Sublingual immunotherapy may be safe and effective for asthma and allergic rhinoconjunctivitis

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Image: PD/Pollen, a common allergen

1. Sublingual immunotherapy was shown to have high strength evidence for the use in patients with asthma, and there is moderate strength evidence for use in allergic rhinoconjunctivitis. 

2. High-quality randomized control trials are needed to answer questions of optimal dosing and length of treatment needed to show improvement of symptoms.

Sublingual immunotherapy is appealing because it is does not require injections, can be self-administered at home, and reduces the number of office visits. The use of sublingual immunotherapy to treat symptoms of asthma and allergic rhinoconjunctivitis is approved for use in Europe but not yet in the United States. This systematic review demonstrated strong evidence that the use of sublingual immunotherapy is safe and beneficial in the reduction of symptoms. As a result, this should prompt the design of randomized control trials to show if there is a difference between the uses of sublingual immunotherapy compared to our current treatment of subcutaneous immunotherapy.

While sublingual immunotherapy has shown to have moderate evidence for the treatment of asthma and allergic rhinoconjunctivitis symptoms, most studies in this review used a single allergen extract. The use of single allergen extract is in contrast to the usual presentation of patients who often have numerous unrelated allergies. Currently, sublingual immunotherapy is used “off-label” in the US using 8 or more allergen extracts. Therefore, when designing randomized control trials this information should be taken into account since multiple allergen mixes could result in a differing response.

Click to read the study in JAMA

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Image: PD/Pollen, a common allergen

1. Sublingual immunotherapy was shown to have high strength evidence for the use in patients with asthma, and there is moderate strength evidence for use in allergic rhinoconjunctivitis. 

2. High-quality randomized control trials are needed to answer questions of optimal dosing and length of treatment needed to show improvement of symptoms.

This [systematic review] study: This study included 63 studies with 5,131 patients ranging from 4 to 74 years. The primary outcomes included symptom and medication scores, quality of life, and safety. Secondary outcomes included pulmonary function tests and allergen challenge. Primary outcomes were graded using the GRADE guidelines. Eight of thirteen studies show strong evidence supporting the use of sublingual immunotherapy in asthma with a magnitude of association of 69% in 9 of the studies. Sublingual immunotherapy demonstrated a 40% improvement of symptoms in patients with asthma. Also, sublingual immunotherapy decreased medication use for allergies by 40% in 16 of 41 studies. Nine of 36 studies show moderate evidence for the use of sublingual immunotherapy for rhinitis or rhinoconjunctivitis. Safety outcomes included application site reactions. No anaphylactic reactions were reported. A meta-analysis could not be performed due to the heterogeneity of the studies included. Overall, this systematic review supports moderate strength evidence for the use of sublingual immunotherapy for allergic rhinoconjunctivits and asthma.

In sum: Sublingual immunotherapy is appealing because it is does not require injections, can be self-administered at home, and reduces the number of office visits. The use of sublingual immunotherapy to treat symptoms of asthma and allergic rhinoconjunctivitis is approved for use in Europe but not yet in the United States. This systematic review demonstrated strong evidence that the use of sublingual immunotherapy is safe and beneficial in the reduction of symptoms. As a result, this should prompt the design of randomized control trials to show if there is a difference between the uses of sublingual immunotherapy compared to our current treatment of subcutaneous immunotherapy.

While sublingual immunotherapy has shown to have moderate evidence for the treatment of asthma and allergic rhinoconjunctivitis symptoms, most studies in this review used a single allergen extract. The use of single allergen extract is in contrast to the usual presentation of patients who often have numerous unrelated allergies. Currently, sublingual immunotherapy is used “off-label” in the US using 8 or more allergen extracts. Therefore, when designing randomized control trials this information should be taken into account since multiple allergen mixes could result in a differing response.

Click to read the study in JAMA

By Brittany Hasty and Rif Rahman

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