ENT E-Update
July 2012

  In This Issue 

Sublingual Immunotherapy: An Update
About Dr. Hoy

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Dear Colleague,   

 

In this month's E-Update,  Dr. Mark J. Hoy gives an overview and update of Sublingual Immunotherapy (SLIT) - history, trends, and research studies on its use for treatment of allergic disorders.

 

You can find more information about Dr. Hoy  below and on our website. Please feel free to contact us with your feedback or questions about our E-Udate articles, your patients, or any other ENT issue at [email protected].

 

 

Paul R. Lambert, MD

Professor and Chair

Sublingual Immunotherapy:
An Update
one drop
Patients are instructed to place one drop under the tongue, three times daily
The last several decades have seen a dramatic increase in the incidence and prevalence of allergic disorders including allergic rhinitis and asthma. The reasons for this increase are not yet fully elucidated, but one interesting theory is that of the Hygiene Hypothesis. This theory, first proposed by Strachan in 1989 (ref. 1) suggests that the increased "urbanization" of our environment with its associated decreased early childhood exposure to infectious agents, symbiotic organisms and parasites suppresses a more favorable path of development of our immune systems. Consequently, a Th2 dominated response to antigens is induced in place of the more favorable Th1 mechanism. In addition, greater recognition of disease burden and greater patient education and expectations for treatment have thrust allergy to the forefront of health issues in the United States. Billions of healthcare dollars are spent annually evaluating and managing allergic disorders. The impact of work and school absenteeism adds to this economic burden in a staggering fashion.

 

Regardless of the causes for the increase in allergic disease, Otolaryngologists are uniquely situated and qualified to encounter and manage patients with allergies involving the upper and lower respiratory tract. Fortunately, the vast majority of our allergic patients can be effectively managed using just the first two of the classic triad of treatment options: environmental control measures and pharmacotherapy. But as the incidence and prevalence of allergic disorders rises, the ranks of patients ultimately requiring antigen specific immunotherapy will undoubtedly grow.

 

treatment vial
SLIT patients are provided their treatment vials from Allergy Choices, Inc.

Classical immunotherapy by the subcutaneous injection route (SCIT) recently celebrated its 100th anniversary marking the landmark work of Noone and Freeman from 1911 (ref. 2). Interestingly, the sublingual route of antigen administration (SLIT) had been suggested nearly a decade earlier by Curtis (ref. 3). SLIT was ultimately overshadowed by the successes of SCIT until 1986 when the British Committee on the Safety of Medicines issued a report documenting 26 deaths and 357 serious adverse systemic reactions associated with SCIT in the UK between 1957 and 1986. This report had the unintended consequence of generating a resurgence of interest in alternative and safer routes of administration of immunotherapy including SLIT. Interest has continued to grow as evidenced by a nearly exponential increase in published literature on the subject. A search under the topic of "sublingual immunotherapy" would have yielded a total of 21 English citations in 1999. In 2011, that number grew to 737 (ref. 8).

Hoy & Oyer
Dr. Hoy assists resident physician, Dr. Sam Oyer  in evaluating an allergy patient.

Most studies examining the efficacy and safety of SLIT originate in Europe where freedom from regulatory and insurance company oversight makes such study and the practice of SLIT easier. Recent studies by Marogna et al (ref. 5) and Di Bona (ref. 6) have clearly demonstrated SLIT with grass allergens as effective and safe in patients with seasonal allergic rhinitis compared to placebo. Further, a 4-5 year duration of treatment has proved most beneficial and mirrors the duration of treatment generally recommended for SCIT.

 

Perhaps the most compelling data to date supporting the efficacy and safety of SLIT in adults and children comes form the Cochrane Collaborative Review of SLIT for allergic rhinitis (ref. 7). This review meta-analyzed 49 randomized, double blinded, placebo controlled trials of SLIT in adults and children including 2333 SLIT and 2256 placebo participants. Overall, a significant reduction in symptom score and medication requirements were found for the treatment group compared to placebo. Furthermore, none of the trials reported any episodes of severe reactions or anaphylaxis. The authors concluded that this updated review further reinforced the findings and conclusions of the original review of 2003 that SLIT is effective and safe for the treatment of allergic rhinitis.

 

More recently, Wise and Schlosser (ref. 8) reviewed and compared the safety, efficacy and immunologic effects of SCIT and SLIT. They concluded that, while safe and effective, the magnitude of SLIT efficacy versus SCIT is undetermined. Further, they point out that relatively few randomized trials have examined multi-antigen therapy which is commonly employed by practitioners of SLIT and that more study in this regard is necessary.

 

Studies cited herein and the 57 clinical trials presently ongoing in the US and Europe continue to provide data that supports SLIT as an efficacious and safe option for treating patients not well controlled with environmental controls and pharmacotherapy. Additionally, such data continues to be used by organized efforts at local and national levels to have SLIT recognized by insurance companies as an acceptable, reasonable and reimbursable service.

 
Mark J. Hoy, M.D.

Assistant Professor, Otolaryngology - Head & Neck Surgery

References:

  1. Strachan DP (Nov 1989) "Hayfever, Hygiene and Household Size". BMJ 299 (6710): 1259-60.
  2. Committee on Safety of Medicines. "CSM Update: Desensitizing Vaccines", BMJ 1986;293:948.
  3. Noone, Freeman et al "Prophylactic Inoculation Against Hayfever". Int Arch Allergy Appl Immunol 4 (4):285-288.
  4. Curtis, HH. (1900) "The Immunizing Cure of Hayfever" Med News (NY); 77:16-18.
  5. M. Marogna, et al "Long lasting Effects of Sublingual Immunotherapy according to it Duration: A 15 year Prospective Study" J Allergy Clin Immunol 2010;126:969-75.
  6. D. Di Bona et al "Efficacy of Sublingual Immunotherapy with Grass Allergens for Seasonal Allergic Rhinitis: A Systematic Review and Meta-analysis" J Allergy Clin Immunol 2010;126:558-66.
  7. Radulovic S, Calderon MA, Wilson D, Durham S       "Sublingual Immunotherapy for Allergic Rhinitis (Review)". The Cochrane Library 2011, Issue 2.
  8. Wise SK, Schlosser RJ "Subcutaneous and Sublingual Immunotherapy for Allergic Rhinitis: What is the Evidence?" Am J Rhinol Allergy 26, 18-22, 2012.
About Dr. Hoy... 
Mark J. Hoy, MD
 
Mark J. Hoy, MD

Assistant Professor

Director, General Otolaryngology & Allergy

 

  MD: Temple University

Residency: University of Louisville

Special interest: Pediatric and adult general otolaryngology, medical and surgical treatment of sinus disorders and allergy

 

Medical University of South Carolina Department of Otolaryngology - Head & Neck Surgery

135 Rutledge Avenue, MSC 550, Charleston, SC 29425-5500 | Phone: 843.792.8299 | Website: ENT.musc.edu | � 2012