Immunotherapy for allergic rhinitis - Twitter summary from #ACAAI16 meeting

Classic lecture by Dr. Nelson on 100 years on immunotherapy #ACAAI16

@docalergias: Allergy immunotherapy for AR effectively prevents asthma:

@choirdoc: Wouldn't we be celebrating discovery of a treatment to reduce risk of developing asthma by 40%? Hmm - there is one: immunotherapy. Treating parents with immunotherapy reduces risk of atopy in their future children (dose dependent, too)!

Probiotics might be able to enhance the effectiveness of immunotherapy. Dr. Nelson warns that confirmation is needed. SCIT in combination with probiotics induces regulatory B cells and 30% improvement on symptoms compared to SCIT without probiotics

@drsilge: Subcutaneous immunotherapy plus probiotics dramatically affected nasal symptoms after 6 months. Fascinating

We can safely administer grass and ragweed sublingual tabs together. Approximately $600/mo wholesale? Cetirizine and fluticasone nasal spray $6.25/mo. Value? @paallergy: That would be $7,200 per year. SCIT is much much cheaper.

Dr Durham: To check for INS spray non-compliance, ask - how many spray bottles did you use during last pollen season? The answers should be 3-4.

There is a need for more research on subtropical and tropical dust mite allergen IT.

Dr Durham explained data from several studies showing efficacy of dust mite SLIT for allergic asthma.

Effectiveness of dust mite SLIT on polisensitized asthmatics: 34% risk reduction in exacerbations - JAMA

Optimal preseason treatment for SLIT is 4 months.

Key points of SLIT vs. SCIT in this slide:

Potential mechanisms of adjuvants for allergen IT in this slide:

Possible anti-cytokines targets as adjuvants for SCIT in this slide:

Mycobacterial antigen as potential new adjuvants for SCIT:

Dr Durham reviewed his well known study of Grass SCIT showing persistent benefit 3 years after discontinuation following 3 yr course.

Grass SLIT-T was also shown to have persistent benefit for 2 years following discontinuation after a 3-year treatment period (given daily year round).

Dr Durham conducted a head to head comparison of Grass SCIT to Grass SLIT-T given over 2 years - funded by Immune Tolerance Network. Durham's SCIT vs SLIT study was placebo controlled - double blind double dummy (i.e. SLIT patients received placebo injections as well). Primary endpoint of the SLIT vs SCIT study was response to nasal allergen challenge at 3 years (2 years treatment, 1 year off treatment). 106 participants randomized - 34 SLIT-T, 36 placebo, 36 SCIT, mean skin test diameter to grass was 8 to 10 mm.

After 2 years of treatment, both SCIT and SLIT showed a significant reduction in response to nasal allergen challenge compared to placebo. After only 1 year of treatment, only SCIT was better than placebo, and in fact, was better than SLIT-T. After 2 years of treatment and 1 year of follow up - neither SCIT nor SLIT were better than placebo. Thus 2 yrs IT was not enough.

There were significant improvement in rhinitis specific QOL during grass in both SCIT and SLIT treated patients even after 1 yr treatment.

@mrathkopf: Durham, GRASS trial - 2 years of treatment is insufficient for long term tolerance for both SCIT and SLIT.

Side effect profile was different - 47% rate of mild systemic reactions in SCIT compared to 2.8% in SLIT. 2 Cases of Grade 3 SR in SCIT.

Dyspepsia occurred in 22% of SLIT treated patients - mild to moderate, no one discontinued secondary to this.

Both SLIT and SCIT reduced nasal IL-4 and IL-13 following nasal allergen challenge after 2 years of treatment. Substantial reduction in grass-specific Th2 cells shown in the SCIT-treated patients c/w placebo. SLIT reduced them as well but less so. Both SCIT and SLIT reduced late phase skin response to intradermal grass test. Grass specific IgG4 increased with both SCIT and SLIT. Both effects were more pronounced with SCIT.

Dr Durham - SCIT and SLIT are in equipoise Both are effective, SLIT is safer - ask the patient which they would prefer. Dr Durham suggests getting patient input for choice of SLIT or SCIT.

SCIT and SLIT are equally effective for seasonal outcomes but we need to treat for 3 years.

@drsilge: 2 years of SCIT OR SLIT are insufficient for lasting benefit. Dr Durham is really the only source for good data on duration.

@dranneellis: The best part of #ACAAI16 so far-spending time with immunotherapy & nasal allergen challenge guru Dr Stephen Durham!

This is a Twitter summary from #ACAAI16 meeting. The post is a part of series. See the rest here:

Several allergists did a great job posting updates on Twitter from the 2016 meeting of ACAAI, the hashtag was #ACAAI16. I used the website Symplur to review the tweets:

@docalergias @drstanfineman @dranneellis

Presentation handouts are available from the ACAAI website:

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