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

Disclosures

Respiratory Research. 2016;17(10) 

In This Article

Results

Patients

A flow-diagram showing enrolment/screening, allocation, and patient follow-up is depicted in Fig. 1. Thirty-six participants were screened between September 2010 and September 2011. They all demonstrated positive SPT, NPT and serum IgE and were therefore enrolled in the trial. Fifteen patients were enrolled in September 2010;[9] 21 patients were enrolled in September 2011. Twenty-one patients received active ILIT (seven in the 2010 study, 14 in the 2011 study) and 15 patients received placebo (eight in the 2010 study, seven in the 2011 study). One patient receiving active ILIT demonstrated localised urticaria following the first intralymphatic injection and did not wish to further participate in the study. The demographics of participants are depicted in Table 1.

Figure 1.

Flow diagram of study cohort. ILIT: Intralymphatic immunotherapy

Primary End-point

At the end of the pollen season following treatment, subjects were asked to compare their seasonal allergic symptoms with the allergic season prior to the start of treatment. A clear improvement in relation to baseline was observed in the active ILIT group (VAS-score: 4.78 ± 0.9) (Fig. 2). This improvement was significantly more marked than the effects recorded in the placebo group (p = 0.047). However, no substantial reduction in medication could be verified in the active ILIT group (Additional file 2).

Figure 2.

Patient-recorded treatment outcome following three intralymphatic injections with active ILIT or placebo. Patients compared seasonal allergic symptoms after treatment, with symptoms prior to treatment. A VAS-score of 0 indicates no improvement, whereas a score of 10 indicates complete recovery. The black box signifies "improved" patients with a VAS-score above 5; the grey box signifies "non-improved" patients with a VAS-score below 1. Circles represent patients with an allergy towards birch pollen; triangles represent patients with an allergy towards grass pollen. *p < 0.05 using an Unpaired t test. ILIT: Intralymphatic immunotherapy

Evaluation of treatment outcome additionally resulted in the emergence of two clear sub-populations among the patients who received active ILIT: one group of 12 patients that reported a clear improvement in symptoms (VAS-score > 5) and a group of 8 patients that reported no improvement (VAS-score < 1) (Fig. 2). No patients reported a VAS-score between 1 and 5.

Secondary End-point

Safety Assessment of Intralymphatic Allergen Administration. The number of local drug-related reactions (e.g. lymph node swelling, itch and redness close to the proximity of the injection site) was higher in the active group than in the placebo group. One patient recorded mild side-effects at the first injection (localised redness and urticaria), which resulted in the individual's withdrawal from the study. However, no moderate or severe reactions were recorded (Table 2). At the follow-up visit, approximately 4 weeks after the final injection, all drug-related reactions were resolved.

Circulating Immunological Markers. No significant differences in total serum levels of IgE or IgG4 were evident in the active ILIT group or placebo group (Fig. 3). In addition there was no significant increase in CD4+CD25+FoxP3+ lymphocytes in the active ILIT or placebo group (data not shown).

Figure 3.

Levels of circulating immunoglobulins. IgE (a-b) and IgG4 (c-d) were measured before treatment, four weeks after treatment and after the consecutive pollen season in patients treated with active ILIT (a, c) or placebo (b, d). Analysis was performed using a repeated measures ANOVA. ILIT: Intralymphatic immunotherapy

Nasal Symptom Scores. No significant change in NSS following NPT could be seen in the active ILIT or placebo groups (data not shown). However, nine out of 12 patients in the active ILIT group with a VAS-score over five demonstrated a reduction of allergic symptoms upon NPT after treatment ("improved" sub-population). In contrast, seven out of eight patients in the active ILIT group with a VAS-score under 1 demonstrated no reduction of allergic symptoms upon NPT after treatment ("non-improved" sub-population) (Fig. 4a).

Figure 4.

Identification and nasal symptom scores of improved and non-improved patients. a Identification of patients reporting change in allergic symptoms 30 min after nasal allergen provocation (NPT), as well as change of seasonal allergic symptoms (VAS-score 0 = no improvement; VAS-score: 10 = complete recovery) after treatment. "Improved" patients are depicted with a black box. Non-improved patients are depicted with a grey box. b Self-reported allergic symptoms 30 min after nasal allergen provocation before treatment, four weeks after treatment and following the consecutive pollen season in improved, non-improved and placebo patients *p < 0.05 using a repeated measures ANOVA followed by a Dunnet's multiple comparison post-test. ILIT: Intralymphatic immunotherapy

Further analysis revealed that improved patients demonstrated a reduction in NSS following NPT 4 weeks after treatment (p = 0.014) and after the consecutive pollen season (p = 0.015) (Fig. 4b). These reductions were not evident in the eight non-improved patients, or in the placebo group. In contrast, an increase in NSS following NPT was evident in non-improved patients, after the consecutive pollen season (p = 0.011)

"Improved" vs "Non-improved" IgG4 Levels and IgG4 Affinity. Analysis of IgG4 levels in the nine improved and 8 non-improved patients, as well as the placebo group, revealed no changes in levels of IgG4 before treatment, after treatment and after the consecutive pollen season (Fig. 5a).

Figure 5.

Change in IgG4 levels and affinity in improved and non-improved patients. a Levels of circulating IgG4 in improved and non-improved actively treated patients, as well as placebo patients, before treatment, four weeks after treatment and following the consecutive pollen season. Analysis was performed using a repeated measures ANOVA. b IgG4 affinity in improved and non-improved patients, measured and presented as percent allergen-bound IgG4 with increasing concentrations of ammonium thiocyanate (NH4SCN). n = 3–7 *p < 0.05 using two-way ANOVA followed by Fisher's LSD

In contrast, analysis of IgG4 affinity in samples taken after the consecutive pollen season demonstrated that allergen-specific IgG4 affinity was significantly increased in improved patients (p = 0.035), as compared to non-improved patients (Fig. 5b).

In addition, a significant and positive correlation between IgG4 and both VAS score (r2 = 0.42, p = 0.04) and reduction in nasal symptom score (r2 = 0.48, p = 0.03) was found.

Tertiary End-point

No substantial reduction in medication (anti-histamines, local nasal steroids) could be verified in the active ILIT group (Additional file 2).

However, improved patients reported a reduction in the use of all allergy medication in the allergy season following treatment. This was not evidenced in the non-improved, actively treated patients. Improved patients demonstrated a stronger reduction in the use of corticosteroid nasal spray and eye drops, but not anti-histamines, as compared to the placebo group (Additional file 2).

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