Evidence‐based dosing of maintenance subcutaneous immunotherapy: a contemporary review of state‐of‐the‐art practice

Background

Subcutaneous immunotherapy is an effective allergy treatment only if properly dosed. In this article we review the data on the probable effective dose range for subcutaneous immunotherapy and convert the recommended doses into a clinically relevant format.

Methods

A comprehensive literature search of dose‐response subcutaneous immunotherapy studies was done of EBM databases, Medline database, PreMedline, and the National Guideline Clearinghouse for the period 1980–2016. Recommended doses were converted to the volume of allergen extract that should be added to a 5‐mL maintenance vial.

Results

A safe and effective dose for subcutaneous immunotherapy is likely 5–20 μg of major allergen per injection. A 0.5‐mL injection from a 5‐mL maintenance vial containing 0.2 mL of manufacturer's extract of each allergen should reach the lower end of the probable effective dose range for most allergens. A larger volume of extract is required to reach that range when treatment includes cat, dog, or only 1 dust mite. Increasing beyond the commonly prescribed 0.2 mL of manufacturer's extract added to a 5‐mL treatment vial is reasonable for nearly all allergens to achieve a maintenance dose higher in the probable effective dose range.

Conclusion

Current otolaryngic allergy practice usually escalates patients to 0.5‐mL injections from 5‐mL maintenance vials containing 0.2 mL of manufacturer's extract of each allergen. With the main exceptions of cat and dog, those injections administered 1 or 2 times per month likely provide an efficacious dose of allergen and are consistent with published guidelines. A larger volume of extract should be considered in certain clinical situations.

     

Randomized placebo‐controlled trial of lactobacillus on asthmatic children with allergic rhinitis

Previous studies have suggested that probiotic administration may have therapeutic and/or preventive effects on atopic dermatitis in infants; however, its role in allergic airway diseases remains controversial. To determine whether daily supplementation with specific Lactobacillus gasseri A5 for 8 weeks can improve the clinical symptoms and immunoregulatory changes in school children suffering from asthma and allergic rhinitis (AR). We conducted a randomized, double‐blind, placebo‐controlled study on school children (age, 6–12 years) with asthma and AR. The eligible study subjects received either L. gasseri A5 (n = 49) or a placebo (n = 56) daily for 2 months. Pulmonary function tests were performed, and the clinical severity of asthma and AR was evaluated by the attending physicians in the study period. Diary cards with records of the day‐ and nighttime peak expiratory flow rates (PEFR), symptoms of asthma, and AR scores of the patients were used for measuring the outcome of the treatment. Immunological parameters such as the total IgE and cytokine production by the peripheral blood mononuclear cells (PBMCs) were determined before and after the probiotic treatments. Our results showed the pulmonary function and PEFR increased significantly, and the clinical symptom scores for asthma and AR decreased in the probiotic‐treated patients as compared to the controls. Further, there was a significant reduction in the TNF‐α, IFN‐γ, IL‐12, and IL‐13 production by the PBMCs following the probiotic treatment. In conclusion, probiotic supplementation may have clinical benefits for school children suffering from allergic airway diseases such as asthma and AR. Pediatr Pulmonol. 2010;45:1111–1120. © 2010 Wiley‐Liss, Inc.     

Otolaryngologist adherence to the AAO‐HNSF Allergic Rhinitis Clinical Practice Guideline

Background

In February 2015, the American Academy of Otolaryngology–Head and Neck Surgery (AAO‐HNSF) published the Allergic Rhinitis Clinical Practice Guideline (AR‐CPG). The objective of this study was to assess otolaryngologists’ perception of the accuracy and adherence to the AR‐CPG.

Methods

A survey was distributed to fellows of the American Academy of Otolaryngic Allergy and members of the American Academy of Otolaryngology–Head and Neck Surgery Foundation. A total of 601 otolaryngologists responded. The survey evaluated otolaryngologists’ demographic data, perception of the accuracy of the guideline, and adherence to the guideline action statements.

Results

The majority of respondents were actively practicing (544 [90.5%]), for a duration of 11–30 years (308 [51.2%]), in a private practice setting (387 [64.4%]). The cohort was largely fellowship trained (348 [57.9%]) and had reviewed the guideline (428 [71.2%]). Most respondents perceived the guideline as being correct “a great deal” (295 [69.7%]) and deviated from the guideline “only a little” (302 [71.6%]). High rates of adherence to the strong guideline recommendations were observed. Respondents “always/most of the time” recommended intranasal steroids (581 [97.6%]), and oral antihistamines (439 [74%]) as primary therapy. Otolaryngologists in practice for longer were more likely to deviate from the guideline recommendations by obtaining sinonasal imaging (p = 0.007) and recommending oral leukotriene receptor antagonists as primary therapy (p = 0.0001).

Conclusion

Overall perception of the correctness of and adherence to the AR‐CPG was high in this cohort. Targeted education resources should be provided to otolaryngologists in practice for longer in efforts to reduce harmful or unnecessary variations in care.