EAACI Guidelines on Allergen Immunotherapy: House dust mite‐driven allergic asthma

Abstract

blind placebo controlled; EAACI, European Academy of Allergy and Clinical Immunology; FEF 25-75, forced expiratory flow at 25-75% of the pulmonary volume; FEV1, forced expiratory volume in 1 second; GINA, Global Initiative for Asthma; GRADE, The Grading of Recommendations Assessment, Development and Evaluation; HCP, healthcare professional; HDM, house dust mites; ICS, inhaled corticosteroids; MEF 25, maximal expiratory flow at 25% of forced vital capacity; MEF 50, maximal expiratory flow at 50% of forced vital capacity; MEF 75, maximal expiratory flow at 75% of forced vital capacity; PD20, provocative dose causing a 20% drop in FEV1; QoL, quality of life; RCTs, randomized control trials; ROB, risk of bias; SCIT, subcutaneous allergen immunotherapy; SLIT, sublingual allergen immunotherapy; SmPC, Summary of product characteristics; WAO, World Allergy Organization; WHO, World Health Organization.Agache and Lau are joint first co-authorship. External peer-reviewers: AbstractAllergen immunotherapy (AIT) has been in use for the treatment of allergic disease for more than 100 years. Asthma treatment relies mainly on corticosteroids and other controllers recommended to achieve and maintain asthma control, prevent exacerbations, and improve quality of life. AIT is underused in asthma, both in children and in adults. Notably, patients with allergic asthma not adequately controlled on pharmacotherapy (including biologics) represent an unmet health need. The European Academy of Allergy and Clinical Immunology has developed a clinical practice guideline providing evidence-based recommendations for the use of house dust mites (HDM) AIT as add-on treatment for HDM-driven allergic asthma. This guideline was developed by a multi-disciplinary working group using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. HDM AIT was separately evaluated by route of administration and children and adults: subcutaneous (SCIT) and sublingual AIT (SLIT), drops, and tablets. Recommendations were formulated for each. The important prerequisites for successful treatment with HDM AIT are (a) selection of patients most likely to respond to AIT and (b) use of allergen extracts and desensitization protocols of proven efficacy. To date, only AITwith HDM SLIT-tablet has demonstrated a robust effect in adults for critical end points (exacerbations, asthma control, and safety). Thus, it is recommended as an add-on to regular asthma therapy for adults with controlled or partially controlled HDM-driven allergic asthma (conditional recommendation, moderate-quality evidence). HDM SCIT is recommended for adults and children, and SLIT drops are recommended for children with controlled HDM-driven allergic asthma as the add-on to regular asthma therapy to decrease symptoms and medication needs (conditional recommendation, low-quality evidence). K E Y W O R D Sallergen immunotherapy, allergy, asthma, asthma control, asthma exacerbations, GRADE, house dust mites, lung function

30 years of sublingual immunotherapy

“…The most important meta‐analyses (with their intrinsic limitations) suggested that AIT, and SLIT, are clinically effective in reducing asthma symptoms and medication score, without an increase in adverse events. It has to be considered that asthma is more frequent in mite‐sensitized patients, where it is more difficult to assess the exposure and to evaluate outcomes (Table ). During the last decade, some SLIT studies were designed specifically for asthma, taking into account the exacerbation rate and/or the use of inhaled corticosteroids .…”

Identification of B Cell Epitopes of Blo t 13 Allergen and Cross-Reactivity with Human Adipocytes and Heart Fatty Acid Binding Proteins

“…Blo t 13 is the first HDM allergen to which a cross-reactivity with human proteins has been demonstrated; therefore, the probability that an autoreactive response to homologous proteins such as FABP3 and FABP4 could be induced during the course of an allergen immunotherapy (AIT) with HDM extract deserves evaluation. In some studies, immunologic diseases such as autoimmune diseases are considered a relative contraindication for AIT [31]. However, in a large nationwide study analyzing data over a decade, patients treated with AIT had lower incidence of autoimmunity compared to those on conventional treatment (nasal steroids and oral antihistamines) [32].…”

Allergen immunotherapy for asthma: Looking “Back to the Future”

“…Moreover, the recently published EAACI Guidelines on Allergen Immunotherapy for HDM-driven allergic asthma provided evidence-based practical recommendations on how optimally applying AIT in asthma. 8 Despite all the above, real-life data reveal that the use of AIT in asthma is at present very limited and evidence is still lacking on the role of AIT on several relevant asthma endpoints, such as the disease control and progression. Furthermore, the reported beneficial effect of AIT in childhood asthma has been recently questioned, based on studies performed in children not treated according to GINA guidelines.…”

“…As secondary outcomes, SCIT also improved quality of life and small airways function (assessed through FEF 25%‐75% values), as well as decreased specific airway hyperreactivity. Moreover, the recently published EAACI Guidelines on Allergen Immunotherapy for HDM‐driven allergic asthma provided evidence‐based practical recommendations on how optimally applying AIT in asthma …”