Intralymphatic Immunotherapy of Pollen-Induced Rhinoconjunctivitis

A Double-Blind Placebo-Controlled Trial

Terese Hylander; Olivia Larsson; Ulla Petersson-Westin; Mia Eriksson; Susanna Kumlien Georén; Ola Winqvist; Lars-Olaf Cardell


Respiratory Research. 2016;17(10) 

In This Article


Study Population and Eligibility Criteria

Study subjects were recruited amongst patients at the allergy department of Skåne University Hospital, Malmö, Sweden. Eligible patients were aged between 18 and 65 and had moderate to severe allergic birch/grass pollen-induced rhinoconjunctivitis, with symptoms including itchy nose and eyes, sneezing, nasal congestion and secretion. Allergy was verified by positive skin prick tests (SPTs), presence of serum-specific IgE antibodies towards birch and/or grass (minimum 0.35 kU/L) and positive nasal provocation tests (NPTs). Sample size was based on our previous study.[9] All eligible participants recruited during the recruitment period were enrolled in the study.

General contraindications were pregnancy or nursing, planning for pregnancy, autoimmune and collagen disease, cardiovascular disease, current persistent asthma (not intermittent asthma), upper airway disease (non-allergic sinusitis, nasal polyps), chronic obstructive and restrictive lung disease, hepatic and renal disease, cancer, previous immune- or chemotherapy, major metabolic disease, alcohol or drug abuse, mental incapability (to cope with the study) or medication with a possible side-effect of interfering with the immune response.

Study Design

This study was a parallel double-blind placebo-controlled trial, performed at the allergy department of Skåne University Hospital, Malmö, Sweden.

In total 36 patients were enrolled. Fifteen patients were recruited in the first cohort (September 2010 to September 2011) and have been previously defined.[9] Twenty-one patients were recruited in the second cohort (September 2011 to September 2012).

At the first visit (visit 1, out of pollen season, 2010 or 2011), patient eligibility was determined, SPTs and NPTs were performed and blood was sampled (further details in Additional file 1). After approximately one week, included patients were randomly allocated to receive either placebo (n = 15) or active (n = 21) intralymphatic treatment. At visits 2–4 (September 2010 – January 2011 or September 2011 – January 2012), the study subjects received three 0.1 ml injections with either placebo (Alutard, ALK Abéllo, Horsholm, Denmark) or 1000 SQ-U of standardised, aluminium hydroxide adsorbed, depot birch- or grass-pollen vaccine (Alutard, ALK Abéllo) at 3- to 4-week intervals. Based on the outcome of the allergy tests, patients were challenged and vaccinated with either birch or grass (mono-sensitised). Patients returned approximately 4 weeks after the last injection (visit 5, February 2011 or February 2012) and after the consecutive pollen season (visit 6, September 2011 or September 2012), and were evaluated as per visit 1. At visit 6, patients were additionally asked to complete a questionnaire regarding their seasonal allergic symptoms as compared to the previous pollen season. One patient did not complete the treatment, due to a non-severe adverse event (local urticaria). Emergency envelopes remained unbroken.

Randomisation, Allocation and Blinding

Participants were randomly assigned to one of two treatment groups following a simple randomisation procedure with opaque, sealed envelopes. The randomisation procedure was generated by independent biomedical assistants. The vaccines used were pre-packed, blinded and allocated according to the randomisation sequence by independent staff with no connection to the study, and thus both patients and physicians were blind. Recruitment was performed by UPW. All those involved in the study, including participants, care-givers and those assessing outcomes, were blinded after assignment to interventions.

Ethics, Consent and Permissions

The study was approved by the local ethics committee (ref. ID 2009/714) and all participants gave their written informed consent.

Intralymphatic Injections

A superficial inguinal lymph node in either the left or right groin was aseptically injected using a 25-gauge needle and ultrasound guidance. The superficial lymph nodes in the groin were identified as hypoechoic nodules with a diameter of 0.5 to 1.5 cm. The same side and, as far as possible the same node, was targeted during all three injections. Aspirations were made before the injections to avoid inadvertent intravascular administration. The peak expiratory flow (PEF) was measured before and after each injection, and all patients were monitored at the ward for no less than 60 min after each injection. The trial staff recorded all signs of local and/or systemic reactions in conjunction with the injections. The patients were subsequently asked to record and report all indications of late reactions for the following 24 h.

Trial Outcomes

Primary Outcome Measures. The primary outcome measure for the study was the change in pollen season-associated allergic symptoms. At the end of the first allergy season, after treatment had been given (visit 6), patients were asked to compare their most recent seasonal allergic symptoms with the symptoms they experienced during the pollen season prior to treatment. To this end, a visual analogue scale (VAS), ranging from 0 (unchanged symptoms, no improvement) to ten (total symptom relief, complete recovery), was used, as previously described.[11]

Secondary Outcome Measures. The secondary outcome measures of the study were 1) the safety of intralymphatic injections; 2) the change in nasal symptom score (NSS) following NPT (comparisons of NSS after NPT before treatment, after treatment and after the consecutive pollen season), as previously described;[9] 3) the change in circulating immunoglobulin (IgE and IgG4) levels (comparisons of levels before treatment, after treatment and after the consecutive pollen season); and 4) change in circulating inflammatory cells (comparisons of levels before treatment, after treatment and after the consecutive pollen season).

Additional Secondary Outcomes. Blood samples acquired at visit 6 (after the pollen season following treatment) were re-analysed following unblinding of the study, to determine alterations in IgG4 affinity. This was due to the appearance of two distinct sub-populations in the active ILIT group ("improved" and "non-improved"; see Results), which demonstrated no difference in IgG4 levels. Further analysis was consequently performed, with the aim to immunologically discriminate between these groups.

Tertiary Outcomes. As a tertiary outcome, patients were asked to report their usage of allergy medication during the pollen season immediately after ILIT, with their use in the allergy season prior to the start of treatment. Patients were asked to report a reduction in use, an increase in use or a no change in use, in terms of their use of anti-histamines, corticosteroid nasal spray and eye drops.

Methods Used for Assessment of Secondary and Additional Trial Outcomes

Methods used for the assessment of trial outcomes, including nasal provocation test, flow cytometry, and assessment of IgG4 affinity can be found in the supplementary material (Additional file 1).