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Specific Immunotherapy
Outcome assessment, duration of treatment, dosage

The outcome (success) of specific immunotherapy continues to be assessed in terms of relief of clinical symptoms and reduced consumption of medications used for symptomatic relief.

Outcome assessment and duration of treatment

There is currently no generally recognised and validated (checked for reproducibility) objectifiable in-vivo or in-vitro test to assess the outcome of SIT. Recent SIT studies have commonly determined IgG titres, with an increase in IgG4 antibodies indicating normalisation of the immune response and an increase in allergen-specific IgG1 reflecting the immunogenic activity of the product used [1]. However, there is a lack of studies showing exact correlations with clinical efficacy.

The outcome (success) of specific immunotherapy continues to be assessed in terms of relief of clinical symptoms and reduced consumption of medications used for symptomatic relief (SMS = symptom-medication score). Improvement in symptoms or reduction in concomitant medication use is often seen as early as after the first year of treatment. However, current data suggest that sustained success of SIT also depends crucially on the total dose attained so that a duration of treatment of at least 3-5 years is recommended [2;3;4].

Dosage

Apart from the duration of treatment, the outcome of SIT also depends to a great extent on the level of allergen content per individual dose administered. Efficacy of SIT depends on the optimal therapeutic dose of each clinically relevant allergen [4]. This conclusion is suggested by analyses of numerous controlled trials. Some of these studies are mentioned in the section on subcutaneous immunotherapy. Experimental studies of the mechanism of action of specific immunotherapy also suggest that the desired TH2-to-TH1 switch is only achieved by high-dose SIT. High-dose SIT can only be given if the administered allergens are well tolerated. The development of hypoallergenic SIT products like allergoids which retain Tcell reactivity and can be used at high dose will permit safer but more effective application of SIT [5].

However, the level of the maintenance dose should always be individualised for each patient. Moreover, allergenicity is different for different allergens. Thus, relatively high doses of birch and grass pollen allergens are safe to use, while high-dose SIT with cat allergens tends to be limited by side effects from their high allergenicity.

Read more on the next page: "Subcutaneous-specific immunotherapy"


REFERENCES:
[1] Jutel M, Jaeger L, Suck R, Meyer H, Fiebig H, Cromwell O. Allergen-specific immunotherapy with recombinant grass pollen allergens. J Allergy Clin Immunol 2005;116:608-13.
[2] Sennekamp J, Fuchs T, Hornung B, Kersten W, Klimek L, Leupold W, et al. Empfehlungen zur praktische Durchführung der spezifischen Immuntherapie mit Allergenen (Hyposensibilisierung). Ärzteverband Deutscher Allergologen e.V. (ÄDA). Aktualisierte Fassung 2002. Abgestimmt mit der Deutschen Gesellschaft für Allergologie und klinische Immunologie (DGAI). Allergo J 2002;11:332-8.
[3] Bousquet J, Lockey RF, Malling HJ. WHO Position Paper - Allergen immunotherapy: therapeutic vaccines for allergic diseases - Geneva, January 27-29,1997. Allergy 1998;53(Suppl.44):4-42.
[4] Kleine-Tebbe J, Bufe A, Ebner C, Eigenmann P, Friedrichs F, Fuchs T, et al. Die spezifische Immuntherapie (Hyposensibilisierung) bei IgE-vermittelten allergischen Erkrankungen. Leitlinie der Deutschen Gesellschaft für Allergologie und klinische Immunologie (DGAKI), des Ärzteverbandes Deutscher Allergologen (ÄDA), der Gesellschaft für Pädiatrische Allergologie und Umweltmedizin (GPA), der Österreichischen Gesellschaft für Allergologie und Immunologie (ÖGAI) und der Schweizerischen Gesellschaft für Allergologie und Immunologie (SGAI). Allergo J 2009;18:508-37.
[5] Rolland JM, Gardner LM, O'Hehir RE. Allergen-related approaches to immunotherapy. Pharmacol Ther 2009;121:273-84.

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