ALLERGEN IMMUNOTHERAPY: AN UPDATED REVIEW OF SAFETY

FCAAIA Notes: The four broad categories of treatment for allergic rhinitis are avoidance of triggers, symptom reliever (rescue) medications, controller (preventive) medications, and allergen immunotherapy.  Only immunotherapy can “cure” the disease by changing the way your immune system recognizes and responds to the triggers of your nasal allergies.

Immunotherapy can be administered by injections (subcutaneous, “SCIT”) or under the tongue (sublingual “SLIT”).  Although many practitioners offer SLIT for all allergens as drops, SLIT is only available and FDA approved for grass and ragweed. Dust mite SLIT has been approved but is not commercially available yet.

Although there are not many well-controlled studies, SCIT is more effective than SLIT for pollen immunotherapy and the two appear to be comparable for perennial allergens when appropriately high doses are used.  There are caveats, however.  When SLIT is give as drops, it is usually in very low doses that are proven less effective than SCIT. Although SLIT sounds like an attractive idea, it is not yet the answer for the great majority of patients.

Of great importance, because both methods are so extraordinarily safe, risk of reactions is usually not a reason to choose one over the other with the currently available materials..  Because of the greater risk of reactions with SCIT as compared to SLIT, SCIT must be given under medical supervision. That’s why we have you wait 30 minutes.  But there have been NO reported deaths from SCIT in the United States in many years.

(Source: http://www.medscape.com/viewarticle/874388?src=wnl_tp10j_170317_mscpedit&uac=112079PK&impID=1310119&faf=1 March 17, 2017. For Medscape articles: User name: FCAAIA, Password: Allergies. Adapted from Curr Opin Allergy Clin Immunol. 2017;17(1):55-59.)

Abstract

Purpose of review: Allergen immunotherapy is the only modality that can modify the immune response upon exposure to aeroallergens and venom allergens. This review will update the allergist on recent studies evaluating safety of sublingual and subcutaneous allergen immunotherapy.

Recent findings: Multiple clinical trials and retrospective studies have been published evaluating overall safety of these therapies. The risk of systemic reactions with subcutaneous immunotherapy remains quite low, but near-fatal and fatal anaphylaxis does occur, requiring physicians to be aware of potential risks for such events. Sublingual immunotherapy has a high incidence of local site application reactions, but severe anaphylactic events are very uncommon.

Summary: Subcutaneous immunotherapy and sublingual immunotherapy are beneficial in treating allergic rhinitis and venom hypersensitivity but should be administered only by physicians familiar with potential risk factors and able to manage treatment-related local and systemic allergic reactions.

Introduction

Allergic rhinitis is one of the most prevalent chronic illnesses, ranking fifth in the United States, and accounting for significant estimated costs (6.1–11.2 billion dollars). Allergic rhinitis is also a major predictor and risk factor for asthma, further expanding its potential economic impact.

Allergen immunotherapy (AIT) is the only modality that can modify TH2-directed immune responses and reduce allergic nasal and ocular symptoms upon exposure to aeroallergens. The two major AIT modalities used in clinical practice are subcutaneous allergen immunotherapy (SCIT) and sublingual allergen immunotherapy (SLIT). Although both approaches have been found to be efficacious in reducing both symptoms and the need for rescue medications, risk of rare systemic reactions following administration is a significant patient safety concern.

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