC and AKC) even in patients at risk of COVID-19. Topical immunomodulation is still recommended in severe forms of VKC and AKC unless the patient is infected. The number of patients treated with these drugs in our Center was similar than previous years. The risk to have a VKC patient affected by COVID-19 is similar to the general pediatric population but with a lower OR. In 2021, still in COVID-time, the management of OA should follow the previous recommendations with an update due to the risk of infection.

[Restatment. Allergic-looking conjunctivitis in children]

ALLERGIC-LOOKING CONJUNCTIVITIS IN CHILDREN Eye allergies are constantly on the rise in Europe and around the world. It is a common pediatric pathology in general medicine consultation. It is important to know the different clinical forms of the disease so as not to ignore the serious forms and to be able to refer them to the ophthalmologist.

A Case of Shield Ulcer Due to Vernal Keratoconjunctivitis

Corneal shield ulcer is an uncommon but serious complication of vernal keratoconjunctivitis (VKC) that can threaten visual acuity. We present a 12-year-old case with a corneal shield ulcer on the superior part of the cornea in the right eye. We learned from his history that he was treated with topical cyclosporine A (CsA) and corneal debridement was performed for the same complaints six months ago. His complaints recurred six months after ceasing topical CsA voluntarily. Topical anti-allergic and CsA treatments were commenced, we also performed corneal debridement. During his follow-ups, the corneal ulcer healed leaving a scar as opacity and neovascularization. This case highlights the role of the anti-inflammatory effect of CsA in preventing the recurrence of shield ulcers.

Peptide allergen-specific immunotherapy for allergic airway diseases-State of the art

Allergen-specific immunotherapy (AIT) is the only means of altering the natural immunological course of allergic diseases and achieving long-term remission. Pharmacological measures are able to suppress the immune response and/or ameliorate the symptoms but there is a risk of relapse soon after these measures are withdrawn. Current AIT approaches depend on the administration of intact allergens, often comprising crude extracts of the allergen. We propose that the challenges arising from current approaches, including the risk of serious side-effects, burdensome duration of treatment, poor compliance and high cost, are overcome by application of peptides based on CD4⁺ T cell epitopes rather than whole allergens. Here we describe evolving approaches, summarize clinical trials involving peptide AIT in allergic rhinitis and asthma, discuss the putative mechanisms involved in their action, address gaps in evidence and propose future directions for research and clinical development.

Geographical and socioeconomic differences in compliance with and access to allergen immunotherapy in Denmark: A nationwide registry-based study - 1998-2016

BACKGROUND

Allergen immunotherapy (AIT) is a cost-effective treatment option in moderate-severe allergic rhino-conjunctivitis. Inequality in access to AIT and variation in compliance related to socioeconomic status or geographical location have not been described previously.

OBJECTIVE

The aim of the study was to evaluate access to grass pollen AIT at various educational attainment levels in the five regions of Denmark. Furthermore, grass pollen AIT treatment compliance was evaluated with respect to age, educational attainment and geographical area.

METHODS

The unique civil registration number of every citizen in Denmark was combined with the nationwide Danish National Health Service Prescription Database and Statistics Denmark Database to extract age, gender, residence and educational attainment of every citizen who collected prescribed AIT medication from 1998 to 2016. Then, compliance and use of AIT were calculated with respect to age, geographical location and educational attainment.

RESULTS

The use of subcutaneous AIT (SCIT) was significantly higher in the Capital Region; this difference was less predominant for sublingual AIT (SLIT). People who were educated only to primary school or vocational training levels were less frequent users of AIT. Compliance was especially low in the Capital Region and among people educated only to primary school level. In the age groups, compliance was similar, apart from SLIT users aged 0-9, for whom compliance was higher.

CONCLUSION

This nationwide study finds that SLIT has the potential to reduce inequality in access to AIT. A focus intervention is needed to facilitate access to and compliance with AIT in groups with lower socioeconomic status.

[Vernal keratoconjunctivitis]

Vernal keratoconjunctivitis. Chronic inflammatory disease of children and young adults, vernal keratoconjunctivitis is a rare pathology. This allergic ocular pathology should know because it may alter the visual prognosis. Its management is mostly multidisciplinary, associating the ophthalmologist and the allergologist.

Emerging Therapeutics for Ocular Surface Disease

PURPOSE OF REVIEW

The purpose of this article is to review treatment advances in ocular allergy that include the treatment of the various signs and symptoms of the allergic inflammatory response of the ocular surface.

RECENT FINDINGS

Recent studies have demonstrated improved pharmacological effect of topical agents with artificial tears and cold compresses; brimonidine, a new ophthalmic decongestant which has demonstrated decreased rebound conjunctivitis; and potential use of contact lens and other novel delivery instruments to increase medication retention time. Currently, there have been limited advances in novel ophthalmic treatments. Non-pharmacological interventions have demonstrated in a randomized control study that artificial tears and the use cold compresses alone or in combination with ophthalmic antihistamines can enhance the effectiveness of a traditional pharmacological therapy. The primary advances have been the start of head-to-head studies comparing various agents actively being used in the treatment of ocular allergy. In addition, there has been increasing interest in the development of novel delivery systems to increase residence time of pharmacological agents in the ocular surface such as nanoparticles, microfilms; examining novel pathways of controlling the allergic inflammatory response of the ocular surface such as modulation of cytokines, transcription factors, and immunophilins.

[Right treatment of red eyes - prescription of topical antibiotics for infectious conjunctivitis is still common in Sweden]

Conjunctivitis is one of the most common ophthalmologic conditions in general medical practice. In most cases, it is self-limiting and do not require topical antibiotic therapy. In a retrospective, observational cohort study during 2013-2017 in a region in Sweden conjunctivitis was diagnosed in 32 000 cases in primary care. Antibiotics were prescribed in 66% of undefined and in 83% of purulent conjunctivitis. Fusidic acid was the most common medication with 81% followed by chloramphenicol with 17%. Although unnecessary, the treatment is probably harmless. Toxicity is uncommon and the cost is low. Increased consciousness of this issue may however decrease resistance to antibiotics and support evidence-based medical practice.

Allergy and Asthma: Allergic Rhinitis and Allergic Conjunctivitis

Allergic rhinitis and allergic conjunctivitis are among the most common conditions seen in family medicine practice. Most cases are due to seasonal allergens, such as pollens, or year-round allergens, such as dust mites, mold, and animal dander. The clinical diagnosis can be made when symptoms of nasal congestion, sneezing, rhinorrhea, nasal or ocular pruritus, or eye tearing are present along with physical findings, such as clear rhinorrhea, pale nasal mucosa, or red watery eyes. Patients should be assessed for any comorbid conditions, such as asthma or eczema, and for symptoms that indicate impaired quality of life, such as poor sleep, daytime somnolence, or irritability. Prevention involves allergen avoidance and environmental controls. Monotherapy with oral antihistamines, intranasal steroids, or intranasal antihistamines are the initial management options for nasal and ocular symptoms. Antihistamine eye drops are fast-acting and safe for management of ocular symptoms; intranasal antihistamines are effective for nasal symptoms. Current guidelines recommend against combining intranasal steroids and oral antihistamines, as this provides no additional benefit. Select patients also may benefit from allergy skin testing or consideration for allergen immunotherapy.

Immunotherapy With the SQ Tree SLIT-tablet in Adults and Adolescents With Allergic Rhinoconjunctivitis

PURPOSE

The SQ tree sublingual immunotherapy (SLIT)-tablet containing allergen extracts with the major allergen Bet v 1 from birch pollen is currently being developed for the treatment of tree pollen-induced allergic rhinitis/conjunctivitis with or without asthma. The aim of this Phase II trial was to investigate the dose-related efficacy and safety of the SQ tree SLIT-tablet.

METHODS

This study was a randomized, parallel-group, double-blind, placebo-controlled, multi-national trial conducted in Europe. A total of 637 participants were randomized equally to receive placebo or treatment with the SQ tree SLIT-tablet in doses of 0.5, 1, 2, 4, 7, or 12 development units (DU). Treatment was initiated ~16 weeks before onset of the 2013 birch pollen season (BPS) and was continued throughout the BPS with a total duration of at least 6 months. During the BPS and tree pollen season (TPS), subjects assessed rhinoconjunctivitis symptoms and medication use on a daily basis in an electronic diary; weekly assessments of rhinoconjunctivitis quality of life were also made.

FINDINGS

Analysis of the average daily symptom score during the BPS and the TPS showed that the difference between active treatment and placebo was statistically significant for the 7 DU group (BPS, P = 0.02; TPS, P = 0.03), with no clear dose-response relationship. All doses of the SQ tree SLIT-tablet induced changes from baseline in birch-specific IgE and IgG₄ that were statistically significant compared with placebo at all time points assessed (P < 0.0001) with a clear dose-response relationship for birch specific IgG₄. In general, the SQ tree SLIT-tablet was well tolerated, with the majority of treatment-related adverse events (≥95%) being mild or moderate in severity. The most frequently reported treatment-related adverse events were generally related to the sublingual administration of the tablet (ie, they occurred in the oral cavity).

IMPLICATIONS

The results from this trial suggest that the SQ tree SLIT-tablet in doses up to 12 DU has a tolerability profile suitable for at-home administration. The immunomodulatory changes indicate a dose-response relationship, but clinical efficacy parameters were inconclusive, probably due to low pollen counts, emphasizing the importance of pollen exposure for the outcome of a pollen allergy immunotherapy trial. EudraCT no: 2012-000031-59.

Allergic conjunctivitis: current concepts on pathogenesis and management

Allergic conjunctivitis (AC) includes a wide spectrum of clinical entities characterized by different incidence, age of onset, natural course, clinical outcome and response to treatment. Taken together, they represent one of the most frequent ocular surface diseases affecting more than 30&#x0025; of the young-adult population and show an increasing incidence over the years. Moreover, comorbidities with other systemic atopic conditions such as asthma, atopic dermatitis and rhinitis require a multidisciplinary approach. Recent advances in the knowledge of the pathogenic mechanism overcome the classic role of type I hyper-sensitivity and mast cells’ activation, demonstrating an involvement of innate immunity and neuroinflammation in the pathogenesis of the most severe forms such as atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC). Ocular itching, swelling and tearing are the most frequent symptoms complained by patients with all forms of AC, while photophobia and pain are typical of the most severe forms, such as VKC and AKC, due to the frequent corneal involvement. Upper tarsal papillary reaction represents the main clinical sign of AC associated with conjunctival hyperemia and mucous secretion. Diagnosis is based on clinical history and eye evaluation and can be confirmed through allergological tests. Additional ocular exams include specific allergen conjunctival provocation tests and the presence of eosinophils in the conjunctival scraping. Current treatments of AC include the use of antiallergic eye drops for mild forms, while recurrences of ocular surface inflammations with corneal involvement in severe forms require the use of topical steroids to avoid visual impairment. Novel steroid sparing therapies such as Cyclosporine A eye drops or topical Tacrolimus have been proposed to improve VKC and AKC management.

Diagnosis and management of allergic conjunctivitis in pediatric patients

BACKGROUND

Allergic conjunctivitis (AC), although one of the most common ocular disorders in pediatric patients, is frequently overlooked, misdiagnosed, and undertreated in children.

OBJECTIVE

To guide pediatric health care professionals in the optimal diagnosis and management of AC in pediatric patients.

METHODS

To identify any existing best practice guidelines for the diagnosis and treatment of AC in pediatric patients, a review of the literature published between 2004 and January 2015 was conducted. Diagnosis and treatment algorithms and guidelines for pediatric patient referrals were then developed.

RESULTS

A literature search to identify best practice guidelines for the treatment of AC in pediatric patients failed to return any relevant articles, which highlighted the need for best practice recommendations. Based on publications on adult AC and clinical experience, this review provides step-by-step guidance for pediatric health care professionals, including recognizing clinical features of AC, establishing a comprehensive medical history, and performing a thorough physical examination to ensure a correct diagnosis and the optimal treatment or referral to an eye care specialist or allergist when required. In addition to established drug treatments, the role of subcutaneous and sublingual immunotherapy is discussed to inform pediatric health care professionals about alternative treatment options for patients who do not tolerate pharmacotherapy or who do not respond sufficiently.

CONCLUSION

The diagnostic and treatment algorithms and guidelines provided in this review help address the current literature and educational gap and may lead to improvements in diagnosis and management of pediatric AC.

Findings from an Online Survey Assessing the Burden and Management of Seasonal Allergic Rhinoconjunctivitis in US Patients

BACKGROUND

Seasonal allergic rhinoconjunctivitis (SARC) affects ≥16% of the US population annually. Telephone and in-office surveys have demonstrated negative effects of allergic rhinitis (AR) symptoms on sleep, daily activities, productivity, concentration, and emotions.

OBJECTIVE

The objective of this study was to assess the patient-perceived burden of SARC in relation to newer treatments, increased access to treatments, and changing management protocols.

METHODS

An online survey of symptom experience, impact on daily life, and management was conducted in US respondents who suffer (or whose child suffers) from SARC symptoms.

RESULTS

A total of 1001 surveys were completed: 500 adults (≥18 years old) and 501 children (12-17 years old, documented by their parents). Similar to earlier AR surveys, SARC symptoms negatively affected the patient's (and family's) quality of life, and were most severe in the spring. Before being treated, >50% of respondents reported daily symptoms during their season; 75% to 80% considered their symptoms moderate to severe. Patients saw a variety of health care professionals (including pharmacists) and used over-the-counter and prescription medications for symptoms. Those using prescription medications were generally more satisfied with treatment and less likely to switch or discontinue treatment. Nasal and/or ocular symptoms drove adherence, seeing a health care professional, and reviewing and/or changing treatment.

CONCLUSIONS

The majority of patients with SARC report moderate-to-severe symptoms that significantly impair their quality of life. However, patients appear to be taking more responsibility for their (child's) condition, and patient expectations for therapy are increasingly being met. Continued efforts will be needed to examine the contribution of better information and/or increased access to and availability of medications to control the disease.

The Effects of Short-Term Immunotherapy Using Molecular Standardized Grass and Rye Allergens Compared with Symptomatic Drug Treatment on Rhinoconjunctivitis Symptoms, Skin Sensitivity, and Specific Nasal Reactivity

BACKGROUND: The efficacy and safety of short-term immunotherapy with molecular standardized allergens (STI) has been demonstrated by double-blind placebo-controlled clinical trials. The aim of this study was to compare STI with symptomatic drug treatment.

METHODS: Forty-eight patients with rhinoconjunctivitis to grass and/or rye pollen were treated either with STI (ALK7, n = 24) plus anti-allergic drugs or anti-allergic drugs, alone (n = 24) in a prospective, randomized study. Symptoms and use of drugs were reported in patient diaries and titrated nasal provocation and skin prick tests were performed at baseline, before, and after season.

RESULTS: Median overall symptom ( P = 0.022, U test) and medication scores ( P = 0.003) were significantly lower in the STI group, as was the result for a simultaneous analysis of conjunctival, nasal, and bronchial symptom scores and medication ( P = 0.005). Sensitivity in the nasal provocation test decreased in the STI group but not in the drug-treated group. These differences became significant directly after STI ( P = 0.027) as well as after the grass pollen season ( P < 0.001). Skin sensitivity did not change in the STI group but increased in the drug-treated group after season, with a significant difference between the two groups for the erythema ( P < 0.001).

CONCLUSIONS: STI reduces grass pollen-induced rhinoconjunctivitis symptoms and drug use, and specific nasal reactivity and skin sensitivity, more efficiently than a standard symptomatic treatment.

Optimum treatment strategies for polyallergic patients - analysis of a large observational trial

OBJECTIVES

To document the effectiveness and safety of sublingual allergen immunotherapy (SLIT) with a five-grass pollen tablet (Oralair ) and compare different treatment options in a broad, non-selected population of patients in a real-world clinical setting.

RESEARCH DESIGN AND METHODS

This was a 2 year, open, prospective, multicenter, single-arm, non-interventional study. Patients with a history of clinically relevant allergic symptoms caused by grass pollen, confirmed by skin prick testing, received treatment with the five-grass pollen tablet. Concomitant treatment with symptomatic medication and/or additional SLIT or subcutaneous immunotherapy (SCIT) was permitted. Twelve-month data are presented here. Effectiveness was assessed comparing a combined rhinoconjunctivitis (RC) score derived from the severity of rhinitis and conjunctivitis symptoms under treatment with retrospective data of the previous year.

RESULTS

A total of 1408 patients participated in the study, of whom 434 were children/adolescents and 962 polyallergic. Compared with the grass pollen season preceding five-grass pollen tablet treatment, a statistically significant reduction of 49.9% was achieved in RC score for the total population (p < 0.001), and an improvement in overall health was perceived by 90.9% of patients. The overall population of polyallergic patients derived similar benefits from treatment with the five-grass pollen tablet as monoallergic patients. The percentage reduction in RC score was larger in polyallergic patients taking no additional therapy (60.2%) than in those taking concomitant symptomatic medication (38.1%) or allergen immunotherapy (AIT) (50.8%). Within the last of these groups, RC score improved by 47.6% among patients receiving additional SCIT, versus 54.8% with additional SLIT. Adverse drug reactions, reported in 15.3% of study participants, were mostly local in nature and mild or moderate in intensity.

CONCLUSIONS

After 1 year of treatment, polyallergic patients responded similarly to the five-grass pollen tablet as monoallergic patients. For polyallergic patients in whom additional treatment was needed, a second SLIT may be more beneficial than a SCIT or symptomatic co-medication.

Safety of house dust mite sublingual immunotherapy standardized quality tablet in children allergic to house dust mites

BACKGROUND

Sublingual immunotherapy (SLIT) tablets could be an important alternative to subcutaneous immunotherapy for house dust mite (HDM) allergy in children.

OBJECTIVE

To characterize the safety, tolerability, and duration of local adverse events (AEs) of an HDM SLIT tablet (MK-8237; Merck, ALK Abellò, and Torii) in North American children 12 to 17 years old with HDM allergic rhinitis with and without conjunctivitis and with or without asthma.

METHODS

In this phase 1, multicenter, double-blinded, randomized trial (NCT01678807), children received placebo, HDM SLIT tablet 6 standardized quality (SQ) HDM, or 12 SQ-HDM once daily for 28 days. The primary end point was the proportion of subjects with treatment-emergent AEs receiving active treatment vs placebo. The secondary end point was the proportion of subjects who discontinued owing to AEs.

RESULTS

In total 195 subjects were randomized. The 2 HDM SLIT tablet doses were well tolerated. No anaphylactic reactions, systemic allergic reactions, AEs requiring epinephrine, serious AEs, or local swellings in the mouth or throat assessed as severe were reported. The proportion of subjects with treatment-emergent AEs was 54% with 6 SQ-HDM and 57% with 12 SQ-HDM (nonsignificant vs 43% with placebo). Local AEs were the most commonly reported treatment-emergent AEs. On day 1, the median duration of individual local AEs ranged from 1 to 43 minutes. The proportion of subjects who discontinued owing to AEs was 0%, 6.2%, and 6.2%, and who experienced treatment-related AEs was 25%, 45%, and 52% for the placebo, 6 SQ-HDM, and 12 SQ-HDM groups, respectively.

CONCLUSION

The 6 and 12 SQ-HDM doses of the HDM SLIT tablet MK-8237 were well tolerated, and local AEs were of short duration.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT01678807.

Cockroach sensitization mitigates allergic rhinoconjunctivitis symptom severity in patients allergic to house dust mites and pollen

BACKGROUND

Modifiers of symptom severity in patients with allergic rhinoconjunctivitis (AR) are imprecisely characterized. The hygiene hypothesis implicates childhood microbial exposure as a protective factor. Cockroach sensitization (C+) might be a proxy for microbial exposure.

OBJECTIVE

We sought to determine whether C+ assayed by means of skin prick tests influenced AR symptom severity in controlled and natural settings.

METHODS

Total symptom scores (TSSs) were recorded by 21 participants with house dust mite allergy (M+) in the natural setting and during repeated exposures of 3 hours per day to house dust mite allergen in an allergen challenge chamber (ACC). In M+ participants the peripheral blood and nasal cells were assayed for T-cell activation and transcriptomic profiles (by using RNA sequencing), respectively. Participants allergic to mountain cedar (n = 21), oak (n = 34), and ragweed (n = 23) recorded TSSs during separate out-of-season exposures to these pollens (any pollen sensitization [P+]) in the ACC; a subset recorded TSSs in the pollination seasons.

RESULTS

The hierarchy of TSSs (highest to lowest) among M+ participants tracked the following skin prick test sensitization statuses: M+P+C- > M+P+C+ > M+P-C- > M+P-C+. In nasal cells and peripheral blood the immune/inflammatory responses were rapidly resolved in M+P+C+ compared with M+P+C- participants. Among those allergic to pollen, C+ was associated with a lower TSS during pollen challenges and the pollination season. After aggregated analysis of all 4 ACC studies, C+ status was associated with a 2.8-fold greater likelihood of a lower TSS compared with C- status (odds ratio, 2.78; 95% CI, 1.18-6.67; P = .02).

CONCLUSIONS

C+ status is associated with mitigation of AR symptom severity in adults with AR.

SQ house dust mite sublingually administered immunotherapy tablet (ALK) improves allergic rhinitis in patients with house dust mite allergic asthma and rhinitis symptoms

BACKGROUND

House dust mite (HDM) allergy is associated with persistent allergic rhinitis (AR) and allergic asthma.

OBJECTIVE

To investigate the efficacy and safety of a SQ HDM sublingually administered immunotherapy tablet (ALK, Hørsholm, Denmark) in adults and adolescents with HDM respiratory allergic disease and report the AR results.

METHODS

Six hundred four subjects at least 14 years old with HDM AR and mild to moderate HDM allergic asthma were randomized 1:1:1:1 to double-blinded daily treatment with 1, 3, 6 SQ-HDM or placebo. End-of-treatment rhinoconjunctivitis symptoms and medication score were predefined extrapulmonary end points. A subgroup analysis was conducted post hoc in subjects with a total combined rhinitis score (TCRS) > 0 (ie, with AR symptoms and/or AR medication use during the 4-week baseline period). The subgroup was comprised of 498 subjects (82%).

RESULTS

In the subgroup, the absolute difference in end-of-treatment TCRS between 6 SQ-HDM and placebo was -0.78 (95% confidence interval -1.47 to -0.07, relative difference 28.8%, P = .0357). Furthermore, a significant difference was found for the total score of the Rhinitis Quality of Life Questionnaire with Standardized Activities RQLQ(S) and for the individual domains: activities, sleep, non-nose and non-eye symptoms, and nasal symptoms. For the TCRS and Rhinitis Quality of Life Questionnaire score, a dose response was seen, with numerically lower, nonsignificant differences for 1 and 3 SQ-HDM. The predefined analysis for the entire trial population showed no statistically significant difference between the placebo and actively treated groups. No safety concerns were observed.

CONCLUSION

Efficacy in mild to severe AR of 6 SQ-HDM compared with placebo was demonstrated by statistically significant improvements in TCRS and Rhinitis Quality of Life Questionnaire score in subjects with AR present at baseline. The treatment was well tolerated.

TRIAL REGISTRATION

EudraCT, no 2006-001795-20; ClinicalTrials.gov, identifier NCT00389363.

Phase II/III clinical trial to assess the tolerability and immunological effect of a new updosing phase of Dermatophagoides mix-based immunotherapy

BACKGROUND

Immunologically enhanced subcutaneous specific immunotherapy (SCIT) has been developed with a fast and simplified updosing phase containing equal parts of the house dust mites (HDM) Dermatophagoides pteronyssinus and Dermatophagoides farinae (Dermatophagoides mix) adsorbed on aluminum hydroxide.

OBJECTIVE

To evaluate the tolerability and immunological impact of the updosing phase of this new allergen extract formulation.

MATERIAL AND METHODS

We performed a multicenter, open-label, single-arm, phase II/III clinical trial. The inclusion criteria were a clinical history of rhinitis/conjunctivitis due to HDM (with/without asthma) and sensitization to HDM (positive specific IgE and skin prick test). Five updosing injections of Dermatophagoides mix (300, 600, 3000, 6000, and 15000 SQ+) were administered at weekly intervals with 1 maintenance injection (15000 SQ+) 2 weeks after the last updosing injection. Two days after each visit, patients were contacted by telephone to follow up on any adverse events. IgE-blocking factor, IgG4, and immediate skin reactivity were evaluated.

RESULTS

The sample comprised 102 patients (mean [SD] age, 29.3 [7.7] years; male, 52.9%). There were 117 adverse drug reactions (ADR): 101 were local, regardless of reaction size, in 48 (47.1%) patients and 7 were systemic (all grade I) in 5 (4.9%) patients. All ADRs were mild, except for 1, which was moderate. Six weeks of treatment led to statistically significant increases in IgE-blocking factor and IgG4, as well as a significant reduction in immediate skin reactivity.

CONCLUSION

This new updosing phase of Dermatophagoides mix-based immunotherapy had a good tolerability profile and induced a significant immunological effect.

Consensus document on allergic conjunctivitis (DECA)

Allergic conjunctivitis (AC) is an inflammatory disease of the conjunctiva caused mainly by an IgE-mediated mechanism. It is the most common type of ocular allergy. Despite being the most benign form of conjunctivitis, AC has a considerable effect on patient quality of life, reduces work productivity, and increases health care costs. No consensus has been reached on its classification, diagnosis, or treatment. Consequently, the literature provides little information on its natural history, epidemiological data are scarce, and it is often difficult to ascertain its true morbidity. The main objective of the Consensus Document on Allergic Conjunctivitis (Documento dE Consenso sobre Conjuntivitis Alérgica [DECA]), which was drafted by an expert panel from the Spanish Society of Allergology and Spanish Society of Ophthalmology, was to reach agreement on basic criteria that could prove useful for both specialists and primary care physicians and facilitate the diagnosis, classification, and treatment of AC. This document is the first of its kind to describe and analyze aspects of AC that could make it possible to control symptoms.

A high polymerized grass pollen extract is efficacious and safe in a randomized double-blind, placebo-controlled study using a novel up-dosing cluster-protocol

BACKGROUND

Cluster immunotherapy represents an interesting alternative to conventional up-dosing schedules because it allows achieving the maintenance dose within a shorter time interval. In this study, the efficacy and safety of cluster immunotherapy with a high polymerized allergen extract of a grass/rye pollen mixture have been evaluated in a randomized, double-blind, placebo-controlled, multicenter study.

METHODS

In total, 121 patients with allergic rhinoconjunctivitis due to grass pollen were randomized 1 : 1 to verum or placebo group. A short cluster up-dosing schedule of only 1 week was applied to achieve the maintenance dose which was administered monthly during the study period of 1 year. Total combined symptom and medication score (TCS) was defined as primary outcome parameter. Secondary outcome parameters were individual symptom and medication scores, 'well days,' global improvement as well as immunological effects and nasal allergen challenge. The safety profile was evaluated based on the European academy of allergy and clinical immunology grading system.

RESULTS

Significant reduction in the verum compared to the placebo group (intention-to-treat, population, verum: n = 55; placebo: n = 47) was found regarding TCS (P = 0.005), rhinoconjunctivitis total symptom score (RTSS, P = 0.006), and total rescue medication score (TRMS, P = 0.002). Additionally, secondary outcomes such as 'well days,' nasal challenge results, and increase of specific IgG4 were in favor of the active treatment. All systemic adverse reactions (0.8% of all injections in the verum group) were of mild intensity. No severe reactions related to the study medication were observed.

CONCLUSION

Cluster immunotherapy with high polymerized grass pollen extracts resulted in significant clinical efficacy and has been shown to be a safe treatment for grass pollen-allergic patients.

[Treatment of chronic allergic blepharoconjunctivitis]

OBJECTIVE

to evaluate the effectiveness of therapeutic eyelid hygiene in the treatment of chronic, or perennial, allergic blepharoconjunctivitis (ABC).

MATERIAL AND METHODS

A total of 30 patients with chronic ABC (11 men, 19 women aged 25-41 years; disease duration 2-4 years) were examined before and after a treatment course which included instillations of olopatodine hydrochloride instillations (1 mg/ml, 2 times daily) and hyaluronic acid (2 mg/ml, 3-4 times daily). Patients from the main group (18 patients, 36 eyes) additionally practiced therapeutic eyelid hygiene using Blepharoshampoo, Blepharolotion or Blepharosalfetka, and Blepharogel-1 (2 times daily). The control group was given only anti-allergic therapy and tear substitutes. Conventional ophthalmological examination, allergy testing, ABC signs and symptoms evaluation, Schirmer's 1 and Norn's tests, tear film break-up time evaluation, assessment of meibomian gland function, optical coherence tomography (OCT) for tear meniscus, xerosis index evaluation and lissamine green staining for lid wiper epitheliopathy, and anterior segment photography with further computer morphometry were performed in all patients.

RESULTS

Dry eye signs and symptoms, including combined lipid, water, and mucus tear deficiency, were found in all patients with chronic ABC. Patients from the main group demonstrated a significantly greater decrease of integral indices of subjective ocular discomfort, reduction of chronic ABC signs as well as more pronounced improvement of the meibomian gland function, appearance of the lid wiper region, tear film break-up time, results of the OCT-meniscometry, and xerosis index.

CONCLUSION

Introduction of therapeutic eyelid hygiene to the complex treatment of chronic allergic blepharoconjunctivitis with the aim of resolving secondary dry eye symptoms enhances the effectiveness of the treatment.

A critical appraisal of analyzing nasal provocation test results in allergen immunotherapy trials

BACKGROUND

The statistical analysis of nasal provocation tests is very complex. We compared the conventional analysis with the maximally selected test statistics and the hierarchical ordered logistic model.

METHODS

We re-analyzed data from a trial with 112 patients suffering from grass pollen allergy. The patients had been randomized to receive either intralymphatic immunotherapy (ILIT) or subcutaneous immunotherapy (SCIT).

RESULTS

The conventional analysis indicated that the logarithmized ratio between the pre- and the post-treatment threshold concentration was significantly lower for ILIT than for SCIT. The maximally selected test statistics was used to test different threshold symptom scores that would imply positive clinical symptoms at the given allergen concentration. A threshold score of 3 maximised the difference in improvement between the ILIT and the SCIT groups. The hierarchical ordered logistic model does not take threshold allergen concentrations as the basis for analysis, but the single scores measured at each concentration. This approach simultaneously considers the treatment effect (ILIT versus SCIT), the time effect (pre- versus post-treatment), and the dose effect (different allergen concentrations). The hierarchical ordered logistic model revealed that the clinical improvement was greater after ILIT than after SCIT.

CONCLUSION

As the choice of method can affect the outcome, guidelines for analysis are highly needed.

Allergic eye disease

Ocular allergy is one of the most common conditions encountered by pediatricians and ophthalmologists and is characterized by bilateral injection with itching as the predominant symptom. Risk factors include history of atopy (asthma, eczema, seasonal allergies). Basic and clinical research have provided insight into the immunologic mechanisms, clinical presentation, differential diagnosis, and pharmacologicmanagement of this condition. New pharmacologic agents have improved the efficacy and safety of ocularallergy treatment. This article discusses the classification of ocular allergy diagnosis and management, and addresses clinical symptoms and signs that indicate more severe allergic disease or alternative diagnosis that should prompt expeditious referral to an ophthalmologist.

A meta-analysis of sublingual allergen immunotherapy and pharmacotherapy in pollen-induced seasonal allergic rhinoconjunctivitis

BACKGROUND

The capacity of sublingual allergen immunotherapy (SLIT) to provide effective symptom relief in pollen-induced seasonal allergic rhinitis is often questioned, despite evidence of clinical efficacy from meta-analyses and well-powered, double-blind, placebo-controlled randomized clinical trials. In the absence of direct, head-to-head, comparative trials of SLIT and symptomatic medication, only indirect comparisons are possible.

METHODS

We performed a meta-analysis of classes of products (second-generation H1-antihistamines, nasal corticosteroids and grass pollen SLIT tablet formulations) and single products (the azelastine-fluticasone combination MP29-02, and the leukotriene receptor antagonist montelukast) for the treatment of seasonal allergic rhinitis in adults, adolescents and/or children. We searched the literature for large (n >100 in the smallest treatment arm) double-blind, placebo-controlled randomized clinical trials. For each drug or drug class, we performed a meta-analysis of the effect on symptom scores. For each selected trial, we calculated the relative clinical impact (according to a previously published method) on the basis of the reported post-treatment or season-long nasal or total symptom scores: 100 × (scorePlacebo - scoreActive)/scorePlacebo.

RESULTS

Twenty-eight publications on symptomatic medication trials and ten on SLIT trials met our selection criteria (total number of patients: n = 21,223). The Hedges' g values from the meta-analyses confirmed the presence of a treatment effect for all drug classes. In an indirect comparison, the weighted mean (range) relative clinical impacts were -29.6% (-23% to -37%) for five-grass pollen SLIT tablets, -19.2% (-6% to -29%) for timothy pollen SLIT tablets, -23.5% (-7% to -54%) for nasal corticosteroids, -17.1% (-15% to -20%) for MP29-02, -15.0% (-3% to -26%) for H1-antihistamines and -6.5% (-3% to -10%) for montelukast.

CONCLUSIONS

In an indirect comparison, grass pollen SLIT tablets had a greater mean relative clinical impact than second-generation antihistamines and montelukast and much the same mean relative clinical impact as nasal corticosteroids. This result was obtained despite the presence of methodological factors that mask the clinical efficacy of SLIT for the treatment of seasonal allergic rhinitis.

Objective approach for fending off the sublingual immunotherapy placebo effect in subjects with pollenosis: double-blinded, placebo-controlled trial

BACKGROUND

Symptom scoring for the assessment of allergen immunotherapy is associated with a substantial placebo effect.

OBJECTIVE

To assess the ability of exhaled breath temperature (EBT), a putative marker of airway inflammation, to evaluate objectively the efficacy of grass pollen sublingual immunotherapy in a proof-of-concept study.

METHODS

This was a double-blinded, placebo-controlled clinical trial in 56 subjects (mean ± SD 30 ± 12 years old, 33 men) sensitized to grass pollen. The objective measurements were EBT, spirometry, and periostin and high-sensitivity C-reactive protein in blood. Overall discomfort scored on a visual analog scale was used as a proxy for subjective symptoms. Evaluations were performed before, during, and after the grass pollen season.

RESULTS

Fifty-one subjects (25 and 26 in the active treatment and placebo groups, respectively) were assessed before and during the pollen season. The mean pre- vs in-season increase in EBT was significantly smaller (by 59.1%) in the active treatment than in the placebo group (P = .030). Of the other objective markers, only the blood periostin level increased significantly during the pollen season (P = .047), but without intergroup differences. Subjectively, the mean pre- vs in-season increase in the visual analog scale score was 32.3% smaller in the active treatment than in the placebo group, although this difference did not reach statistical significance (P = .116).

CONCLUSION

These results suggest that the efficacy of grass pollen sublingual immunotherapy can be assessed by EBT, a putative quantitative measurement of airway inflammation, which is superior in its power to discriminate between active and placebo treatment than a subjective assessment of symptoms assessed on a visual analog scale.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01785394.

Improvement of quality of life in allergic rhinoconjunctivitis patients using nasal filters, a preliminary study

BACKGROUND

Allergic rhinoconjunctivitis is a clinical condition that impairs quality of life. The use of traditional drugs in many cases is not enough to improve quality of life in these patients.

METHODS

In this pilot study we used the Sanispira Nasal filters in 15 patients (mean age 34,7 years) affected by allergic rhinoconjunctivitis for 18 days. At each follow-up visit, patients were assessed with a specific quality of life questionnaire, a symptoms form and a drugs form that evaluates the use of antiallergic drugs in the last week. Patients sensitive to environmental allergens wore Sanispira nasal filters during the day, while patients sensitive to domestic allergens wore the device during the night.

RESULTS

Thirteen patients completed the study. We found an improvement significative (p=0,0241) of the total score of RQLQ of 23,10 points between baseline and 18 days ( total score at baseline prior to nasal filter insertion= 60,60, at 1 week = 42, 28, at 18 days= 34, 10). A significative improvement in the nasal symptoms domain between baseline and 18 days (in particular stuffy nose p=0,047; runny nose p=0,012; sneezing p=0,0021; ) and one item of practical problems domain, the need to repeatedly blow the nose(p=0,082). The total score of symptoms evaluated with the symptoms form improved significantly from baseline to 18 days. Total symptoms score at baseline was 9,7; at 1 week it was 8,1 and at 18 days it was 4,7. The improvement was statistically significant (p=0,0092). Three of the thirteen patients that completed the study eliminated completely the use of drugs during of the study.

CONCLUSIONS

The use of SANISPIRA ®, has shown encouraging results, with an improvement in the quality of life in Rhinoconjunctivitis patients specially an improvement in nasal and ocular symptoms.

Localized interstitial granuloma annulare induced by subcutaneous injections for desensitization

We describe a patient with interstitial granuloma annulare associated with subcutaneous injection therapy (SIT) for desensitization to a type I allergy. Asymptomatic, erythematous, violaceous annular patches were located at the injection sites on both her arms. Medical history revealed perennial rhinoconjonctivitis treated with SIT (Phostal Stallergen® cat 100% and D. pteronyssinus/D.farinae 50%:50%).

[Fast onset of action of sublingual immunotherapy in dust mite caused allergic rhinoconjunctivitis]

OBJECTIVE

To investigate whether sublingual immunotherapy(SLIT) can take effect during the early phase in allergic rhinoconjunctivitis.

METHOD

Sixty subjects diagnosed as allergic rhinoconjunctivitis were enrolled and divided into the SLIT group and the control group. The daily symptom and medication scores were recorded and analyzed.

RESULT

After 4 weeks treatments, the daily symptoms score had significantly reduced in SLIT group(P<0. 05). After 6, 8, 10 weeks treatments, the daily symptoms scores of subjects in the SLIT group had all shown continuous reduction, with no consumption of medication. The comparison between daily symptom score at 4th week and those in 6th week or 8th week or 10th week in the SLIT group had shown no significant difference (all P > 0.05). Whereas, the daily symptoms score and daily medication score in control group had shown changes with fluctuations. The correlation analysis had indicated that the daily medication score in the control group had a significant negative correlation with the daily symptom score (F = 554.9, P < 0.01). No serious adverse events occurred in this study.

CONCLUSION

SLIT could take effect in patients with allergic rhinoconjunctivitis sensitive to house dust mite as fast as the 4th week.

Specific immunotherapy-indications and mode of action

BACKGROUND

It is estimated that up to 24% of the population in Germany suffers from allergic rhinoconjunctivitis and 5% from allergic asthma. Allergic rhinoconjunctivitis is closely related to other atopic diseases.

METHODS

This review is based on pertinent publications retrieved by a selective search of the Medline database, guidelines from Germany and abroad, and Cochrane meta-analyses.

RESULTS

Specific immunotherapy (SIT) is the only diseases-modifying treatment option for allergies. Meta-analysis reveals standardized mean differences in allergic rhinitis symptom scores of -0.73 for subcutaneous immunotherapy (SCIT) and -0.49 for sublingual immunotherapy (SLIT); the corresponding mean differences in medication scores are -0.57 and -0.32, respectively. The treatment should be carried out for at least three years. It is indicated when the symptoms are severe and allergen avoidance is not a realistic option. The efficacy of treatment depends on the allergen dose; thus, every allergen preparation should be evaluated individually, independent of route of administration. SCIT can cause systemic adverse effects, including anaphylaxis. SLIT is safer but often causes allergic symptoms of the oral mucosa at the beginning of treatment.

CONCLUSION

Even though the efficacy of SIT is well documented, it is still underused. SIT should be offered as standard treatment to patients suffering from allergic rhinitis.

Tolerability of a new fast updosed immunologically enhanced subcutaneous immunotherapy formulation with an optimized allergen to adjuvant ratio under routine practice conditions: a noninterventional observational study

BACKGROUND AND OBJECTIVES

A fast updosed immunologically enhanced subcutaneous immunotherapy (SCIT) formulation with an optimized allergen to aluminium hydroxide ratio was first introduced in September 2009 in Germany. A large randomized controlled trial showed that the formulation had considerable immunologic effects and good tolerability. In this open-label, uncontrolled, noninterventional study, tolerability was investigated during routine application.

PATIENTS AND METHODS

Patients with allergic rhinoconjunctivitis and/or asthma were treated with pollen and mite allergens using a 5-injection updosing schedule (AVANZ: 300, 600, 3000, 6000 and 15 000 SQ+ units) with weekly intervals, followed by a maintenance schedule with injections of 15,000 SQ+ units.Adverse events (AEs) were recorded by physicians, and symptoms and use of symptomatic medication were analyzed before the start of therapy and after an average 8-month treatment period.

RESULTS

SCIT was documented by 362 allergists in 1036 patients between September 2009 and February 2011. AEs mainly consisted of local reactions during updosing (in 24.5% of patients). Systemic reactions were observed during updosing (8.4%) and maintenance therapy (1.7%), the most frequent of which was dyspnea. Overall, tolerability and the effect of treatment were rated as good or very good by 94.9% and 86.6% of patients and by 96.2% and 89.6% of physicians, respectively.

CONCLUSIONS

In this open-label, noninterventional study, fast updosed immunologically enhanced SCIT (AVANZ) was well tolerated in a large group of patients.

[Effectiveness of allergen immunotherapy in patients with vernal keratoconjuctivitis]

BACKGROUND

Allergen immunotherapy has demonstrated usefulness in the management of allergic diseases such as asthma, allergic rhinitis and conjunctivitis. However, little is known about its effectiveness in vernal keratoconjunctivitis (VKC), a disease mediated by IgE and lymphocytes, that can cause loss of visual acuity in a permanent way.

OBJECTIVE

To describe safety and effectiveness of allergen immunotherapy in a group of patients with VKC.

METHODS

From a sample of 575 patients sensitized to house dust mites, who received ultra-rush immunotherapy for asthma, allergic rhinoconjuctivitis or atopic dermatitis, 28 patients with VKC were selected and a retrospective analysis was performed with the evaluation of factors related to safety, pharmacological treatment and clinical response to immunotherapy..

RESULTS

Twenty eight patients with VKC who received allergen immunotherapy were studied. There were 21 men and 7 women, with an average age of 11 years. A total of 490 doses were administered (35 for build-up and 455 for maintenance) for different periods. The average number of doses per patient was 17. There were no local or systemic reactions. Seventy one percent of the patients presented a clear reduction in the use of medications, with an improvement in symptoms 89% and physical findings 68%.

CONCLUSIONS

Allergen immunotherapy seems to be a safe and efficient treatment for patients with VKC, and can contribute along with pharmacological management to the improvement of symptoms and reduction in the use of medications.

[Sublingual immunotherapy in children with grass pollen induced allergic rhinoconjunctivitis]

Specific immunotherapy is the only current treatment that may modify the disease process in allergic rhinoconjunctivitis. Recent studies have evidenced that sublingual administration of grass extract tablets is an efficacious, safe and convenient form of specific immunotherapy in children with grass pollen induced allergic rhinoconjunctivitis. It is recommended that daily treatment is initiated four months before the pollen season begins and continued through three years, though paediatric studies of long-term and potential asthma and allergy prevention effects are still awaited.

Treatment of seasonal allergic rhinoconjunctivitis with a once-daily SQ-standardized grass allergy immunotherapy tablet

OBJECTIVES

Specific immunotherapy with the grass allergy immunotherapy tablet (AIT) has been developed as an effective, well tolerated, and convenient treatment for grass pollen induced seasonal allergic rhinoconjunctivitis (ARC). Six phase II/III randomized, placebo-controlled trials with the duration of a single grass pollen season of treatment using the SQ-standardized grass AIT, Grazax (Phleum pratense, 75,000 SQ-T/2,800 BAU, ALK, Denmark), have been published previously. This review compares results from these trials.

METHODS

As outcome measures and methods of assessing them were similar across the trials, we have summarized the main efficacy findings (Total Combined Score [TCS], average daily rhinoconjunctivitis symptom and medication scores, percentage of well days, quality of life scores) during a single season of treatment with grass AIT in adults and children with seasonal ARC.

RESULTS

The results of the European and North American trials were similar. Compared with the placebo group, who received symptomatic medications only, treatment with grass AIT resulted in fewer rhinoconjunctivitis symptoms, a lower intake of symptomatic medication, better patient self-rated quality of life and a greater percentage of well days during the entire grass pollen season. The data indicate that grass AIT treatment is equally effective in adults and children; the measured effect varies with pollen exposure, but is comparable across regions and continents, with a consistent difference compared with placebo in TCS that was above 20% for all trials. Local adverse events were experienced by the majority of patients. These reactions were generally mild to moderate in severity and transient in duration. Systemic adverse events were rare.

CONCLUSIONS

This review confirms SQ-standardized grass AIT as a suitable therapeutic option for seasonal use in patients aged 5 years or older with grass pollen induced ARC.