2019 ARIA Care pathways for allergen immunotherapy

Allergen immunotherapy (AIT) is a proven therapeutic option for the treatment of allergic rhinitis and/or asthma. Many guidelines or national practice guidelines have been produced but the evidence-based method varies, many are complex and none propose care pathways. This paper reviews care pathways for AIT using strict criteria and provides simple recommendations that can be used by all stakeholders including healthcare professionals. The decision to prescribe AIT for the patient should be individualized and based on the relevance of the allergens, the persistence of symptoms despite appropriate medications according to guidelines as well as the availability of good-quality and efficacious extracts. Allergen extracts cannot be regarded as generics. Immunotherapy is selected by specialists for stratified patients. There are no currently available validated biomarkers that can predict AIT success. In adolescents and adults, AIT should be reserved for patients with moderate/severe rhinitis or for those with moderate asthma who, despite appropriate pharmacotherapy and adherence, continue to exhibit exacerbations that appear to be related to allergen exposure, except in some specific cases. Immunotherapy may be even more advantageous in patients with multimorbidity. In children, AIT may prevent asthma onset in patients with rhinitis. mHealth tools are promising for the stratification and follow-up of patients.Peer reviewe

Dust mite allergy in discussion : early diagnosis, better treatment

Hintergrund : Hausstaubmilbenallergiker zeigen im Vergleich zu Patienten mit saisonalen Atemwegsallergien wahrscheinlich aufgrund der ganzjährigen Allergenexposition ein höheres Asthmarisiko. Im Versorgungsalltag werden diese Patienten häufig später als zum Beispiel Gräserpollenallergiker diagnostiziert. Therapeutische Schritte werden oft relativ spät eingeleitet und sind vielfach ungerichtet und unspezifisch. Zielsetzung und Methodik : In fünf überregionalen Rundtischgesprächen zum Thema Hausstaubmilbenallergie erarbeiteten praktisch tätige Allergologen und Experten mögliche Gründe für die schlechte Versorgung der Patienten mit Hausstaubmilbenallergie sowie Lösungsmöglichkeiten. Gespräche und Konsensusbildung mithilfe der Metaplan-Technik wurden von einem neutralen Leiter moderiert. Ergebnisse : Nach Ansicht der Experten liegen Ursachen für die schlechte Versorgung von Hausstaubmilbenallergikern vor allem in der verzögerten oder unvollständigen Diagnose, oft bedingt durch mangelndes Wissen zur Symptomatik bei Patient, Apotheker und Hausarzt. Die Symptome der Hausstaubmilbenallergiker sind unspezifisch, sodass oft nicht an eine Allergie gedacht wird. Im Konsens wurden wichtige Symptome wie nasale Obstruktion, Niesreiz, insbesondere bei Staubexposition, (fehlgedeutete) langwierige und rezidivierende Atemwegsinfekte und Schlafstörungen identifiziert. Daneben kommen zahlreiche Nebenbefunde wie Räusperzwang oder eine bronchiale Hyperreagibilität vor. Durch die ganzjährige Belastung und Gewöhnungseffekte empfinden Patienten ihre Probleme als eher gering. Neben der diagnostischen besteht noch eine therapeutische Lücke bei der Versorgung der Milbenallergiker: Beim Hausarzt ebenso wie beim Facharzt werden zuverlässige und evidenzbasierte Therapieoptionen, insbesondere bei der Karenz und bei der spezifischen Immuntherapie, unterdurchschnittlich eingesetzt. Besser dokumentierte, zugelassene Immuntherapiepräparate können durch eine nachgewiesene hohe Evidenz für die Indikationen allergische Rhinitis und allergisches Asthma bronchiale zu einer verbesserten Therapie beitragen. Fazit : Die bisher unzureichende Versorgung von Hausstaubmilbenallergikern sollte sowohl hinsichtlich einer zeitnahen Diagnose, als auch in Bezug auf eine breitere Anwendung der spezifischen Immuntherapie verbessert werden. Hier gilt es, durch bessere Interaktion von klinischer Forschung, behandelnden Ärzten, versorgenden Apothekern und aufgeklärten Patienten diese Ziele gemeinsam anzugehen und zu erreichen

Placebo effects in allergen immunotherapy-An EAACI Task Force Position Paper

The placebo (Latin "I will please") effect commonly occurs in clinical trials. The psychological and physiological factors associated with patients' expectations about a treatment's positive and negative effects have yet to be well characterized, although a functional prefrontal cortex and intense bidirectional communication between the central nervous system and the immune system appear to be prerequisites for a placebo effect. The use of placebo raises certain ethical issues, especially if patients in a placebo group are denied an effective treatment for a long period of time. The placebo effect appears to be relatively large (up to 77%, relative to pretreatment scores) in controlled clinical trials of allergen immunotherapy (AIT), such as the pivotal, double-blind, placebo-controlled (DBPC) randomized clinical trials currently required by regulatory authorities worldwide. The European Academy of Allergy and Clinical Immunology (EAACI) therefore initiated a Task Force, in order to better understand the placebo effect in AIT and its specific role in comorbidities, blinding issues, adherence, measurement time points, variability and the natural course of the disease. In this Position Paper, the EAACI Task Force highlights several important topics regarding the placebo effect in AIT such as a) regulatory aspects, b) neuroimmunological and psychological mechanisms, c) placebo effect sizes in AIT trials, d) methodological limitations in AIT trial design and e) potential solutions in future AIT trial design. In conclusion, this Position Paper aims to examine the methodological problem of placebo in AIT from different aspects and also to highlight unmet needs and possible solutions for future trials.status: publishe

Perspectives in allergen immunotherapy: 2019 and beyond

The seventh "Future of the Allergists and Specific Immunotherapy (FASIT)" workshop held in 2019 provided a platform for global experts from academia, allergy clinics, regulatory authorities and industry to review current developments in the field of allergen immunotherapy (AIT). Key domains of the meeting included the following: (a) Biomarkers for AIT and allergic asthma; (b) visions for the future of AIT; (c) progress and data for AIT in asthma and the updates of GINA and EAACI Asthma Guidelines (separated for house dust mite SCIT, SLIT tablets and SLIT drops; patient populations) including a review of clinically relevant endpoints in AIT studies in asthma; (d) regulatory prerequisites such as the "Therapy Allergen Ordinance" in Germany; (e) optimization of trial design in AIT clinical research; (f) challenges planning and conducting phase III (field) studies and the future role of Allergen Exposure Chambers (AEC) in AIT product development from the regulatory point of view. We report a summary of panel discussions of all six domains and highlight unmet needs and possible solutions for the future.status: publishe

Medical diagnostics for indoor mold exposure

In April 2016, the German Society of Hygiene, Environmental Medicine and Preventative Medicine (Gesellschaft fur Hygiene, Umweltmedizin und Praventivmedizin (GHUP)) together with other scientific medical societies, German and Austrian medical societies, physician unions and experts has provided an AWMF (Association of the Scientific Medical Societies) guideline 'Medical diagnostics for indoor mold exposure'. This guideline shall help physicians to advise and treat patients exposed indoors to mold. Indoor mold growth is a potential health risk, even without a quantitative and/or causal association between the occurrence of individual mold species and health effects. Apart from the allergic bronchopulmonary aspergillosis (ABPA) and the mycoses caused by mold, there is only sufficient evidence for the following associations between moisture/mold damages and different health effects: Allergic respiratory diseases, asthma (manifestation, progression, exacerbation), allergic rhinitis, exogenous allergic alveolitis and respiratory tract infections/bronchitis. In comparison to other environmental allergens, the sensitizing potential of molds is estimated to be low. Recent studies show a prevalence of sensitization of 3-10% in the total population of Europe. The evidence for associations to mucous membrane irritation and atopic eczema (manifestation, progression, exacerbation) is classified as limited or suspected. Inadequate or insufficient evidence for an association is given for COPD, acute idiopathic pulmonary hemorrhage in children, rheumatism/arthritis, sarcoidosis, and cancer. The risk of infections from indoor molds is low for healthy individuals. Only molds that are capable to form toxins can cause intoxications. The environmental and growth conditions and especially the substrate determine whether toxin formation occurs, but indoor air concentrations are always very low. In the case of indoor moisture/mold damages, everyone can be affected by odor effects and/or impairment of well-being. Predisposing factors for odor effects can be given by genetic and hormonal influences, imprinting, context and adaptation effects. Predisposing factors for impairment of well-being are environmental concerns, anxieties, conditioning and attributions as well as a variety of diseases. Risk groups that must be protected are patients with immunosuppression and with mucoviscidosis (cystic fibrosis) with regard to infections and individuals with mucoviscidosis and asthma with regard to allergies. If an association between mold exposure and health effects is suspected, the medical diagnosis includes medical history, physical examination, conventional allergy diagnosis, and if indicated, provocation tests. For the treatment of mold infections, it is referred to the AWMF guidelines for diagnosis and treatment of invasive Aspergillus infections. Regarding mycotoxins, there are currently no validated test methods that could be used in clinical diagnostics. From the perspective of, preventive medicine, it is important that mold damages cannot be tolerated in indoor environments. (C) 2016 Elsevier GmbH. All rights reserved

Use of biologics in allergic and type 2 inflammatory diseases in the current Covid 19 pandemic

Klimek L, Pfaar O, Worm M, et al. Anwendung von Biologika bei allergischen und Typ-2-entzündlichen Erkrankungen in der aktuellen Covid-19-Pandemie. Allergo Journal . 2020;29(4):14-27

EAACI Molecular Allergology User's Guide 2.0

Since the discovery of immunoglobulin E (IgE) as a mediator of allergic diseases in 1967, our knowledge about the immunological mechanisms of IgE-mediated allergies has remarkably increased. In addition to understanding the immune response and clinical symptoms, allergy diagnosis and management depend strongly on the precise identification of the elicitors of the IgE-mediated allergic reaction. In the past four decades, innovations in bioscience and technology have facilitated the identification and production of well-defined, highly pure molecules for component-resolved diagnosis (CRD), allowing a personalized diagnosis and management of the allergic disease for individual patients. The first edition of the "EAACI Molecular Allergology User's Guide" (MAUG) in 2016 rapidly became a key reference for clinicians, scientists, and interested readers with a background in allergology, immunology, biology, and medicine. Nevertheless, the field of molecular allergology is moving fast, and after 6 years, a new EAACI Taskforce was established to provide an updated document. The Molecular Allergology User's Guide 2.0 summarizes state-of-the-art information on allergen molecules, their clinical relevance, and their application in diagnostic algorithms for clinical practice. It is designed for both, clinicians and scientists, guiding health care professionals through the overwhelming list of different allergen molecules available for testing. Further, it provides diagnostic algorithms on the clinical relevance of allergenic molecules and gives an overview of their biology, the basic mechanisms of test formats, and the application of tests to measure allergen exposure.Peer reviewe