xRead - September 2022

Wise et al.

Page 132

included in Table IX.D.3-1, as these achieve an Aggregate Grade of Evidence of A. • Benefit: Improvement in symptoms and decreased need for rescue medication. Decreased likelihood of progression from AR to bronchial asthma. Persistent benefit for years after completion of 3 to 5 years of SCIT. • Harm: Inconvenience of multiple visits to a medical facility to receive injections. Potential for systemic reactions, including anaphylaxis. • Cost: Cost for preparation of allergen extract for treatment. Cost of visits to medical facilities to receive injections. • Benefits-Harm Assessment: Benefit greater than harm for patients who cannot obtain adequate relief with symptomatic treatment and whose symptoms extend more than a few weeks each year. • Value Judgments: Patients who can obtain adequate relief of symptoms with medication must decide if the short-term increased cost and inconvenience of SCIT is compensated for by the long-term persisting clinical benefit and relief from need to take medication. Pharmacoeconomic studies suggest that in the long term, SCIT is cost effective over symptomatic therapy. • Policy Level: Strong recommendation for SCIT in patients unable to obtain adequate relief with symptomatic therapy. • Intervention: SCIT should be recommended to the AR patient who cannot obtain adequate relief from symptomatic medication for significant periods of time each year and to those who would benefit from its secondary disease-modifying effects (prevention of bronchial asthma and new sensitization), particularly children and adolescents. IX.D.4. Sublingual immunotherapy (SLIT)— SLIT is an alternative application variant of SCIT, which was first practiced over a century ago by Noon and others. 1570,1666 The first double-blind placebo-controlled trial with SLIT was not conducted until 1986 by Scadding and Brostoff 1667 in London, UK. After that, only several small trials were conducted until the beginning of the new millennium, when several “big trials” finally demonstrated the clinical efficacy and safety of SLIT. Since then, many high-quality SLIT trials have been reported. As a result, the actual evidence for SLIT appears to be at least as solid as that for SCIT. The literature on SLIT for AR/rhinoconjunctivitis is vast and several good meta-analyses and systematic reviews have been published over the past decade; the decision was made to primarily analyze results from these reviews and to complement them with findings from large randomized trials published during 2016 (Table IX.D.4-1). Efficacy in adults.: Most systematic reviews and meta-analyses show a low to moderate efficacy of SLIT over placebo (SMD = 0.30 to 0.50), and this approaches high efficacy with longer treatment 1668 (greater than 12 months’ treatment SMD = 0.70). It must be considered that all patients, both those in the SLIT and the placebo arms, have open access to rescue

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.