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Wise et al.

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medications. Lasting effect at least 2 years off treatment. Minimal harm with SLIT, greater risk for SCIT. • Value Judgments: SLIT improved patient symptoms with low risk for adverse events. • Policy Level: • ∘ Use of SLIT: grass pollen tablet, ragweed tablet, HDM tablet, tree pollen aqueous solution - Strong recommendation. • ∘ Alternaria SLIT - Recommendation. • ∘ Epithelia SLIT - Option. • ∘ Dual SLIT in biallergic patients - Recommendation. • Intervention: We recommend high-dose tablet or aqueous SLIT be administered in patients (adults and children) with SAR and/or PAR who wish to reduce their symptoms and their medication use. SLIT can be continued safely in the pregnant patient. IX.D.5. Transcutaneous/epicutaneous immunotherapy— Transcutaneous or epicutaneous immunotherapy is a noninvasive form of AIT that consists of the application of allergens to the skin. The epidermis is rich in APCs while being less vascularized potentially reducing the risk for systemic reaction. 1707,1708 To improve delivery of antigens through the stratum corneum to the immune cells of the epidermis and dermis, different techniques have been used: scarification or scratching of the skin, tape stripping, microneedle arrays, and sweat accumulation through the application of a patch. 1709 Epicutaneous immunotherapy has recently been investigated in a mouse model using nanoparticles containing an allergen encoding DNA. 1710 Records of allergen administration via the skin date back to 1926, where 29 patients with hay fever received intradermal pollen extract administrations; all benefited after only 3 doses without significant side effects. 1711 The first RCT was in 2009. To date, 4 clinical trials using this procedure have been published (Table IX.D.5) In a single-center, placebo-controlled, double-blind trial, 37 adults with positive SPT and nasal challenge to grass pollen were randomized to treatment with allergen (n = 21) or placebo patches (n = 16). 1712 Treatment was started 1 month before the 2006 pollen season. The skin was tape-stripped 6 times; patches were applied weekly for 12 weeks, and removed 48 hours later. Patients were assessed before, at the beginning of, and after the 2006 pollen season, and followed up before (n = 26) and after (n = 30) the pollen season of 2007. The primary outcome was nasal provocation test with grass extract; secondary outcomes included a rhinitis questionnaire, medication use, and adverse events. In grass immunotherapy-treated patients, nasal challenge test scores significantly decreased in the first ( p < 0.001) and second year ( p = 0.003). In placebo-treated patients, scores decreased after year 1 ( p = 0.03), but the effect diminished in year 2 ( p = 0.53). However, the improvement of nasal provocation test scores was not significantly better in the treatment vs placebo groups. Patients in the treatment arm had improvement in subjective symptom scores, both after the pollen seasons of 2006 ( p = 0.02) and 2007 ( p = 0.005). Eczema at the

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