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Wise et al.

Page 135

• Double-blind, placebo-controlled trials with ragweed SLIT reduced the combined symptom-medication score when administered as drops 1684,1685 and as tablets, particularly at the high dose. 1686,1687 • In a small, double-blind, placebo-controlled trial of moderate-high quality, Alternaria SLIT for AR (and asthma) was shown to be effective in significantly reducing the AR combined symptom-medication score. 1688 • As for the SLIT HDM tablets, a dose-effect for a reduction in AR symptoms medication scores has been shown in 3 double-blind, placebo-controlled trials. 1064,1689 One trial demonstrated a significant difference and a symptom score reduction of 29% only in those patients with more moderate-severe disease. 799 • Moderate evidence for efficacy of dual grass pollen-HDM SLIT after 12 months of treatment and 1 year after discontinuation. 1690 • Multi-allergen SLIT has been tested in a single-center, double-blind, placebo controlled trial with Timothy grass monotherapy, Timothy grass plus 9 other pollen allergens, or placebo. Only the Timothy grass monotherapy group showed statistically significant improvement in the nasal challenge test, titrated SPT, sIgE (reduction), and IgG4 (increase). Due to a very low pollen season, there were no differences in symptom-medication scores between any of the groups. 1691 Additional study on multi-allergen SLIT is needed. Aggregate grade of evidence and recommendations.: In Table IX.D.4-2 the grade of evidence is shown and how this leads to recommendations in the decision-making concerning SLIT. • Aggregate Grade of Evidence: A (Level 1a: 10 studies; Level 1b: 3 studies; Level 2a: 11 studies; Level 3a: 1 study; Table IX.D.4-1). • Benefit: SLIT improved patient symptom scores, even as add-on treatment on top of rescue medication. SLIT reduced medication use. The effect of SLIT lasts for at least 2 years after a 3-year course of high-dose therapy. Benefit is generally higher than with single-drug pharmacotherapy; however, it is possibly somewhat less than with SCIT. Although a very recent high-quality head-to-head trial did not show a statistically significant difference in efficacy between SCIT and SLIT, this evidence is not presented here, as the publication date is outside the review period for this manuscript. 797 • Harm: Minimal harm with very frequent, but mild, local adverse events. Very rare systemic adverse events. SLIT seems to be safer than SCIT. • Cost: Intermediate, SLIT becomes cost-effective compared to pharmacotherapy after several years of administration. Data on cost of SLIT compared to SCIT is variable. • Benefits-Harm Assessment: Benefit of treatment over placebo is small, but tangible. SLIT benefit is demonstrated beyond the improvement seen with rescue

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