Immunotherapy for allergic rhinitis

September 24, 2011 11:00 am

Summary

Allergic rhinitis (AR) affects more than 20% of the population in the United Kingdom and western Europe and represents a major cause of morbidity that includes interference with usual daily activities and impairment of sleep quality. This guidance prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) is for the management of AR in patients that have failed to achieve adequate relief of symptoms despite treatment with intranasal corticosteroids and/or antihistamines. The guideline is based on evidence and is for use by both adult physicians and paediatricians practising allergy. During the development of these guidelines, all BSACI members were included in the consultation process using a web-based system. Their comments and suggestions were carefully considered by the SOCC. Where evidence was lacking, consensus was reached by the experts on the committee. Included in this guideline are indications and contraindications for immunotherapy, criteria for patient selection, the evidence for short- and long-term efficacy of subcutaneous and sublingual immunotherapy, and discussion on safety and the different modes of immunotherapy including, pre-seasonal and co-seasonal treatments. There are sections on children, allergen standardization, vaccines used in the United Kingdom, oral allergy syndrome, cost effectiveness of immunotherapy and practical considerations of undertaking immunotherapy including recommendations on who should undertake immunotherapy and dosing schedules. Finally, there is discussion on potential biomarkers of response to immunotherapy, the use of component-resolved diagnostics, novel approaches, alternative routes and potential areas for future research.

Executive summary

  • Untreated rhinitis represents a major cause of morbidity that includes interference with usual daily activities and impaired sleep quality.
  • Immunotherapy, both subcutaneous and sublingual, is an effective treatment for adults and children with severe allergic rhinitis (AR) that does not respond to conventional pharmacotherapy and allergen avoidance measures.
  • The efficacy of immunotherapy depends on correct patient selection, the type of allergen and the product chosen for treatment. Each vaccine requires individual assessment before recommendation for routine use.
  • In asthma, the risk benefit is less favourable than for rhinitis and therefore immunotherapy for asthma is not routinely recommended in the United Kingdom.
  • Subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) has been shown to give long-lasting benefit for some years after stopping treatment.
  • Single allergen vaccines are more effective than vaccines containing mixtures of allergens.
  • Selection of patients for immunotherapy requires accurate identification of an underlying allergic trigger through a combination of clinical history and skin and/or blood tests for allergen specific IgE.
  • SCIT is safe when undertaken in selected individuals in a specialist allergy clinic by trained health professionals – in a setting with access to immediate treatment for anaphylaxis and resuscitation if required.
  • The safety profile of SLIT appears to be superior to SCIT although there have been no head to head comparisons of efficacy.
  • Cost effectiveness for immunotherapy has been shown but only in vaccines that provide long-term benefit.
  • Patients receiving immunotherapy should be carefully monitored for at least 1 h (UK recommendation) and systemic reactions treated promptly.

Introduction

Allergen immunotherapy involves the repeated administration of allergen extracts with the aim of reducing symptoms on subsequent allergen exposure, improving quality of life (QoL) and inducing long-term tolerance. In order to be effective immunotherapy requires careful patient selection. Immunotherapy is safe provided adequate precautions are taken. A decision whether to treat with immunotherapy will depend on a variety of personal and organizational factors which determine whether one type of immunotherapy is more suitable than another (e.g. SCIT vs. SLIT).

AR affects more than 20% of the population in the United Kingdom and western Europe [1]. Rhinitis represents a major cause ofmorbidity that includes interference with usual daily activities and impaired sleep quality [2]. The majority of patients respond adequately to pharmacotherapy, provided that it is taken properly and regularly. Nevertheless, a substantial proportion of patients report inadequate relief of symptoms despite treatment with intranasal corticosteroids and oral or topical antihistamines [3]. It is also reasonable to offer allergen immunotherapy to those unable to tolerate pharmacotherapy, The main indications for immunotherapy in the United Kingdom are

  1. IgE-mediated seasonal pollen induced rhinitis, if symptoms have not responded adequately to optimal pharmacotherapy [4, 5].
  2. Systemic reactions caused by hymenoptera venom allergy [see separate British Society for Allergy and Clinical Immunology (BSACI) guideline]
  3. Selected patients with animal dander or house dust mite (HDM) allergy in whom rigorous allergen avoidance and reasonable pharmacotherapy fail to control symptoms.

The selection, initiation and monitoring of all patients for immunotherapy should be supervised by specialists in allergy. Immunotherapy should only be administered by physicians and nurses with specialist knowledge of allergy and specific immunotherapy (SIT) [6].

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