Subcutaneous Immunotherapy Research Articles

Health and economic impact of subcutaneous allergen immunotherapy in patients with pollen-induced allergic rhinoconjunctivitis: real-word evidence from the Czech Republic.

Background: The prevalence of allergic rhinoconjunctivitis (AR) has been increasing over the years, and allergen immunotherapy (AIT) remains the only disease-modifying treatment. However, cost-effectiveness data remain scarce. Methods: In this single-arm, noninterventional, prospective, multicenter study, we describe the effectiveness, safety and costs of subcutaneous AIT for pollen-induced allergic rhinoconjunctivitis. Results: Of 471 new AIT users, 317 completed three courses of treatment, and symptoms improved in 96%; no serious adverse reactions were reported. The cost of symptomatic medication decreased by 49% and the cost of unscheduled specialist visits decreased by 73%. Except for AIT administration, total healthcare costs decreased by 54% compared with the baseline pollen season without AIT. Conclusion: In clinical practice, subcutaneous AIT is an effective treatment generating savings on symptomatic medication and unscheduled consultations.

Impact of coronavirus pandemic on safety and time of administration of subcutaneous immunotherapy among pediatric patients

Introduction: Allergen immunotherapy is the only targeted therapy that can modify the natural course of allergic diseases. In pediatric patients, SCIT with aeroallergens is an effective treatment and should be considered as a preventive strategy in the treatment of allergic diseases, even though one of the major concerns about it is its safety. The main purposes of this study were to assess the safety of SCIT ultra-rush schedules with polymerized extracts in a pediatric population and to determine the impact of the COVID-19 pandemic on the safety and time of administration of subcutaneous immunotherapy among pediatric patients. Methods: A retrospective medical records review of patients under 18 years of age undergoing SCIT was made and re-scheduling due to restrictions imposed by the COVID-19 pandemic was recorded. Results: A total of 192 pediatric patients were included. Fifty-nine (31%) had local reactions and systemic reactions were not reported. In March 2020, the first case of COVID-19 was diagnosed in Portugal and all non-urgent appointments and procedures were postponed. In our group of pediatric patients, 43 (22%) were referred to primary care, 38 (20%) stopped AIT definitively and 111 (58%) maintained administrations in the hospital. Only 2 (2%) of them had reactions upon reinitiation. Conclusion: In this study, the ultra-rush protocol using polymerized extracts was safe in pediatric patients. Although the effectiveness of AIT may be compromised due to prolonged suspension of the treatment, it is important to note that despite longer interruptions, administrations may continue without compromising safety, maintaining shorter visits and a lower number of injections.

Exosomes Derived hsa-miR-4669 as a Novel Biomarker for Early Predicting the Response of Subcutaneous Immunotherapy in Pediatric Allergic Rhinitis.

PurposeSubcutaneous immunotherapy (SCIT) is an effective treatment for pediatric allergic rhinitis (AR), but its efficacy fluctuates among individuals. This study aims to identify the profile of serum exosomes derived microRNAs (miRNAs) and evaluate their capacities to early predict SCIT efficacy in pediatric AR.Patients and MethodsHigh-throughput sequencing was applied to identify the miRNA of serum exosomes in AR children. GO enrichment and KEGG pathway analysis were performed to enrich the biological annotations of target mRNAs of miRNAs. Then we validated differentially expressed miRNAs in two independent cohorts by RT-qPCR. Logistic regression and receiver operating characteristic curve (ROC) were applied to evaluate the abilities of identified miRNAs in predicting the efficacy of SCIT in AR children.ResultsA total of 812 miRNAs were detected in the serum exosomes, including 16 upregulated and 14 downregulated. Differentially expressed genes are enriched in the biological process of developmental process and regulation of cellular process, and gathered in pathways such as the signaling pathways regulating pluripotency of stem cells and the Wnt signaling pathway. In the first validation cohort, hsa-miR-4669 (P=0.009) and hsa-miR-4686 (P=0.032) were significantly downregulated in the effective group than the ineffective group, while hsa-miR-3196 (P=0.015) was upregulated. In the second cohort, hsa-miR-4669 level (P<0.0001) was downregulated in the effective group than the ineffective group. In addition, logistic regression revealed that hsa-miR-4669 level was correlated with the visual analogue scale (r=0.323, P=0.001) and total nasal symptoms score (r=0.269, P =0.007). ROC curve highlighted that hsa-miR-4669 level exhibited a reliable accuracy in predicting SCIT efficacy in pediatric AR (AUC=0.785).ConclusionSerum exosomes derived miRNA were associated with the efficacy of SCIT. Serum exosomes derived hsa-miR-4669 might serve as a novel biomarker for early predicting the response of SCIT in AR children.

Efficacy and safety of subcutaneous immunotherapy with a mixture of glutaraldehyde-modified extracts of Dermatophagoides pteronyssinus, Dermatophagoides farinae, and Blomia tropicalis

BackgroundAllergen Immunotherapy (AIT) is an effective treatment of allergic respiratory diseases induced by the inhalation of house dust mite allergens. ObjectivesTo evaluate the efficacy and safety of glutaraldehyde polymerized allergen extracts using a mixture of Dermatophagoides pteronyssinus, D. farinae and Blomia tropicalis in mite allergic individuals residing in Colombia. MethodsTwo hundred and fifty (250) patients with allergic rhinoconjunctivitis with, or without asthma and sensitized to D. pteronyssinus, D. farinae and B. tropicalis were included. A glutaraldehyde-modified extract containing a mixture of D. pteronyssinus, D. farinae and B. tropicalis was employed, using a cluster up-dosing schedule followed by a monthly maintenance dose. The primary endpoints to evaluate the clinical impact were the Combined Symptom and Medication Scores (CSMS) for allergic rhinitis, the Asthma Control Test (ACT) and the reduction in medication consumption. ResultsSignificant improvement was found after 3 months of treatment regarding CSMS (p < 0.0001) and ACT (p < 0.0001). Additionally, a significant decrease in medication consumption was found after 3 months of treatment (p < 0.0001). Adverse reactions, either local or systemic were mild and no severe reactions related to the vaccines were observed. ConclusionAfter 12 months of allergen immunotherapy, glutaraldehyde-modified mixture of D. pteronyssinus, D. farinae and B. tropicalis proved to be safe and effective in the treatment of patients with rhinoconjunctivitis with or without asthma due to allergy to mites.

Safety of subcutaneous immunotherapy with carbamylated allergoids based on data from a pharmacovigilance database.

Aims: Allergen immunotherapy aims to induce tolerance, which persists after its discontinuation, to targeted allergens. However, concern exists regarding the use of subcutaneous immunotherapy with whole extracts due to frequently reported events of anaphylactic reactions. Materials & methods: In this pharmacovigilance study, the authors assessed the safety of subcutaneous immunotherapy with the monomeric allergoid Lais-in using a database of adverse reactions documented in real-world postmarketing reports from 2010 to 2020. Results & conclusion: The results showed that more than 171,916 doses of Lais-in were administered from 2010 to 2020, resulting in five adverse drug reactions. Nonserious adverse events, including hives, eye irritationand skin reactions, were reported. These data indicate that monomeric allergoids prevent serious reactions to subcutaneous immunotherapy.

Safety of subcutaneous immunotherapy in patients with severe asthma

BackgroundSevere asthma (SA) has been identified as a risk factor for severe systemic reactions (SR) to allergen subcutaneous immunotherapy (SCIT). However, the incidence and characterization of SRs in SA in comparison to less severe or no asthma is not known. ObjectiveThe objective of this study was to characterize the incidence of SRs in patients with SA receiving SCIT in comparison to patients with no asthma or less SA. MethodsA retrospective cohort study was performed on patients receiving SCIT from a multicenter national network of private allergy practices between January 2015 and December 2019. Demographics, asthma severity (International Classification of Diseases–10 codes), concomitant medications, aeroallergen skin testing, measures of asthma control with the asthma control test and forced expiratory volume in 1 second values, SCIT prescription, and an SR standardized form were assessed. ResultsA total of 65,855 patients, with 1072 patients having SA receiving SCIT, were included with a total of 4415 SRs (19.9 SR per 10,000 injection visits). Severe asthma had 23.9 SRs per 10,000 injection visits (incidence rate, 0.239; 95% confidence interval [0.189-0.298]). There were 155 grade III or IV SRs; 5 (3.2%) occurred in the SA group. There was no difference in rates of grade III or IV SRs between SA and no asthma and in rates of total SRs between SA and less SA. ConclusionIn a large cohort of patients with SA undergoing multiallergen SCIT drawn from a diverse outpatient allergy population, the diagnosis of SA was not associated with increased moderate-severe SRs compared with patients without asthma and any severity of asthma.

Predictive Value of Nasal Nitric Oxide and Serum NOS2 Levels in the Efficacy of Subcutaneous Immunotherapy in Pediatric Patients with Allergic Rhinitis.

Background Subcutaneous immunotherapy (SCIT) is an effective therapy for allergic rhinitis (AR), but some AR patients still do not benefit from it. Nasal nitric oxide (nNO) and inducible nitric oxide synthase (iNOS/NOS2) act important roles in AR. This study aims to explore the abilities of serum NOS2 and nNO in predicting the clinical efficacy of SCIT in AR patients. Methods We recruited 40 healthy controls (HCs) and 120 AR patients in this study. Serum NOS2 and nNO levels were compared between the two groups. In the AR group, patients underwent and finished 1-year of SCIT, and divided into the effective and ineffective groups, and the relationships between serum NOS2 and nNO levels and efficacy of SCIT were evaluated. Results The serum NOS2 and nNO levels were higher in AR patients than HCs. In the effective group, the serum NOS2 and nNO levels were increased than the ineffective group. ROC curves presented that a combination of serum NOS2 and nNO exhibited promising predictive ability in predicting the clinical efficacy of SCIT. Conclusions Serum NOS2 and nNO levels were enhanced in AR patients and might affect the efficacy of SCIT. The combined use of serum NOS2 and nNO levels could be a reliable and useful method for predicting the clinical efficacy of SCIT.

Suppression spontaneous and induced expression of CD203c basophils after &#x0D; subcutaneous immunotherapy with ragweed and mugwort allergens

BACKGROUND: The basophil activation test (BAT) reflects the presence of IgE on the cell surface and can be a tool for monitoring the effectiveness of allergen-specific immunotherapy (ASIT). It is likely that spontaneous and allergen-induced BAT levels may change after effective subcutaneous immunotherapy (SCIT) and this is of clinical importance.&#x0D; AIMS: determination of basophil activation markers in patients sensitized to weed pollen during SCIT.&#x0D; MATERIALS AND METHODS: A real clinical study (2 years, 60 patients) with allergic rhinitis who underwent SCIT with weed allergens for 2 seasons. The proportion of basophils expressing CD203c spontaneously and after exposure to a trigger allergen was determined. BAT was performed before treatment, after the first and second courses of pre-season SCIT (0, 3, 15 months of treatment). The effectiveness of SCIT was assessed by the dynamics of the symptom scale (Rhinoconjunctivitis total symptom score) and the drug assessment (Daily medical score).&#x0D; RESULTS: SCIT with water-salt extracts was effective: median RTSS in patients after two courses decreased from 13.0 [10.0; 15.0] to 4.5 [3.00; 7.25] points (p 0.001), DMS score from 2.0 [2.0; 2.0] vs 1.0 [1.0; 2.0] points (p0.001).&#x0D; Spontaneous BAT remained unchanged after the first course of ASIT. Mean BAT values ​​before therapy and after the first course of SCIT did not differ (8.15 [6.10; 11.9] vs 9.0 [6.30; 12.0] %). After the second course of treatment, spontaneous BAT decreased (8.15 [6.10; 11.9] vs 6.20 [4.27; 9.00] %, 2 = 15.5, p0.001).&#x0D; Allergen-induced BAT decreased significantly from the first year of treatment. The overall change in the total group for BAT with ragweed after the first course of SCIT was 11.25 (CI 95 %: 7.10; 15.10) %, p 0.001. The overall difference in the induced ВAT test at the end of therapy reached 8.63 (CI 95: 5.30; 12.05) %, p 0.001. After the first course of therapy with mugwort allergens, the indices of induced BAT decreased by 12.0 (CI 95 %: 6.95; 17.90) %, p 0.001; after the second course, the difference from the initial values ​​was 9.67 (CI 95%: -6.85; 15.90) %, p0.001.&#x0D; CONCLUSIONS: SCIT with ragweed and mugwort allergens was effective. The change in spontaneous and induced BAT is associated with a positive effect of ASIT.

Pediatric subcutaneous allergen immunotherapy.

Subcutaneous immunotherapy (SCIT) is a widely used therapy for allergic rhinitis and asthma. It is a useful adjunct to standard medical management of these conditions that can lead to long-term benefits and possible resolution of symptoms. The benefits of SCIT, particularly for children, include avoiding prolonged use and side effects from medications, preventing new aeroallergen sensitizations, and reducing the risk of developing asthma. The primary risks of SCIT include local and systemic reactions. Standard schedules for SCIT include advancing through multiple doses usually in four vials (diluted to 1:1000) on a weekly basis; however, there are benefits of using accelerated schedules, especially for children who need to coordinate school and parent work schedules. Special considerations for pediatric patients include fear of needles, avoiding discomfort with injections, consent, optimal injection scheduling, and difficulty communicating about symptoms during reactions in very young children. Overall, SCIT can be a safe and beneficial therapy for children.

Long-term efficacy of the sublingual and subcutaneous routes in allergen immunotherapy.

Allergen immunotherapy is highly effective in selected patients with allergic rhinitis, allergic asthma, and Hymenoptera venom allergy. Unlike anti-allergic drugs, both subcutaneous and sublingual immunotherapies have been shown to modify the underlying cause of the disease, with proved long-term clinical benefits after treatment cessation. In this review, we analyzed 10 randomized, double-blind, placebo controlled clinical trials of allergen immunotherapy that included blinded follow-up for at least 1 year after treatment withdrawal. Three studies of pollen subcutaneous immunotherapy provided evidence that a sustained, tolerogenic effect of subcutaneous immunotherapy can be achieved after 3 years of treatment. Six trials of sublingual immunotherapy provided robust evidence for long-term clinical benefit and persistent immunologic changes after grass pollen, house-dust mite, or Japanese cedar immunotherapy, whereas a clinical trial of both sublingual and subcutaneous grass pollen immunotherapies showed that 2 years of immunotherapy were efficacious but insufficient to induce long-term tolerance. These studies strongly supported international guidelines that recommend at least 3 years of allergen immunotherapy of proven value to achieve disease modification and sustained clinical and immunologic tolerance.

Subcutaneous allergen immunotherapy in the treatment of allergic respiratory disease.

Subcutaneous immunotherapy is recognized as a cornerstone in the management of allergic respiratory disease in patients who are properly characterized with allergy and with allergic rhinoconjunctivis and/or well-controlled asthma, and who are willing to adhere to the rigorous treatment program. A key tenet is that it affords the opportunity to effect long-term clinical remission through its disease-modifying properties. Furthermore, it has the potential to prevent the progression of allergic rhinitis to asthma, prevent new allergen sensitivities, and improve a patient's quality of life.

Association of allergen sensitization patterns with clinical outcome of subcutaneous allergen-specific immunotherapy in polysensitized allergic patients

Abstract Introduction Understanding sensitization patterns helps clinicians tailor care more effectively. Most clinical studies with positive results used single allergens, but many patients are sensitized to multiple allergens. Aim This study was planned to assess the correlation between different allergen sensitization patterns (the presence of sensitization to some but not other allergens) and clinical effectiveness of subcutaneous allergen-specific immunotherapy. Patients and methods This ex post facto study was conducted on patients with already diagnosed allergic disorders, who were attending our allergy and immunotherapy clinic and receiving subcutaneous allergen-specific immunotherapy. Data collected include patient’s demographic data, diagnosis of allergic disorders, and sensitization pattern duration of subcutaneous immunotherapy. The outcome of subcutaneous allergen-specific immunotherapy was assessed based on symptom score, medication score, and overall clinical outcome. Results A total of 100 patients were included. The frequencies of allergens, to which the patients were sensitized, were pollen (1 and 2) (63%), mold (61%), mite (59%), hay dust (41%), and chicken feather (23%). There were no significant association between sensitization patterns and the preimmunotherapy symptom and medication. Apart from cotton pollen, all other allergens were not associated with improvement in symptom score, and apart from chicken feather and dog sensitization all other allergens were not associated with improvement in medication score. Conclusion Allergen sensitization pattern could affect clinical outcome of subcutaneous allergen-specific immunotherapy in polysensitized patients. Cotton pollen sensitization is associated with less improvement in symptoms score. Chicken feather sensitization is associated with significant improvement in medication score in contrast to dog hair sensitization. The number of allergens in each patient is not significantly associated with the clinical outcome of subcutaneous immunotherapy.

Essentials of allergen immunotherapy: A primer for the practitioner.

It has been more than a decade since the most recent allergen immunotherapy (AIT) practice parameter was published and 5 years since a focused practice parameter on sublingual immunotherapy (SLIT) was issued. There is an unmet need, therefore, for a more up-to-date, concise summary of AIT to be published to provide allergy/immunology practitioners, allergy/immunology fellows-in-training, medical students, residents, and other health-care practitioners with the most current information available on AIT. The Allergen Immunotherapy Primer (AITP) is not intended to define a standard of care or to be inclusive of all proper methods of care, nor is it intended to replace or supplant established AIT practice parameters; rather, the goal of this AITP is to supplement the established practice parameters and to serve primarily as an updated tool for the practicing allergist/immunologist, allergy/immunology trainees, and health-care professionals seeking practical and concise information with regard to AIT. Primer topics include the history of AIT; descriptions of the mechanisms and biomarkers of subcutaneous immunotherapy (SCIT) and SLIT; the efficacy and safety of SCIT; the efficacy and safety of SLIT, pediatric SLIT, and SCIT; the long-term efficacy of SLIT and SCIT; long-term adherence strategies for AIT; the implications of real-world data for AIT; the role of AIT for asthma; patterns of cross-allergenicity among pollens; a practical implementation guide for optimized construction of AIT vaccines; standardization of allergen extracts; updated information on federal regulations about the United States Pharmacopeia and the compounding of allergenic extracts; an update on AIT venom immunotherapy; the advantages and disadvantages of accelerated immunotherapy regimens; the important role of shared decision-making in AIT and how it can be incorporated into the informed consent process; and a forecast of future directions in allergen immunotherapy.

Efficacy and safety of sublingual allergen immunotherapy.

Sublingual immunotherapy (SLIT)-tablets represent a new allergen immunotherapy option for clinicians. In North America, there are five SLIT-tablets approved for the treatment of allergic rhinoconjunctivitis (ARC). No SLIT-drops products are currently approved in the United States or Canada. This work reviewed the efficacy of the timothy grass SLIT-tablet, five-grass SLIT-tablet, ragweed SLIT-tablet, house-dust mite SLIT-tablet, and tree SLIT-tablet in patients with ARC. All the SLIT-tablets showed consistent clinical efficacy for the treatment of ARC in large, double-blind, placebo-controlled trials, including for both patients who were monosensitized and those who were polysensitized. Treatment with house-dust mite SLIT-tablet has shown efficacy in patients who are pollen sensitized during their respective pollen seasons. In contrast to SLIT-tablets, efficacy studies of SLIT-drops show high heterogeneity of treatment effect. Although data are scarce, data that compared the efficacy of SLIT-tablets versus ARC pharmacotherapy generally indicated that SLIT-tablets had a greater benefit than pharmacotherapy when compared with placebo, particularly for perennial ARC. When compared with subcutaneous immunotherapy, analysis of these data indicated that SLIT-tablets had a benefit over subcutaneous immunotherapy in regard to safety but somewhat less benefit in regard to efficacy. The safety of SLIT-tablets has been well documented, and a U.S. Food and Drug Administration class label with safety considerations is present in the prescribing information for all SLIT-tablets. No new safety signals have been observed after reinitiating SLIT-tablets after a short treatment interruption.

United States Pharmacopeia guidance for compounding of allergenic extracts for allergen immunotherapy.

Patient-specific allergen-specific subcutaneous immunotherapy (SCIT) has been used as a disease modifying treatment for type 1 IgE mediated allergy to inhalants for > 100 years. Traditionally, the extracts used for a treatment set have been "mixed" under the supervision of allergists in their clinics. Until 2008, there were no specific requirements for mixing procedures. Allergenic extracts are classified as biologics by the U.S. Food and Drug Administration (FDA) and are subject to the biologics license application requirements. One of the conditions is that it must be prepared in accordance with U.S. Pharmacopeia (USP) Chapter <797>, which was first published in 2008. What allergists have always considered "mixing" of allergen extracts is considered "compounding" by the FDA and other state and federal regulatory agencies. A revision of USP Chapter <797> was proposed after a series of "never events," including deaths, from compounded products. No reports of infections from SCIT have ever been reported. "Allergy" (ACAAI, AAAAI, AAOA, and other stakeholders) worked cooperatively with the USP Compounding Expert Committee to develop Section 21. "Compounding Allergenic Extracts" of what is expected to be accepted as the next version of USP Chapter <797> in mid 2022.

Long-term adherence strategies for allergen immunotherapy.

Adherence is crucial for allergen immunotherapy (AIT) efficacy, and a long-term 3-year adherence is indispensable for the long-term benefits beyond AIT administration. Nonadherence causes should be analyzed not only at the patient level but from a broader perspective, including socioeconomic factors, health-care system factors, and disorder- and therapy-related factors. Subcutaneous immunotherapy (SCIT) adherence is ∼50% at best and, for sublingual immunotherapy, the numbers are even much worse in some regions. In this review, causes for AIT loss of adherence and strategies, published and from personal experience, to reduce nonadherence are presented. Although the broader picture of causes of nonadherence has to be taken into account, in all this, the patient-physician and patient-health care professional (AIT nurse, assistant) are still in the center, and, in SCIT, each clinic visit for a shot is an opportunity to exploit this interaction in a positive way and stimulate adherence. Patient factors of nonadherence are not so much forgetfulness but more perception of ineffectiveness and adverse effects. An explanation of what can be expected before starting AIT is crucial because most of those who drop out are seen during the first year. Adherence is especially under risk when administration is temporarily interrupted (lockdown, illness, disease flare, vacation, preseasonal AIT administration schedules). The pandemic has caused higher rates of nonadherence specifically due to a fear of getting infected with severe acute respiratory syndrome coronavirus 2, which can be mitigated with good hygiene techniques and strict sanitization protocols, which ensure the patients. Also, patient mobile discussion networks related to AIT can help encourage adherence and reduce fear of infection, even in these difficult times.

Safety of subcutaneous allergen immunotherapy.

Subcutaneous allergen immunotherapy (SCIT) is a unique treatment option for managing patients with allergic rhinitis, asthma, atopic dermatitis, and stinging insect allergy. Although systemic reactions to allergen injections are rare, near-fatal, and fatal anaphylactic reactions can occur. Patients with asthma are at greatest risk for more severe reactions as are those with previous systemic reactions. Treating allergists should institute best clinical practices to prevent and manage severe systemic reactions to SCIT, including the following: (1) prescreening patients with asthma for recent increases in asthma symptoms, (2) not prescribing SCIT to patients with severe and uncontrolled asthma, (3) instituting clinic protocols to prevent dosing errors, (4) considering modifying allergen doses during peak allergy seasons in patients at high risk, (5) instituting measures that require all patients on SCIT to be observed for at least 30 minutes after injections, and (6) regular training of all clinical staff in the recognition and expeditious treatment of anaphylaxis.

Future directions in allergen immunotherapy.

Both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) are effective clinically against allergic rhinitis and allergic asthma, and modify the underlying immunologic abnormalities. Despite this, many patients who could benefit from receiving SCIT and SLIT do not because of concerns about safety and the inconvenience in receiving SCIT, and the long duration of treatment with both, 3-4 years being required for lasting benefit. Attempts to improve the efficacy and safety, and to shorten the course of allergen immunotherapy have taken many approaches. Some approaches have generated great enthusiasm, only to fail in larger trials and be discarded. Other approaches show some promise but perhaps not enough to achieve regulatory approval. Those approaches that seem to have the best chance of becoming available in the next few years include the following: intralymphatic and epicutaneous immunotherapy, vitamin D in patients with insufficient serum 25 hydroxy vitamin D, probiotics, and allergoids, but all require further studies before being ready for nonexperimental use or, where necessary, for regulatory approval.

Pediatric sublingual allergen immunotherapy.

Sublingual immunotherapy (SLIT) offers an important therapeutic modality in the management of children with respiratory allergies. Along with subcutaneous immunotherapy, these modalities are the only selections that have shown not merely relief of symptoms but also disease-modifying activity. SLIT can be given as either a dissolvable tablet (SLIT-T) or liquid drops (SLIT-D). In studies that examined the efficacy and safety in allergic rhinitis and asthma, SLIT-T and SLIT-D both show efficacy in reducing symptoms and the need for medication, although it seems that SLIT-T may show a better response. Almost all SLIT-D efficacy studies are with single allergens. There are virtually no data on the efficacy of mixing unrelated allergens in the same prescription. Both SLIT-T and SLIT-D treatments are safe, with the most common adverse effects being local ones, such as oral pruritus and mouth irritation, which tend to be mild and short lived. Studies that assess the role of SLIT in the prevention of new sensitizations and asthma in the pediatric population are insufficient and of mixed results; therefore, no conclusions can be made. In the treatment of other pediatric conditions, such as food allergy and atopic dermatitis, there are few studies that assessed if, and the degree of, the benefit with SLIT. In determining if SLIT should be prescribed for the pediatric patient, there is a need for shared decision-making to allow the older child and parents or caregivers to understand the pros and cons, and the costs of all the options and relate their values and preferences to the physician.

Accelerated/rush allergen immunotherapy.

Accelerated allergy shot schedules for inhalant and venom allergens provide individuals with allergy symptom relief but in a shorter time frame than conventional therapy. Accelerated immunotherapy (IT) protocols allow patients to reach therapeutic doses in a shorter time frame while improving adherence and reducing direct costs (e.g., fewer office visits and medications) and indirect costs (e.g., less travel time, missed work or school). Rush IT and cluster IT are believed to work through mechanisms similar to conventional subcutaneous IT (SCIT). The risk for severe systemic reactions during accelerated IT is low when appropriately administered; however, life-threatening and fatal reactions do occur. To reduce the incidence of systemic allergic reactions during cluster and rush IT protocols, premedication is recommended. It is important to exclude individuals at high risk such as those with poorly controlled asthma or those who are on β-blockers to mitigate the risk for developing systemic allergic reactions. However, accelerated SCIT regimens offer increased convenience, faster improvement in allergy symptoms, and the potential to reduce health-care costs while providing equivalent safety outcomes compared with conventional IT protocols.