Management of the polyallergic patient with allergy immunotherapy: a practice-based approach

Abstract

BackgroundThe great majority (60–80 %) of patients consulting specialist physicians for allergic respiratory disease are polysensitized and thus may be potentially clinically polyallergic. However, management approaches to allergen immunotherapy (AIT) in polysensitized and polyallergic patients are not standardized.MethodsAn international group of clinicians with in-depth expertise in AIT product development, clinical trials and clinical practice met to generate up-to-date, unambiguous, pragmatic guidance on AIT in polysensitized and polyallergic patients. The guidance was developed after reviewing (1) the current stance of regulatory bodies and learned societies, (2) the literature data on single- and multi-AIT and (3) the members’ confirmed clinical experience with polysensitized patients.ResultsAIT is safe and effective in polysensitized and polyallergic patients, and should always be based on the identification of one or more clinically relevant allergens (based on the type and severity of symptoms, the duration of induced symptoms, the impact on quality of life and how difficult an allergen is to avoid). Single-AIT is recommended in polyallergic patients in whom one of the relevant allergens is nevertheless clearly responsible for the most intense and/or bothersome symptoms. Parallel 2-allergen immunotherapy or mixed 2-allergen immunotherapy is indicated in polyallergic patients in whom two causal relevant allergens have a marked clinical and QoL impact. In parallel 2-allergen immunotherapy (whether subcutaneous or sublingual), high-quality, standardized, single-allergen formulations must be administered with an interval of 30 min. Mixing of allergen extracts may be considered, as long as (1) the mixture is technically feasible, (2) the mixture is allowed from a regulatory standpoint, (3) the allergen doses are reduced in proportion to the number of components but are still at concentrations with demonstrated efficacy.ConclusionsPhysicians can prescribe AIT (preferably with high-quality, standardized, single-allergen formulations) with confidence in polysensitized and polyallergic patients by focusing on clinical/QoL relevance and safety.

European Survey on Adverse Systemic Reactions in Allergen Immunotherapy (EASSI): a real-life clinical assessment

“…Although the present survey was not sufficiently powered to determine the relevance of AIT mixtures, we did not identify these preparations as risk factors for SRs . Moreover, the great majority of patients (90%) received AIT with one allergen source in accordance with current European guidelines.…”

EAACI Guidelines on Allergen Immunotherapy: Allergic rhinoconjunctivitis

“…151 This may be apparent from the history or may need investigation with component-resolved diagnostics or assessment with nasal or conjunctival provocation challenges where the clinician is experienced in these diagnostic procedures. 137 Polysensitized patients who are monoallergic are recommended to receive AIT for the specific allergen that is driving their AR symptoms (Grade A).…”

Allergen immunotherapy in polysensitization

“…Otwarte jest pytanie, czy należy rozpocząć AIT od alergenów pyłkowych (potencjalnie zjawisko primingu alergenowego, lepsza odpowiedź kliniczna, a także chęć kontynuowania leczenia) czy od alergenów całorocznych (najczęściej roztocze, alergeny zwierząt, długi czas ekspozycji i objawów klinicznych). Dopuszcza się również dołączenie drugiego preparatu równolegle do trwającej immunoterapii z zastosowaniem innego preparatu [13,14].…”