Steroids vs immunotherapy for allergic rhinitis – out with the old, in with the new

Abstract

Treatment for seasonal allergic rhinitis induced by airborne allergens can be divided into two major groups: symptom-dampening drugs, such as antihistamines and corticosteroids, and disease-modifying drugs in the form of immunotherapy. It has been speculated that depot-injection corticosteroids given once or twice a year are a safe and patient-friendly alternative to the time-consuming immunotherapy. Our data indicate otherwise.It has been estimated that 20% of the population in western societies has allergic rhinitis triggered by airborne allergens [1]. The severity of rhinitis varies greatly between individuals, ranging from mild symptoms easily alleviated with oral antihistamines to severe rhinitis with systemic impairment, which is more difficult to manage. Treatment of rhinitis is a cumulative stepwise approach, beginning with antihistamines or topical steroids and progressing to specific immunotherapy; only in rare cases should short-term treatment (<7 days) with oral corticosteroids be considered [2]. Specific immunotherapy is the only disease-modifying treatment available and therefore also the only potentially curative treatment. All other treatment modalities, including antihistamines and topical corticosteroids, are purely symptom dampening.Specific immunotherapy is available in three forms: subcutaneous immunotherapy (SCIT; the traditional treatment available for most airborne allergens); sublingual allergen tablets (SLIT tablets; currently available to treat only grass pollen-induced allergic rhinitis) and sublingual allergen droplets (SLIT-droplets), a treatment likely to be gradually replaced by SLIT tablets, and which, accordingly, will not be discussed further here. SCIT treatment consists of increasing doses of allergens, initially administered weekly, and subsequently, with increasing time spans and allergen doses until a high maintenance dose is administered every 8 weeks for 3-5 years. By contrast, SLIT tablets give a fixed allergen dose administered daily as a sublingual tablet for 3-5 years, that is, a treatment period similar to that of SCIT. The efficacy and safety of SCIT [3] and SLIT [4] have been thoroughly investigated, and both treatments provide a 50-70% decrease in symptoms and a 30-60% reduction in rescue medication score (antihistamines and steroids). Recent data on the treatment of grass pollen-induced allergic rhinitis indicate that SCIT and SLITtablet treatments are similar in terms of efficacy [5]; however, safety is an issue. SCIT treatment has involved the loss of human life, and lessons have been learned. Nevertheless, the risk of experiencing a severe adverse event is minimal when SCIT is performed by a trained specialist [6]. In comparison, SLIT-tablet treatment with grass pollen looks very promising; the treatment seems safe and tolerable for most individuals and administration does not require the same level of expert training [7]. Consequently, SLIT tablets are seemingly the better option for monotreatment of grass pollen-induced allergic rhinitis [5]. KEYWORDS Edit...