Rush Immunotherapy Research Articles

Automated analysis of flow cytometry data for the identification of cellular markers of allergy therapeutic responses (91.2)

Abstract Mechanistic studies of biological specimens obtained during the conduct of clinical trials are frequently used to identify markers of therapeutic responses and to understand the underlying physiological processes associated with therapeutic efficacy. The Immunology Database and Analysis Portal (ImmPort; www.immport.org) is a public database resource funded by NIAID to support the management and analysis of clinical and mechanistic data generated by their funded investigators. We demonstrate the use of the ImmPort clinical data management platform and novel data analysis methods in the analysis of the allergen immunotherapy experiments conducted by the Casale group of Immune Tolerance Network. In the Casale study, immune response assays were conducted on samples taken before, during and after a 12-week course of allergen-specific immunotherapy to investigate whether anti-IgE antibody (omalizumab) can enhance the safety and efficacy of rush immunotherapy. Flow cytometry data was re-analyzed with FLOCK, a novel automated flow cytometry analysis pipeline in ImmPort, to determine if the level of any blood cell population correlated with treatment conditions. The analysis has identified a unique cell population expressing CD14, CXCR3 and high levels of the Fc-epsilon receptor (CD23), which is significantly increased in patients undergoing rush immunotherapy. Such data-driven analysis using ImmPort can generate hypotheses for further experimental design and verification.

(1) An Office Based, One Day Rush Immunotherapy (1DRIT) Protocol for Pollens and Environmental Aeroallergens in Children

RATIONALE: The administered dose determines the efficacy of immunotherapy (IT). IT reaction risk is dose related. Previous studies of rush IT have used different target doses. Practitioners often limit the IT dose in children. We reviewed our experience with 1DRIT in children under 12 years.METHODS: A retrospective chart review of children under 12 who underwent 1DRIT for pollens and environmental allergens.RESULTS: 155 children, 3.4 to 12 years were treated with 1DRIT with a target maintenance dose of 0.2-0.4 ml of a 1:10 dilution of aeroallergen extract mixtures (Mixtures of standardized and non-standardized aeroallergens, designated 1:1 concentration per AAAAI Allergen I.T. Practice Parameter Guidelines). 85% had asthma. All patients were pre-treated for three days with oral corticosteroids, H1 and H2 blockers and monteleukast. 20% received one extract and 80% received two extracts. 88% received at least 0.2 ml of the 1:10 concentration vials, representing a 1 log dilution of the target maintenance dose. Allergic reactions occurred in 33% of patients. 45% of reactions were treated with antihistamine alone; 49% required epinephrine and 31% aerosol bronchodilator. No patient required IV medications or hospital admission.CONCLUSIONS: RIT may be administered to pediatric patients in a private practice setting. Although the reaction rate was 33%, reactions were easily managed. 1DRIT is a reasonable and safe approach for appropriately selected pediatric patients. RATIONALE: The administered dose determines the efficacy of immunotherapy (IT). IT reaction risk is dose related. Previous studies of rush IT have used different target doses. Practitioners often limit the IT dose in children. We reviewed our experience with 1DRIT in children under 12 years. METHODS: A retrospective chart review of children under 12 who underwent 1DRIT for pollens and environmental allergens. RESULTS: 155 children, 3.4 to 12 years were treated with 1DRIT with a target maintenance dose of 0.2-0.4 ml of a 1:10 dilution of aeroallergen extract mixtures (Mixtures of standardized and non-standardized aeroallergens, designated 1:1 concentration per AAAAI Allergen I.T. Practice Parameter Guidelines). 85% had asthma. All patients were pre-treated for three days with oral corticosteroids, H1 and H2 blockers and monteleukast. 20% received one extract and 80% received two extracts. 88% received at least 0.2 ml of the 1:10 concentration vials, representing a 1 log dilution of the target maintenance dose. Allergic reactions occurred in 33% of patients. 45% of reactions were treated with antihistamine alone; 49% required epinephrine and 31% aerosol bronchodilator. No patient required IV medications or hospital admission. CONCLUSIONS: RIT may be administered to pediatric patients in a private practice setting. Although the reaction rate was 33%, reactions were easily managed. 1DRIT is a reasonable and safe approach for appropriately selected pediatric patients.

Safety of a Modified Rush Immunotherapy (RIT) Protocol for Multiple Aeroallergens

Safety of a Modified Rush Immunotherapy (RIT) Protocol for Multiple Aeroallergens

The Effect of Rush Immunotherapy with House Dust Mite in the Production of IL-5 and IFN-γ from the Peripheral Blood T Cells of Asthmatic Children

Although the mechanisms are unclear, rush immunotherapy (RIT) may be effective to treat allergic diseases. We investigated the long-term modifications of cellular immunity as a mechanism of RIT. The RIT group, included 15 house dust mite (HDM)-sensitized asthmatic children, received RIT only with Dermatophagoides farinae (Der f) and Dermatophagoides pteronyssinus (Der p), whereas the control group, consisted of 10 HDM-sensitized asthmatic children, did not receive RIT. The asthma symptom scores and the skin reactivities to Der f were measured. The cellular proliferative responses and intracellular interleukin (IL)-5 and interferon (IFN)-γ productions from peripheral blood T cells were also measured before, 8 weeks and 1 yr after RIT. The symptom scores, skin reactivity to Der f and cellular proliferative responses to Der f were decreased significantly after 8 weeks and maintained until 1 yr of RIT. The IFN-γ/IL-5 ratio of the CD3(+) and CD4(+) cells were increased significantly after 8 weeks and maintained until 1 yr of RIT, while there were no changes in the control group. These data indicate that the continuous functional modification from Th2 to Th1 phenotype of the CD4(+) T cells are developed after RIT in the asthmatic children sensitized with HDM.

Evaluation of subcutaneous versus mucosal (intranasal) allergen-specific rush immunotherapy in experimental feline asthma

Rush immunotherapy (RIT) is effective for the treatment of experimental feline allergic asthma. In humans, the safety profile of immunotherapy is improved by delivering allergen by a mucosal route. We hypothesized that mucosal (intranasal) RIT would have similar efficacy to subcutaneous RIT with improved safety. Twelve cats sensitized and challenged with Bermuda grass allergen (BGA) were randomized to receive subcutaneous (SC) or intranasal (IN) RIT. Increasing doses of BGA (20–200 μg) were administered over 24 h followed by 200 μg BGA weekly as maintenance. Adverse reactions were recorded. Clinical respiratory scores after BGA aerosol challenge, bronchoalveolar lavage fluid (BALF) % eosinophils, and cytokine concentrations were measured before RIT (day 1) and at months 1, 3 and 6 (M1, M3, M6). More adverse events were recorded with SC RIT ( n = 12) compared with IN RIT ( n = 6). Respiratory scores were lower by M6 compared with D1 in both the groups. The % BALF eosinophils declined significantly after RIT for both groups (mean ± SEM, SC RIT D1 62 ± 12, M6 9 ± 4; IN RIT D1 54 ± 9, M6 14 ± 6). The BALF IL-4:IFN-γ ratio significantly decreased over time in the IN RIT group (mean ± SEM, D1 2.4 ± 0.2, M6 1.0 ± 0.2). While both protocols decreased eosinophilic airway inflammation, the SC RIT protocol did not cause life-threatening adverse events and demonstrated more consistent resolution of clinical signs after allergen challenge. Either protocol could be considered for the treatment of feline allergic asthma.

Successful administration of a 1-day imported fire ant rush immunotherapy protocol

Young children with a history of systemic reactions to imported fire ant (IFA) stings are at substantial risk of recurrent stings because of their maturational inability to practice appropriate avoidance techniques. To present 3 cases in which patients 36 months or younger completed a 1-day rush immunotherapy (RIT) protocol with IFA whole-body extract (WBE). The 1-day RIT protocol used for these patients was modified from the Wilford Hall 2-day rush protocol previously published. A 1:1 vol/vol maintenance vial consisted of 1 mL of IFA WBE and 9 mL of human serum albumin diluent in a 10-mL vial. All 3 patients had positive intradermal skin test results to IFA WBE. No systemic reactions occurred during the 1-day RIT. This case series provides data with which we can begin to assess the efficacy and safety of a 1-day IFA RIT protocol for the prevention of anaphylaxis in IFA allergic children. Further studies with larger numbers of patients are needed to confirm the findings.

Allergen-Induced Basophil CD203c Expression as a Biomarker for Rush Immunotherapy in Patients with Japanese Cedar Pollinosis

Background: Rush immunotherapy (RIT) can confer rapid clinical benefit on patients with allergic rhinitis or asthma. However, biomarkers representing mechanisms for the efficacy of RIT are still to be established. CD203c is a basophil activation marker known to be upregulated by cross-linking of the FcΕRIα receptor and may serve as a useful marker. Objective: We sought to investigate the changes in allergen-induced CD203c expression in patients with Japanese cedar pollen (JCP) pollinosis who received RIT. Methods: Nine patients treated with RIT were enrolled in the study. Whole blood was incubated with various concentrations of JCP extract. CD203c expression on basophils was quantitated by means of flow cytometry. JCP-specific IgG₄ levels in sera were measured with ELISA. Basophil histamine release, CAP-RAST to JCP (JCP-IgE) and total IgE were also examined. The biomarkers listed above were evaluated before and sequentially after RIT. Symptom and quality of life scores were obtained during pre- and posttreatment pollen seasons. Results: All patients showed significant improvement in symptom and quality of life scores after RIT. Serum JCP-specific IgG₄ titers were significantly elevated at 1 month and remained at high levels 12 months after the treatment. Stimulation with JCP extract induced enhancement of basophil CD203c expression in a concentration-dependent manner except for 2 subjects in whom no increase in CD203c by an anti-IgE antibody was observed (nonresponders). Significant reductions in the responses were observed in 4 subjects after RIT (reduction in CD203c expression, RCE) whereas no changes were seen in 3 subjects (non-RCE). RCE subjects were older than non-RCE counterparts, with mean ages of 20 and 12 years, respectively. No significant changes in JCP-specific IgE and total IgE levels were seen before and after RIT. Conclusion: Allergen-induced CD203c expression in basophils may represent, at least in part, the cellular mechanism for the therapeutic responses to RIT for JCP pollinosis. However, further larger-scale studies to confirm the utility of the test are necessary.

Early Changes in Gene Expression with Rush Immunotherapy

Early Changes in Gene Expression with Rush Immunotherapy

Efficacy of a Rush Immunotherapy with a Depigmented Polymerized Extract of Grass pollen using an Enviromental Challenge Chamber (ECC)

Efficacy of a Rush Immunotherapy with a Depigmented Polymerized Extract of Grass pollen using an Enviromental Challenge Chamber (ECC)

Faster reach to maintainance pleteau by delayed rush immunotherapy

Faster reach to maintainance pleteau by delayed rush immunotherapy

Adjuvanted rush immunotherapy using CpG oligodeoxynucleotides in experimental feline allergic asthma

Allergic asthma is driven by relative overexpression of Th2 cell-derived cytokines in response to aeroallergens. In independent studies, both allergen-specific rush immunotherapy (RIT) and CpG oligodeoxynucleotides (ODN) showed promise in blunting eosinophilic inflammation in a model of feline allergic asthma. We hypothesized that RIT using allergen and CpG ODN would work synergistically to dampen the asthmatic phenotype in experimentally asthmatic cats. Twelve cats with asthma induced using Bermuda grass allergen (BGA) were studied. Of these, six were administered adjuvanted BGA RIT using CpG ODN #2142; six were administered placebo (saline) RIT and later crossed over to adjuvanted RIT. Over 2 days, subcutaneous CpG ODN (0.5 ng/kg) with BGA (increasing doses every 2 h from 20 to 200 μg) was administered. Adverse events were recorded and compared with historical controls. Percentage of eosinophils in bronchoalveolar lavage fluid (BALF), % peripheral CD4 + CD25+ T regulatory cells (Tregs), lymphocyte proliferation in response to ConA, and cytokine concentrations in BALF were measured over 2 months. Group mean BALF % eosinophils for the adjuvanted RIT cats were significantly lower at week 1 and month 1 ( p = 0.03 for both), and marginally significantly lower at month 2 ( p = 0.09) compared with placebo RIT cats. By the end of the study, 8/12 treated cats had BALF % eosinophils within the reference range for healthy cats. Adjuvanted RIT, but not placebo RIT, cats had significant decreases in the ConA stimulation index over time ( p = 0.05). BALF IL-4 concentrations were significantly higher at week 1 in adjuvanted RIT cats compared with baseline and month 2, and also with placebo RIT cats at week 1. No significant differences were detected between treatments or over time for IL-10 or IFN-γ concentrations in BALF or for %Tregs cells in peripheral blood. Adjuvanted RIT using CpG ODN in experimental feline asthma dampens eosinophilic airway inflammation. Adverse effects associated with adjuvanted RIT were less severe compared with a historical, non-adjuvanted RIT protocol. The exact mechanism(s) by which adjuvanted RIT alters the aberrant allergic immune response were not elucidated in this study.

Anti-IgE-Antikörper und spezifische Immuntherapie (SIT)

For patients with a confirmed association between allergic sensitization and disease (allergic rhinitis or asthma), SIT is indicated as the only current treatment option with curative capabilities. However, the application of SIT is limited by the relative high risk for severe side-effects and the possibility of weak or delayed efficacy especially for patients with severe allergic asthma. Therefore a combination of omalizumab, a monoclonal anti-IgE antibody, and SIT might be useful for the treatment of allergic diseases. There are now published three clinical studies, which demonstrated consistently that the combination of active immunization with standardised allergen extracts (SIT) and passive immunization with anti-IgE antibody (omalizumab) was superior to SIT alone in reducing symptoms and rescue medication use in patients with allergic rhinitis and in patients with moderate allergic asthma and comorbid allergic rhinitis. Moreover, pre-treatment with omalizumab prior to an intensified rush immunotherapy compared to SIT alone significantly decreased the otherwise high rates of allergic side effects, including anaphylaxis reactions, in patients with ragweed-induced allergic rhinitis. Conclusion: Combination of omalizumab with SIT for treatment of patients with allergic is safe and reduced symptom load in a statistically significant and clinically meaningful manner. The clinical implication of these findings is that also patients with moderate to severe allergic asthma pretreated with anti-IgE might prospectively benefit from a SIT as a causal treatment option.

Combination treatment with omalizumab and rush immunotherapy for ragweed-induced allergic rhinitis: Inhibition of IgE-facilitated allergen binding

The combination of anti-IgE (omalizumab) therapy with ragweed injection immunotherapy for seasonal allergic rhinitis results in a significant reduction in systemic side effects and enhanced efficacy compared with immunotherapy alone. One proposed mechanism of immunotherapy is to induce regulatory antibodies that inhibit facilitated antigen presentation. We sought to determine whether the combination protocol has a cumulative effect on inhibition of facilitated antigen presentation both during and after discontinuation of treatment. Ragweed allergen immunotherapy with and without omalizumab therapy was tested in a 4-arm, double-blind, placebo-controlled study. Flow cytometry was used to detect serum inhibitory activity for IgE-facilitated CD23-dependent allergen binding to B cells as a surrogate marker for facilitated antigen presentation. Serum ragweed-specific IgG4 was measured by means of ELISA. Immunotherapy alone resulted in partial inhibition of allergen-IgE binding after 5 to 19 weeks of treatment compared with baseline (P < .01). Complete inhibition of allergen-specific IgE binding was observed in both treatment groups receiving omalizumab (P < .001). Allergen-specific IgG4 levels were only increased after immunotherapy (P < .05), both in the presence and absence of anti-IgE treatment. Combined treatment resulted in the induction of long-lasting inhibitory antibody function for up to 42 weeks compared with either treatment alone. Ragweed immunotherapy induced serum regulatory antibodies that partially blocked binding of allergen-IgE complexes to B cells. Additional treatment with anti-IgE, by directly blocking IgE binding to CD23, completely inhibited allergen-IgE binding. The combination of ragweed immunotherapy and anti-IgE resulted in prolonged inhibition of allergen-IgE binding compared with either treatment alone, events that might contribute to enhanced efficacy.

Premedication with Montelukast Reduces Local Reactions of Allergen Immunotherapy

Background: Local reactions (LRs) are a very frequent side effect of specific immunotherapy with allergens and can impair patients’ adherence. Antihistamine pretreatment – originally introduced as a safety measure to reduce anaphylactic side effects – has been the only treatment option for LRs so far, although these swellings usually do not appear immediately but after hours. We were interested whether pretreatment with the leukotriene antagonist montelukast would be better suited for preventing those reactions than pretreatment with the antihistamine desloratadine. Methods: Fifteen patients with a history of severe anaphylactic reactions to hymenoptera stings were enrolled into a prospective, double-blind, randomized, placebo-controlled pilot study. We selected a rush immunotherapy protocol consisting of 19 injections of hymenoptera venom administered over 5 consecutive days, where the majority is developing LRs, and counted the number of injections until an LR of >3 cm occurred. The patients were randomized to 3 treatment groups: premedication with placebo, 10 mg montelukast and 5 mg of the antihistamine desloratadine. Results: Compared with placebo, the occurrence of LRs (>3 cm) was significantly delayed by montelukast (p < 0.01, analysis of variance) but not by desloratadine (p = 0.19). The difference between montelukast and desloratadine was close to significant (p = 0.054). Itching, recorded on a scale from 0 to 5, did not differ between the 3 groups. Conclusion: Montelukast can be useful in the prevention of LRs after specific immunotherapy.

Safety of rush immunotherapy using a modified schedule: A cumulative experience of 893 patients receiving multiple aeroallergens

Conventional immunotherapy (IT) is effective in treating allergic rhinitis, allergic asthma, and chronic rhinosinusitis. Disadvantages include poor compliance, delayed efficacy, and patient frustration. Rush IT, or rapid desensitization, offers the advantages of rapid response, improved compliance, and cost-effectiveness. Although premedication with corticosteroids and antihistamines dramatically reduces systemic reactions, safety remains a primary concern. Two separate half-day schedules with minor differences were used to rapidly desensitize 893 patients (aged 1.5-77 years) in two typical outpatient settings equipped to treat anaphylaxis. All patients exhibited positive skin-prick tests to perennial and seasonal allergens. Diagnoses included allergic rhinitis (857/96%), allergic asthma (505/57%), and chronic rhinosinusitis (384/43%). Five hundred sixty-eight patients were premedicated with prednisone and HI-antihistamine for 3 days. Three hundred twenty-five patients were premedicated for 3 days with prednisone and H1- and H2-blockade. The protocol's final dose ranged from 0.1 to 0.5 mL of a 1:1000 dilution of extracts manufactured by ALK and Greer Laboratories. Patients continued on to higher doses by resuming a conventional schedule. Eighteen patients (2.0%) experienced a mild systemic reaction. All responded to subcutaneous epinephrine and/or nebulized albuterol and were sent home after observation. One patient (0.1%) experienced true anaphylaxis and received appropriate treatment and observation. Our experience with rush IT confirms that maintenance IT can be reached quickly and safely under careful supervision. Caution must be exercised when using this procedure because anaphylaxis does occur. Systemic reactions occur less frequently using a lower targeted final dose than previously described in the literature.

Transcriptome Seasonal Regulation in Ragweed Allergy

RATIONALE: To examine transcriptional regulation in a subset of Immune Tolerance Network ragweed allergy clinical trial participants treated with Omalizumab plus Rush Immunotherapy (RIT), Omalizumab or RIT alone, and Placebo.

The Effects of Rush Immunotherapy on Hymenoptera Allergy

The Effects of Rush Immunotherapy on Hymenoptera Allergy

Basophil Interleukin 4 and Interleukin 13 Production Is Suppressed during the Early Phase of Rush Immunotherapy

Background: Studies using rush immunotherapy (RIT) have shown that rapid protection can be achieved using protocols allowing a fast increment of allergen dose. We examined the early effects of RIT on basophil numbers and expression of CD203c, production of interleukin (IL)-4 and IL-13 and histamine release by basophils in the peripheral blood of patients treated with immunotherapy and controls. Methods: Twelve patients treated with RIT and 4 untreated controls were included in the study. Any adverse events were evaluated during the incremental phase of RIT. Mononuclear cells were isolated before the start of RIT and 3 days, 1 week, 4 weeks and 3 months after the beginning of the treatment. Histamine release upon allergen stimulation, expression of CD203c and allergen-induced production of IL-4 and IL-13 by basophils were examined. Results: Significant decreases in blood basophil count (p = 0.02) were observed early in the treatment, returning to baseline values 1 week after the start of RIT. Similarly, histamine release decreased at day 3 (p = 0.02), but returned to pretreatment levels after 1 week. Also, the percentage of IL-4+ and IL-13+ basophils and levels of CD203c expression were markedly reduced early in the treatment. IL-4 and IL-13 production correlated with histamine release and CD203c expression. Histamine release and production of IL-4 and IL-13 by basophils before the treatment correlated with the severity of adverse events during the incremental phase of RIT. Conclusion: We report the decrease in blood basophil numbers, their lower activation status and the reduced production of IL-4 and IL-13 early in the course of RIT. This early suppression of basophil activation could be one mechanism behind the protective effect of RIT.

Production of interleukin-12 by monocytes and interferon-γ by natural killer cells in allergic patients during rush immunotherapy

Allergen specific immunotherapy modifies the immunologic response to allergen exposure; however, the role of cells composing the innate immune system, such as monocytes and natural killer (NK) cells, in this mechanism is still unclear. To examine the effect of rush immunotherapy (RIT) on early allergen-induced cytokine production by peripheral blood mononuclear cells from treated cat- and birch-allergic patients. Twelve allergic patients received RIT, and another 4 served as controls. Blood samples were taken before the start and after 3 days, 1 week, 3 weeks, and 3 months of RIT. Allergen-induced production of interleukin-12 (IL-12) by monocytes and interferon-gamma (IFN-gamma) by NK cells was evaluated by means of flow cytometry. Before the start of RIT, allergic patients had significantly lower numbers of IL-12+ monocytes compared with healthy subjects (P = .01). The percentage of IL-12+ monocytes increased after 3 months of RIT (P = .003). In the allergic control group, the proportion of IL-12+ monocytes evaluated after 3 months was not different from baseline and was significantly lower compared with that in the RIT group (P = .005). Before treatment, the percentage of IFN-gamma+ NK cells was lower in allergic patients than in healthy subjects (P = .04). The percentage of IFN-gamma+ NK cells increased after 3 weeks (P = .03) and 3 months (P = .01) of RIT. Restoration of the cytokine imbalance by immunotherapy is not only restricted to the cells of the adaptive immune system but also concerns cells composing the innate immune system.

Accelerated immunotherapy schedules: review of efficacy and safety

To provide a comprehensive evaluation of accelerated immunotherapy build-up schedules in terms of adverse reactions and clinical efficacy. Peer-reviewed studies and review articles were selected from the PubMed database for articles published in the years 1976 to 2006 using the following keywords: rush, cluster immunotherapy in combination with allergic rhinitis, asthma, Hymenoptera, and imported fire ant. Studies were selected if they provided safety and efficacy information on accelerated allergen immunotherapy schedules. Most of the studies reviewed were double-blind, placebo controlled, but some open-observational studies were included if they provided immunotherapy safety or other information the author thought was relevant. A wide range of systemic reactions were reported in the literature with inhalant allergens: ranging from 27% to 100% of the patients in rush immunotherapy studies and 0% to 79% of patients in the cluster studies. Predictors of systemic reactions with rush immunotherapy were forced expiratory volume in 1 second less than 80% of predicted and a high degree of skin test reactivity. Premedication clearly reduces the risk of systemic reactions with rush immunotherapy, but the effect on cluster schedules was not as clear. Accelerated immunotherapy build-up schedules in selected patients may provide a rapid alternative to conventional build-up schedules without a significant increase in risk.