Allergen immunotherapy in asthma; what is new?

Giovanni Passalacqua,Anthi Rogkakou,Giorgio Walter Canonica,Marcello Mincarini

doi:10.1186/s40733-015-0006-2

Giovanni Passalacqua, Anthi Rogkakou + Show 2 more

Open Access

https://doi.org/10.1186/s40733-015-0006-2

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Abstract

The use and role of allergen immunotherapy (AIT) in asthma is still a matter of debate, and no definite recommendation about this is made in guidelines, both for the subcutaneous and sublingual routes. This is essentially due to the fact that most controlled randomised trials were not specifically designed for asthma, and that objective measures of pulmonary function were only occasionally considered. Nonetheless, in many trials, favourable results in asthma (symptoms, medication usage, bronchial reactivity) were consistently reported. There are also several meta analyses in favour of AIT, although their validity is limited by a relevant methodological heterogeneity. In addition to the crude clinical effect, a disease modifying action of AIT (prevention of asthma onset and long-lasting effects) have been reported. The safety is an important aspect to consider in asthma. Fatalities were rare: in Europe no fatality was reported in the last three decades, as in the United States in the last 4 years. Based on previous surveys, and common sense, uncontrolled asthma is still recognized as the most important risk factor for severe adverse events. On the contrary, there is no evidence that AIT can worsen or induce asthma. According to the available evidence, AIT can be safely used as add-on treatment when asthma is associated with rhinitis (a frequent condition), provided that asthma is adequately controlled by pharmacotherapy. AIT cannot be recommended or suggested as single therapy. When asthma is the unique manifestation of respiratory allergy, its use should be evaluated case by case.

Highlights

Considering the systemic mechanisms of action of allergen immunotherapy (AIT) [1] and the immunological unity of respiratory airways [2], it is clear that AIT is not specific for the type of disease but only for the allergen causing the disease itself [3]
The efficacy of AIT has been usually kept separated for asthma and rhinitis, as testified by meta-analyses, commentaries and guidelines [4,5,6]
The most important questions are which children with rhinitis should receive AIT to prevent the future development of asthma, and which biomarkers are relevant to identify the potential responders

Summary

Introduction

Considering the systemic mechanisms of action of AIT [1] and the immunological unity of respiratory airways [2], it is clear that AIT is not specific for the type of disease (rhinitis or asthma) but only for the allergen causing the disease itself [3]. The efficacy of AIT has been usually kept separated for asthma and rhinitis, as testified by meta-analyses, commentaries and guidelines [4,5,6]. The majority of data available concern clinical trials including patients with allergic rhinitis (AR), which was the primary outcome measure, with/without asthma. Asthma-related parameters, were either secondary outcomes or subject of post-hoc analyses. This reflects the clinical practice in real life, where isolated allergic asthma without rhinitis is infrequent, but asthma is present in more than 30 % of rhinitis patients, and the. CRITICAL ASPECTS Patients should be selected matching asthma severity and, current asthma therapy

Objective parameters

Findings

Conclusions