Subcutaneous Versus Sublingual Immunotherapy for Allergic Rhinitis and/or Asthma

Nerin Nadir Bahceciler; Nazan Cobanoglu

Disclosures

Immunotherapy. 2011;3(6):747-756. 

In This Article

Safety

Subcutaneous Immunotherapy

The adverse reactions during SCIT depends on numerous factors, including the presence and severity of asthma, dosing, specially accelerated schedules (rush immunotherapy) and high-dose allergen, new vials, treatment during peak pollen season, extensive sensitivity to the offending allergen and concomitant β-blocker use.[55]

In a review evaluating 38 SCIT studies using inhalant allergens, the rate of systemic reactions during conventional SCIT per injection ranged from 0.05 to 3.2% mostly associated during the build-up period.[56]

In a study of conventional immunotherapy with grass pollen or HDM allergens, 4.8% of patients experienced systemic reactions, of whom 84% had asthma. Reactions mostly occurred during the build-up phase with none being life threatening.[57] In addition, there were 141 nonfatal reported systemic reactions between 1981 and 2000 in a report from Europe evaluating 4600 SCIT patients.[58]

Fatal reactions (n = 46) to SCIT had been reported by the American Academy of Allergy Asthma and Immunology (AAAAI) committee on allergen standardization with an estimation of one in 2–2.5 million doses administered.[59] Two additional surveys found similar results with 17 fatalities in each. These surveys had different time spans: one was 10 years and the other was 12 years. Asthmatic patients accounted for more than 75% of deaths, 50% being on build-up therapy with an onset of symptoms within 30 min of injection.[60]

Sublingual Immunotherapy

Frequently reported side effects from SLIT include oral itching and irritation.[41,61,62] Those side effects mostly remitted with ongoing treatment. Meanwhile, patients rarely experience abdominal pain, nausea or diarrhea.[63]

In a review of 66 SLIT studies involving 4378 patients, no serious life-threatening reactions were reported. The rate of adverse events was 2.7 per 1000 doses affecting 12% of patients.[64]

A severe systemic reaction associated with SLIT was reported in a 31-year-old woman with allergic rhinitis and mild intermittent asthma treated with a mixture of allergens including alternaria, cat, dog and pollens. The patient experienced generalized pruritus, angioedema of hands and feet, dyspnea, wheezing and dizziness on the third day within minutes after administration of SLIT.[65] Another severe systemic reaction was experienced in an 11-year-old girl with asthma/allergic rhinitis receiving a mixture of HDMs in the morning and a seasonal pollen mixture in the night during the peak pollen season. Within 3 min of administering pollen drops, she developed lip swelling accompanied by chest and abdominal pain, high fever and nausea.[66] Both of these patients were treated successfully with reliever medication not requiring epinephrine. In another report, a 16-year-old girl who took six-times the normal dose of HDM SLIT developed generalized pruritus, flushing, urticaria, wheezing and hypotension within 5 min. She was treated in the intensive care unit and recovered over a 24-h period.[67] Two patients on sublingual pollen tablet experienced systemic reactions within minutes after administration and were treated with reliever medications.[55]

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