Preventive capacity of allergen immunotherapy on the natural history of allergy

Allergen immunotherapy (AIT) is the practice of administering gradually increasing doses of the specific causative allergen to reduce the clinical reactivity of allergic subjects. A bulk of lit- erature demonstrates that AIT is an effective and safe treatment to reduce allergic symptoms and the use of drugs. The preventive capacity of AIT is less investigated. The studies thus far avail- able showed that this treatment, in both forms of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) is able to prevent the development of asthma in patients with aller- gic rhinitis and the occurrence of new sensitizations in patients monosensitized. Such outcomes demonstrate the ability of AIT to change the natural history of respiratory allergy. Of particular importance, SCIT with Hymenoptera venom has an invaluable role in preventing potentially fatal anaphylactic reactions to the culprit sting in venom-allergic patients. Ongoing studies are aimed at evaluating the possible capacity of AIT in primary pre- vention of allergy. All these capabilities are related to the mecha- nisms of action of AIT. In fact, both SCIT and SLIT are able to modify the allergen presentation by dendritic cells that in turn modify the phenotype of allergen-specific T cells, switching from the Th2-type response, typical of allergic inflammation, to a Th1- type response. An important role is played by allergen-specific T regulatory (Treg) cells, which produce suppressive cytokines such as IL-10 and TGF-beta

Allergen immunotherapy for respiratory allergy: to what extent can the risk of systemic reactions be reduced?

Introduction: Allergen immunotherapy is an effective treatment for respiratory allergy, but the administration to patients of extracts of the causative allergen may elicit systemic reactions, which include, particularly with subcutaneous immunotherapy (SCIT), anaphylaxis. In the past, the occurrence (tough rare) of fatal reactions has represented a serious problem that has limited the prescription of SCIT. Areas covered: The authors analyzed in this review the safety data of SCIT, especially concerning the years following the identification of uncontrolled asthma at the moment of allergen injection as the major risk of life-threatening reactions and fatalities. The safety of SLIT, which is far better than SCIT, was analyzed and its specific risk factors for systemic reactions were highlighted. Expert opinion: Presently, the safety profile of SCIT and SLIT is satisfactory, provided the treatment is administered by physicians experienced in this treatment, who are aware of the known risk factors for severe reactions and who implement all measures to avoid them. For SLIT, which is self-administered by the patient, receiving the first dose under medical control is recommended

The role of allergoids in allergen immunotherapy: from injective to sublingual route

SummaryAllergen immunotherapy (AIT) is aimed at inducing tolerance to allergens, such as pollens, dust mites or moulds, by administering increasing amounts of the causative allergen through subcutaneous or sublingual route. The evidence of efficacy of AIT is high, but the issue of safety, especially for the subcutaneous route, must be taken into account. The search for safer AIT products aimed at reducing the allergenicity, and thus adverse reactions, while maintaining the immunogenicity, that is essential for effectiveness, gave rise to the introduction of allergoids, which were conceived to fulfill these requirements. In the first allergoids glutaraldehyde or formaldehyde were used as cross-linking agent to polymerize allergens, this resulting in high molecular weight molecules (200,000 to 20,000,000 daltons) which were significantly less allergenic due to a decreased capacity to bridge IgE on its specific receptor, while maintaining the immunogenicity and thus the therapeutic efficacy. In recent years further agents, acting as adjuvants, such as L-tyrosine, monophosphoryl lipid A, aluminium hydroxide, were added to polymerized extracts. Moreover, a carbamylated monomeric allergoid was developed and, once adsorbed on calcium phosphate matrix, used by subcutaneous route. At the same time, in virtue of its peculiarities, such allergoid revealed particularly suitable for sublingual administration. A lot of clinical evidences show that it is well tolerated, largely safer and effective. Importantly, the higher safety of allergoids allows faster treatment schedules that favor patient compliance and, according to pharmaco-economic studies, they might be more cost-effective than other AIT options

Effectiveness of omalizumab in a patient with severe asthma and atopic dermatitis

The anti-IgE antibody omalizumab is currently indicated in severe asthma not controlled by standard drug therapy. Recently, new indications for omalizumab were suggested, which include atopic dermatitis (AD), a skin disorder characterized by elevated levels of IgE. We report the case of a 39-year old woman with severe asthma and severe AD, both resistant to conventional drug treatment. The patient had a IgE level of 1304 kU/L, which exceeded the recommended maximum level for treating asthma with omalizumab (stated in 700 Ku/L) but was far lower than previously reported in cases of AD treated with anti-IgE. The treatment consisted of a dose of omalizumab 375 mg every two weeks, and induced a rapid improvement of asthma, with no need of other drugs after three months, along with a progressive decline of severity of AD, which after five months was completely cured. These findings suggest the usefulness of omalizumab in patients with concomitant severe asthma and AD, also considering the pharmaco-economic balance obtained by withdrawing the multiple drugs used to treat both diseases

Maximizing rehabilitation outcomes in geriatric hip fracture patients: the impact of surgical variables

Background and aim: Hip fracture is a major traumatic event with high mortality and disability rate. Its management in the acute setting and in the rehabilitation process is highly debated. This study evaluates the possible determinants of hip fracture rehabilitation outcome, among which surgical intervention type, weight-bearing status and hospitalization length Methods: The data of 738 hip fracture patients, who completed rehabilitation process in our centre, were collected and patients' functional abilities at the time of admission and discharge were analysed. Results: It has been observed that functional recovery depends on several factors: the type of surgery, the post-operative course and related complications, the hospitalisation time, the surgeon's techniques and expertise and the Orthopaedics centre where the operation is performed. Conclusions: In conclusion, data integration in perspective of an individualised rehabilitation program appears crucial for the functional recovery of the hip fracture patient

Sublingual reactivity to rBET V1 and rPHL P1 in patients with oral allergy syndrome.

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Adherence issues related to sublingual immunotherapy as perceived by allergists

Sublingual immunotherapy (SLIT) is a viable alternative to subcutaneous immunotherapy to treat allergic rhinitis and asthma, and is widely used in clinical practice in many European countries. The clinical efficacy of SLIT has been established in a number of clinical trials and meta-analyses. However, because SLIT is self-administered by patients without medical supervision, the degree of patient adherence with treatment is still a concern. The objective of this study was to evaluate the perception by allergists of issues related to SLIT adherence.We performed a questionnaire-based survey of 296 Italian allergists, based on the adherence issues known from previous studies. The perception of importance of each item was assessed by a VAS scale ranging from 0 to 10.Patient perception of clinical efficacy was considered the most important factor (ranked 1 by 54\% of allergists), followed by the possibility of reimbursement (ranked 1 by 34\%), and by the absence of side effects (ranked 1 by 21\%). Patient education, regular follow-up, and ease of use of SLIT were ranked first by less than 20\% of allergists.These findings indicate that clinical efficacy, cost, and side effects are perceived as the major issues influencing patient adherence to SLIT, and that further improvement of adherence is likely to be achieved by improving the patient information provided by prescribers

Effectiveness of high dose sublingual immunotherapy to induce a stepdown of seasonal asthma: a pilot study

There is ample evidence to support the efficacy of sublingual immunotherapy (SLIT) on allergic rhinitis, while there is less solid data regarding asthma. We evaluated the effects of a high dose birch SLIT on birch-induced rhinitis and asthma in a controlled study

Safety of sublingual-swallow immunotherapy in children aged 3 to 7 years

The minimum age to start specific immunotherapy with inhalant allergens in children has not been clearly established, and position papers discourage its use in children younger than 5 years