Sublingual Immunotherapy for Allergic Rhinitis and Conjunctivitis

Giovanni Passalacqua; Valentina Garelli; Francesca Sclifò; Giorgio Walter Canonica

Immunotherapy. 2013;5(3):257-264.

Conclusion

Allergic rhinitis is a major public health concern with significant healthcare costs, also representing an independent risk factor for the development of asthma. SLIT has been consistently shown to be capable of reducing symptoms and medication use in allergic rhinitis and possibly in coexistent asthma^[70] for all the relevant allergens. In addition, due to the complex mechanism of action, SLIT profoundly modifies the immune response, thus, its effects last for many years.^[71] Finally, SLIT, as well as SCIT, can reduce the risk of asthma onset in children with allergic rhinitis. According to this evidence, SLIT is confirmed to be a viable alternative to SCIT in the treatment of allergic rhinoconjunctivitis, with a very favorable safety profile and the possibility of expanding the indications to other diseases.

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Table 1. Meta-analyses of sublingual immunotherapy.
Study (year)	Patients	Disease	Trials	Effect size on symptoms	Effect size on medications	Comment	Ref.
Calamita et al. (2006)	303 adults + children	Asthma	5 pollens 4 mite	-0.38 (p = 0.07)	-0.82 (p = 0.01)	No change in symptom score Significant reduction in medication score	[15]
Wilson et al. (2005)	959 adults + children	Rhinitis	16 pollens 6 mite	-0.42 (p = 0.002)	-0.43 (p < 0.001)	Decreased symptoms and medications for rhinitis Asthma not evaluable	[14]
Penagos et al. (2008)	484 children	Rhinitis	5 pollens 4 mite	-0.56 (p = 0.02)	-0.76 (p = 0.03)	Decreased symptoms and medications for rhinitis No subanalysis feasible	[16]
Penagos et al. (2006)	441 children	Asthma	3 pollen 3 mite	-1.42 (p = 0.02)	-1.63 (p = 0.007)	Decreased symptoms and medications for asthma	[17]
Compalati et al. (2009)	858 adults + children	Rhinitis Asthma	Mite 8 rhinitis 9 asthma	Rhinitis: -0.95; asthma: -0.95 (p = 0.02)	-1.88 (p = 0.04)	Significant effect on symptoms and drug intake for both rhinitis and asthma	[18]
Di Bona et al. (2010)	2791 adults + children	Rhinitis	19 grass	-0.32 (p < 0.0001)	-0.33 (p = 0.001)	Decreased symptoms and medications for rhinitis Greater effect in adults	[19]
Radulovic et al. (2010)	4589 adults + children	Rhinitis	23 grass 8 mite 18 other	SMD: -0.49; (p < 0.00001)	-0.32 (p < 0.001)	Similar size effect also for medications	[20]
Calderon et al. (2011)	3950 adults + children	Conjunctivitis	35 seasonal 12 perennial	SMD: -0.41; (p < 0.001)	-0.1 (p = NS)	Significant difference also for individual symptoms	[21]

NS: Not significant; SMD: Standardized mean difference.

Table 2. Large trials with sublingual immunotherapy.
Study (year)	Age range (years)	Pts (A/P)	Allergen	Duration	Dose preparation	Main positive results over placebo	Ref.
Durham et al. (2006)	18–66	569/286	Grass 3 doses	6 months	15 µg (136 pts) 150 µg (139 pts) 450 µg (294 pts) Phl p5/month Tablets	Drug score -28% (p = 0.012) Symptoms -21% (p = 0.002) only with the highest dose QoL improved. No clinical change with the two low doses	[24]
Dahl et al. (2006)	23–35	316/318	Grass	6 months	450 µg Phl p5/month Cumulative 2.7 mg Tablets	RC symptoms -30% (p = 0.001); RC drugs -38% (p = 0.001); well days -52% (p = 0.004)	[25]
Didier et al. (2007)	25–47	472/156	Grass 3 doses	6 months	240 µg (157 pt) 750 µg (155 pt) 1.2 mg (160 pt)/month Tablets	For 300 and 500 IR Total and individual symptom and drug scores (p < 0.001) RQLQ improved	[26]
Wahn et al. (2009)	4–17	139/139	Grass	8 months	600 µg major allergen/month Tablets	Rhinitis score -28% (p = 0.01) Medications -24% (p = 0.006) Medication free days (p = 0.01)	[27]
Ott et al. (2009)	20–50	142/67	Grass	5 years 4 seasons	Cumulative 1.5 mg major allergen/season	Combined score and symptom score significantly reduced since first season. Symptoms decrease from -33 to 47% (third season). No change in medication scores	[28]
Bufe et al. (2009)	5–16	126/127	Grass	6 min	450 µg Phl p5/month Tablets	Significant reduction in RC symptom score (-24%), asthma score (-64%), RC medications (-34%) and well days (+28%) All p < 0.03	[29]
Blaiss et al. (2011)	5–17	349/358	Grass	6 min	450 g Phl p5/month	Significant reduction in combined score (-26%); QoL -38%	[30]
Nelson et al. (2011)	18–63	213/225	Grass	10 min	450 µg Phl p5/month Tablets	Significant reduction in combined (-20%) and medication score (-20%)	[31]
de Bot et al. (2012)	6–18	126/125	Mite	2 years	4.06 µg Der p1/week Drops	No difference between active and placebo in all parameters	[12]