Evolving patterns in the diagnosis and management of allergy‐mediated disorders

Background

This analysis explores the increasing heterogeneity of trends in allergy management under the premise that the practice of allergy has undergone significant changes in national economics, healthcare delivery, and treatment options from 2007 to 2016.

Methods

Centers for Medicare and Medicaid Services (CMS) data were obtained for: (1) temporal trends in allergy immunotherapy injection (Current Procedural Terminology [CPT] codes 95115, 95117) and testing (CPT 95004, 95024) from 2007 to 2016; (2) geographic trends; and (3) practitioners administering immunotherapy. Although there are no sublingual immunotherapy (SLIT) CPT codes, billing for unlisted allergy/immunologic services (CPT 95199) were obtained.

Results

Since 2007, there were 99.5 million allergy tests and 33.5 million immunotherapy injections billed to Medicare beneficiaries. Increases in testing have outpaced rising immunotherapy administration (49.7% vs 19.6% increase). Significant regional variation in testing rates was noted, with the greatest ratio of testing to immunotherapy in the South (0.35) and smallest ratio in the Northeast (0.18). The maximum unlisted allergy services billed was 594 (of which includes SLIT), compared to annual subcutaneous immunotherapy (SCIT) totals in the millions. The majority of immunotherapy in 2016 was administered by allergists/immunologists (51.6%) followed by otolaryngologists (31.2%), trends that have remained consistent since 2012.

Conclusion

Physicians have been more aggressive in the workup of allergy‐mediated disorders in recent years. Although differences in allergen load exist, there is tremendous geographic variation in the ratio of testing to immunotherapy. While the role otolaryngologists play in immunotherapy remains stable, allergists manage the majority of patients, reinforcing the importance of interdisciplinary cooperation and outreach. SLIT does not appear to play a significant role in this population.

     

Amyloid‐ß‐directed immunotherapy for Alzheimer's disease

Current treatment options for Alzheimer's disease (AD) are limited to medications that reduce dementia symptoms. Given the rapidly ageing populations in most areas of the world, new therapeutic interventions for AD are urgently needed. In recent years, a number of drug candidates targeting the amyloid‐ß (Aß) peptide have advanced into clinical trials; however, most have failed because of safety issues or lack of efficacy. The Aß peptide is central to the pathogenesis, and immunotherapy against Aß has attracted considerable interest. It offers the possibility to reach the target with highly specific drugs. Active immunization and passive immunization have been the most widely studied approaches to immunotherapy of AD. A favourable aspect of active immunization is the capacity for a small number of vaccinations to generate a prolonged antibody response. A potential disadvantage is the variability in the antibody response across patients. The potential advantages of passive immunotherapy include the reproducible delivery of a known amount of therapeutic antibodies to the patient and rapid clearance of those antibodies if side effects develop. A disadvantage is the requirement for repeated infusions of antibodies over time. After more than a decade of research, anti‐amyloid immunotherapy remains one of the most promising emerging strategies for developing disease‐modifying treatments for AD. In this review, we examine the presently ongoing Aß‐directed immunotherapies that have passed clinical development Phase IIa.     

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.

     

Efficacy and safety of sublingual immunotherapy with Dermatophagoides farinae drops in pre-school and school-age children with allergic rhinitis

Background

The safety and efficacy of sublingual immunotherapy (SLIT) have been confirmed by many studies. However, in China, the research on efficacy and safety in young and older children with allergic rhinitis (AR) is still rare.

变应原特异性舌下免疫治疗

变应原特异性舌下免疫治疗(sublingual immunotherapy,SLIT)是一种经口腔黏膜给药并逐渐达到免疫耐受的特异性免疫治疗方法.SLIT作为一种新的治疗途径,在国外已广泛应用于治疗变应性鼻炎、支气管哮喘.世界卫生组织对SLIT给予充分的肯定,进一步奠定了SLIT在变应性鼻炎、支气管哮喘治疗中的重要地位.现就SLIT的研究进展做以下阐述.     

支气管哮喘和变应性鼻炎的舌下特异性免疫疗法进展

舌下特异性免疫疗法在支气管哮喘和变应性鼻炎的治疗方面发挥了重要作用,它提供了一种可以替代传统皮下免疫疗法的变应原免疫治疗方法.目前已经有两种制剂(滴剂和片剂)可以用于舌下特异性免疫疗法.研究表明舌下特异性免疫疗法是安全、有效的.     

Single vs multiallergen sublingual immunotherapy in the polysensitized patient: a pilot study

Background

Sublingual immunotherapy (SLIT) has emerged as an effective and exceptionally safe method of treatment of the atopic patient. However, the optimal number of allergens that should be included in the SLIT treatment regimen for the polysensitized patient is not known and practices vary widely. This study aims to compare the efficacy of single‐allergen SLIT with pauci‐allergen vs multiallergen aqueous SLIT in polysensitized patients.

Methods

Sixteen subjects sensitized to 6+ allergens were enrolled in the study. Subjects were blinded and randomized to SLIT treatment groups that included 1 (single), 3 (pauci), or all sensitized allergens (multi). Allergens selected were those to which the patient was most sensitized and correlated with history. Primary outcomes included daily allergy medication use, weekly Rhinoconjunctivitis Symptom Score (RCSS), and the mini–Rhinoconjuncitivitis Quality of Life Questionnaire (m‐RQLQ). All metrics were measured at baseline, 6 weeks, 3 months, 6 months, and 9 months.

Results

There were significant decreases from baseline in RCSS and m‐RQLQ scores in all study groups at each interval after beginning SLIT (p < 0.05). There was no significant decrease in number of daily allergy medications used regardless of number of allergens in patient's treatment vial (p = 0.50). No significant differences emerged based on number of allergens used.

Conclusion

Single‐antigen, pauci‐antigen, and multiantigen aqueous SLIT significantly improved allergy symptoms. There was no significant difference observed in efficacy of single‐allergen SLIT vs pauci‐allergen or multi‐allergen SLIT in polysensitized patients.