Professore di Pediatria - 70° Congresso Italiano di Pediatriacongresso2014.sip.it/dia/7840.pdf · SLIT sublingual immunotherapy for the treatment respiratory allergies and IgE mediated

Giovanni B Pajno

Professore di Pediatria

Dipartimento di Pediatria – UOC DI PEDIATRIA

UOS Allergologia Pediatrica

Policlinico Universitario Messina

IMMUNOTERAPIE

The main routes and forms of immunotherapy. Due to the complexity of IgE mediated disorders the

triad could be considered as complementary therapy. Thus SCIT, SLIT and OIT could be used in

various combination and timing in order to optimize both adherence to treatment and therapeutics

effect.

SCIT subcutaneous immunotherapy for the treatment of allergic asthma and allergic rhinitis.

SLIT sublingual immunotherapy for the treatment respiratory allergies and IgE mediated food allergies.

OIT oral immunotherapy for the active treatment of IgE mediated food allergy.

On the horizon: the treatment of extrinsic form IgE mediated atopic dermatitis.

THE IMMUNOTHERAPY’S TRIAD

SCIT

SLIT OIT

FDA Committee Votes to Approve SLIT Treatments Last month, the Allergenic Products Advisory Committee (APAC) of the Food and

Drug Administration (FDA) met and voted that the available safety and efficacy

data support approval of two sublingual allergy immunotherapy (AIT) products.

One is a grass pollen AIT tablet developed by Stallergenes and the other is

Merck’s grass pollen AIT tablet. The APAC voted 9-1 regarding approval of the

Stallergenes tablet and 9-0 regarding the Merck tablet. The FDA will need to give

final approval, but it usually follows the advice of its advisory committees.

AAAAI President Linda Cox, MD, FAAAAI, said in an email to members:

“There are no FDA-approved forms of sublingual AIT currently available here in

the United States, so these products would be the first licensed therapies of their

kind. It’s worth noting that the committee felt very strongly about including

language in the prescribing instructions for both products that recommended the

patient has autoinjectable epinephrine in the event of a severe allergic reaction."

Dr. Cox also discusses the news in this month's President's Message.

More information, including a webcast of the meetings, is available from the FDA

website

SCIT

Efficacia della SCIT

Efficacia a lungo termine della SCIT

In età pediatrica studi di follow-up hanno dimostrato un

effetto di carry-over anche fino a 12 anni dopo la SCIT,

anche se con studi di scarsa qualità metodologica.

Calvo M, et al. J Investig Allergol ClinImmunol 1994;

Cools M, et al. Allergy 2000;

Reinhold M, et al. Allergy 2002;

Eng PA, et al. Allergy 2006;

Tabar AI, et al. JACI 2011

In 13 trials, 920 children received SCIT or usual care;

In 18 studies, 1583 children received SLIT or usual care;

3 studies compared SCIT with SLIT head-to-head in 135

children.

The Cochrane Library 2010

Matricardi PM, et al. Subcutaneous immunotherapy and pharmacotherapy in

seasonal allergic rhinitis: A comparison based on meta-analyses. JACI 2011

SLIT

Calderon MA et al, JACI 2011

SLIT

Efficacia e sicurezza della SCIT e della SLIT per il

trattamento dell’asma bronchiale allergico e della

rinite allergica

1. L’effetto dell’ITS è duraturo dopo la

sospensione?

2. L’ITS è in grado di prevenire le nuove

allergie nei bambini monosensibili?

3. L’ITS è in grado di prevenire l’asma nei

bambini con rinite?

Durham S.R. et al.

Long-Term Clinical Efficacy of Grass-Pollen Immunotherapy.

N Eng J Med 1999; 341: 468-475

Initial Trial Current Trial

Figure 1. Percentage of children in the immunotherapy and control groups who

developed asthma after 3 years, in the 3 available trials. In the study by Marogna et

al,37 the development of persistent asthma was assessed

Specific immunotherapy: beyond the clinical scores

Passalacqua G

Annals of Allergy 2011;107:401-406

Clinical

Pathological

Pysiological

Response to

treatment

Prognostic

factors

Clin

ically o

bserv

ed

ch

ara

cte

risti

cs

Increasing post-natal age

Birth

S

L

I

T Hampering

the progression and

worsening of IgE

mediated disorders

Allergens

Exposure

Food Allergens

Inhalant Allergens

TH2 polarized

Immunity

Persistent Wheeze

Atopic Dermatitis

Hay Fever

Food Allergy

Persistent

Allergic

Diseases

J Allergy Clin Immunol 2007;119:796-801.

G.B. Pajno

OIT

OIT

Schematic representation of the putative mechanisms of action of oral

immunotherapy (OIT), with the various pathways that Treg cells can exert on cells

of the innate and adaptive immune systems, leading to suppression of a variety of

effector cell functions. OIT works primarily through allergen activation of

dendritic cells (DC) in the gut mucosa, resulting in effector cell modulation.

( Adapted with permission of Akdis CA).

Post desensitization strategy

and follow-up

The issue of “ad libitum” diet

Nowadays seems that to consume food (s) “ad

libitum” to maintain tolerance is not required

and a more flexible maintenance regimen is

possible at least for children successfully

desensitized with CM.

CONCLUSIONI

•La SCIT e la SLIT sono efficaci e sicure

per il trattamento della rinite allergica

e dell’asma allergico in età pediatrica.

•Auspicabile l’intervento terapeutico

precoce anche prima dei cinque anni:

con la SLIT.

•Le Immunoterapie rappresentano

l’unico trattamento eziologico delle

allergie IgE mediate inclusa l’allergia

alimentare.