Abstrakt

The present guideline on allergen-specific immunotherapy (SIT) was established by German, Austrian and Swiss allergy societies in conjunction with other scientific and medical societies (dermatology, ear-nose-throat, pediatrics, lung and airway diseases) and a German patient support group according to criteria of the Association of the Scientific Medical Societies in Germany (AWMF). Subcutaneous immunotherapy (SCIT) induces long-term tolerance to the applied allergens after completion due to numerous immunologic effects. Regarding immunologic mechanisms of sublingual immunotherapy (SLIT), no consistent concepts exist. In case of preparations with high doses, though, similar systemic immunologic effects have been observed as with SCIT. Allergen concentrations and products for SCIT or SLIT cannot be compared at present due to their heterogeneous composition and variable assay methods of their active components. Non-modified allergens are used as aqueous or physically coupled (depot) allergen extracts; chemically modified allergens (allergoids) are used as depot extracts for SCIT. Mainly non-modified allergen extracts for SLIT are used as aqueous solutions or tablets. Results from controlled studies differ in extent and in quality, requiring product-specific evaluation of SIT. Systematic reviews demonstrate considerable heterogeneity between study results of SIT, partially explained by different subject groups, the utilized allergen products, the duration of treatment, and the therapeutic dose. Efficacy of SCIT has been demonstrated for pollen and house dust mite allergens in many controlled studies in patients with allergic rhinoconjunctivitis, and for animal dander (cat) and mold allergens (Alternaria, Cladosporium) in few studies. SCIT has been well studied in controlled asthma (according to new GINA guidelines, 2008) and intermittent and mild persisting IgE-mediated allergic asthma (according to former GINA guidelines, 2005) and is recommended as a therapeutic option besides allergen avoidance and pharmacotherapy, particularly in case of concomitant allergic rhinoconjunctivitis. Secondary preventive aspects, especially less novel allergic sensitizations and reduced development of bronchial asthma, are important reasons for an early start of SCIT during childhood and adolescence. Diagnostic allergy work-up, indication and selection of appropriate allergens for SCIT are, in general, made by a physician with allergy training within his/her specialization or carrying a certified (sub)speciality in allergy. SCIT is indicated in patients with IgE-mediated sensitizations and corresponding clinical symptoms to allergens, which do not or insufficiently permit allergen avoidance and which are available as suitable, efficacious extracts. Contraindications have to be considered on an individual basis. Injections of SCIT are administered by a physician experienced in this therapy and who is able to perform emergency treatment in case of an allergic adverse event. A preceeding patients information is mandatory and should be documented. The therapy should last 3 years. Children tolerate the SCIT well and benefit notably from its immunomodulatory effects. Severe, potentially life-threatening systemic adverse events can occur after SCIT, being very rare in case of complete adherence to safety standards. Most adverse events are mild to moderate and easily treatable. Risk factors for and results of unwanted systemic effects can effectively be minimized by training the staff members involved, adhering to safety standards and immediate emergency treatment. In case of systemic reactions due to hymenoptera (bee, wasp) venom hypersensitivity, SCIT has excellent efficacy and should be continued for at least 3 – 5 years. An extended, sometimes lifelong SCIT is necessary in some patients. Efficacy of SLIT in grass pollen-induced allergic rhinoconjunctivitis has been proven in several large-scale, controlled clinical studies. Applying other allergen sources (house dust mites, animal dander, molds), less and in part methodologically insufficient studies with contradictory results exist so far. Efficacy of SLIT in allergic bronchial asthma has not enough evidence until now. SLIT with efficacious products is an option for adults with allergic rhinoconjunctivitis due to pollen allergens, particularly if SCIT is not suitable. In case of house dust mite allergy or symptoms due to other allergen sources and allergic asthma due to inhalants, SLIT does not substitute SCIT. SLIT can be indicated in children and adolescents, if SCIT is not an option, using a preparation with proven clinical efficacy in this age group. SLIT is started by a physician experienced in the therapy of allergic diseases (see guideline wording) and who is able to perform emergency treatment in case of an allergic adverse event. According to the leaflet of the product manufacturer, the patient should be informed about the therapy, usually lasting 3 years as pre- and coseasonal or perennial regimen. During this course consultations should take place at least every 3 months. Apart from very frequently to frequently occurring dose-dependent unwanted local oral and pharyngeal symptoms, systemic reactions, mostly of mild nature, have rarely been described after SLIT. With regard to anaphylactic and other severe systemic reactions SLIT demonstrates a superior safety profile compared to SCIT. Various research fields like allergen characterization, routes of application, adjuvants, updosing regimen and preventive aspects demonstrate new developments in SIT being currently examined for clinical efficacy.

Autoreninformation

Autoren

• J. Kleine-Tebbe¹
• A. Bufe²
• C. Ebner³
• P. Eigenmann⁴
• F. Friedrichs⁵
• T. Fuchs⁶
• I. Huttegger⁷
• K. Jung⁸
• L. Klimek⁹
• M. Kopp¹⁰
• W. Lässig¹¹
• H. Merk¹²
• B. Niggemann¹³
• U. Rabe¹⁴
• J. Saloga¹⁵
• P. Schmid-Grendelmeier¹⁶
• H. Sitter¹⁷
• J.C. Virchow¹⁸
• M.

Abteilungen

• ¹ Allergie- und Asthma-Zentrum Westend, Berlin,
• ² Abteilung für experimentelle Pneumologie, Universitätsklinik Bergmannsheil, Bochum,
• ³ Ambulatorium für Allergie und klinische Immunologie, Wien, Österreich,
• ⁴ Allergologie Pédiatrique, Hôpital des Enfants, Hôpitaux Universitaires de Genève, Schweiz,
• ⁵ Praxis für Kinder- und Jugendmedizin, Laurensberg,
• ⁶ Abteilung Dermatologie und Venerologie, Universitätsmedizin Göttingen,
• ⁷ Universitätsklinik für Kinder- und Jugendheilkunde, Paracelsus Medizinische Privatuniversität, Salzburger Landeskliniken, Salzburg, Österreich,
• ⁸ Praxis für Dermatologie und Immunologie, Erfurt,
• ⁹ Zentrum für Rhinologie und Allergologie, Wiesbaden,
• ¹ 
• ⁰ Zentrum für Kinder- und Jugendmedizin, Universitätsklinikum Freiburg,
• ¹ 
• ¹ Klinik für Kinder- und Jugendmedizin, Krankenhaus St. Elisabeth und St. Barbara, Halle/Saale,
• ¹ 
• ² Universitätshautklinik, Rheinisch-Westfälische Technische Hochschule, Aachen,
• ¹ 
• ³ Pädiatrische Allergologie und Pneumologie, Hedwig-von-Rittberg-Zentrum, DRK-Kliniken Westend, Berlin,
• ¹ 
• ⁴ Abteilung Pneumologie, Klinik III, Johanniterkrankenhaus im Flämig, Treuenbrietzen,
• ¹ 
• ⁵ Universitätshautklinik, Johannes-Gutenberg-Universität, Mainz,
• ¹ 
• ⁶ Allergiestation, Dermatologische Universitätsklinik, Zürich, Schweiz,
• ¹ 
• ⁷ Institut für theoretische Chirurgie, Universität Marburg,
• ¹ 
• ⁸ Abteilung Pneumologie, Klinik und Poliklinik für Innere Medizin, Universität Rostock,
• ¹ 
• ⁹ Hals-Nasen-Ohren-Klinik, Universitätsklinikum Düsseldorf,
• ² 
• ⁰ Klinik für Dermatologie, Venerologie und Allergologie, Medizinische Hochschule Hannover,
• ² 
• ¹ Allergie-Centrum Charité, Klinik für Dermatologie, Venerologie und Allergologie, Charité – Universitätsmedizin Berlin

Adresse

PD Dr. med. J. Kleine-Tebbe
Allergie- und Asthma-Zentrum Westend
Praxis Hanf, Herold und Kleine-Tebbe
Spandauer Damm 130, Haus 9
D–14050 Berlin
Email: [email protected]

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