Current concepts in optimized construction of allergen immunotherapy vaccines: Practical implications.

The administration of allergen immunotherapy, since its inception more than 100 years ago, remains a therapy unique to the field of allergy and immunology. The practicing, board-certified allergist is best equipped to evaluate and manage the allergic patient. The safety and efficacy of allergen immunotherapy is well established, and both are discussed in specific chapters in this primer. The practical application of each of these within the confines of the shot room (i.e., the places or places in the medical facility where injections are administered in the allergy clinic) are addressed in this chapter. In addition, practical suggestions are provided to enhance patient adherence with allergen immunotherapy while maximizing the practice management model as services are executed. The successful implementation of each of these areas (safety, efficacy, adherence, and profit margin) will allow the practicing allergist to optimize the clinical delivery of allergen immunotherapy within communities and to the patients being served. The optimization of allergen immunotherapy (AIT) depends on four specific defining factors: 1) safety; 2) efficacy; 3) adherence; and 4) profit margin. Identifying specific problems which could impede each of these four factors is necessary to ensure the success of AIT. The practical implications of these core concepts as they apply to AIT will be explored in this chapter.

Allergen Immunotherapy in Young Children.

PURPOSE OF REVIEW: Allergen immunotherapy (AIT) has been shown to be safe and effective in children and is a unique treatment strategy that has disease-modifying and preventative effects that are not shared with other treatment options for allergic diseases. This article reviews the present knowledge and relevant updates on AIT in children. RECENT FINDINGS: Although there is no definite lower age limit for starting AIT, clear indications for AIT are established and each case should be considered individually by weighing risks and benefits. Documented short- and long-term benefits of AIT in children with allergic disease include significant improvement of symptoms and quality of life, and decreased use of medications as well as preventing the development of new allergen sensitizations and the progression of allergic rhinitis to asthma. This review provides a comprehensive overview of the present knowledge and key updates on AIT in the pediatric population.

Preference for Immunotherapy with Tablets by People with Allergic Rhinitis.

BACKGROUND: People with allergic rhinitis (AR) who are not controlled on conventional therapy can be treated using allergy immunotherapy (AIT) administered as tablets, injections or drops. In the US, the use of sublingual immunotherapy as tablets (SLIT-tablets) is limited in comparison to subcutaneous immunotherapy (SCIT). OBJECTIVE: This study investigated patients' preference for SLIT-tablets vs monthly or weekly SCIT from a US patient perspective. METHODS: We carried out a discrete choice experiment (DCE) consisting of two blocks with eight choice sets. Adults and caregivers of children with moderate-to-severe AR were included if they had not previously or were not currently receiving AIT. Three attributes were included in the design: the mode and frequency of administration, the risk of systemic reactions and the co-payment. RESULTS: A total of 724 adults with AR and 665 caregivers of children with AR were included in the study. Both adults and caregivers had a significant preference for SLIT-tablets compared with both weekly and monthly injections and for less risk of anaphylactic shock. Caregivers were more risk-averse than adults when choosing their treatment, and the younger the child, the more risk-averse the caregiver. The preference for SLIT-tablets was found for both monoallergic and polyallergic adults and caregivers of monoallergic and polyallergic children. Respondents not wanting AIT for free were more risk-averse than those indicating that they wanted AIT for free. CONCLUSION: Our findings suggest that SLIT-tablets is the preferred route of administration for AIT among adults and caregivers of children with AR.

Subcutaneous immunotherapy takes more than the time in the clinic.

OBJECTIVE: The aim of this study was to investigate the time use and both direct and indirect costs associated with subcutaneous immunotherapy (SCIT) for adults with allergic rhinitis (AR) and caregivers of children with AR in the US. METHODS: We conducted a survey to assess the retrospective time use and direct costs of SCIT. The populations surveyed included adults and caregivers of children (aged 5-17) with symptomatic AR of moderate or higher severity who are currently receiving or have previously started allergy immunotherapy (AIT). The retrospectively collected, self-reported time consumption and direct costs per clinic visit when receiving SCIT were assessed as well as the productivity loss associated with SCIT. Data were analyzed using univariate descriptive statistics. RESULTS: The study included 106 adults with AR and 191 caregivers of children with AR. We found that the median time spent per visit to the clinic was 50 min for both groups, including travel time and time at the clinic. The direct costs related to each visit included parking fees, road tolls and other costs. Adults spent $10 on parking, $9 on tolls and $10 on other costs. Finally, a median of 4 h of work was missed for both the adult patients and the adults accompanying a child. CONCLUSIONS: We found that SCIT is associated with substantial direct patient costs and productivity loss for both adults with AR and caregivers of children with AR.

Scribes, EHRs, and Workflow Efficiencies in Allergy Practices.

PURPOSE OF REVIEW: In the ever-changing healthcare system, along with new advancements in the field of allergy, the workflow for the allergist continues to evolve requiring more time spent doing non-clinical duties such as documentation and reviewing reimbursement challenges in the midst of busy clinics. The use of electronic medical records and medical scribes has emerged as tactics to aid the clinic's workflow and efficiency in the modern allergy and immunology clinic. RECENT FINDINGS: The practicing allergist can implement various additional strategies in their office workflow to maximize and synthesize good medicine and good business. Optimal use of office staff, electronic health records, and various workflow efficiencies has been shown to improve job satisfaction and reduce physician burnout. By utilizing these methods and integrating them into their practices, allergists will be able to meet the demands of the healthcare system and still provide patients with evidence based, compassionate, and cost-effective care.

Clinical aspects of sublingual immunotherapy tablets and drops.

BACKGROUND: Sublingual immunotherapy (SLIT) is administered via tablets (SLIT-T) or liquid drops (SLIT-D). In North America, currently 4 SLIT-T formulations are approved by the US Food and Drug Administration for allergy immunotherapy, and SLIT-D is an off-label use of subcutaneous immunotherapy (SCIT) extracts. OBJECTIVE: To compare and contrast aspects of SLIT-T and SLIT-D, including physical characteristics, mechanism of action, dosing, efficacy, safety, adherence, and cost. DATA SOURCES: PubMed literature review (no limits), product prescribing information, and manufacturer websites. STUDY SELECTIONS: Publications related to physical characteristics, mechanism of action, dosing, efficacy, safety, and adherence. RESULTS: Published evidence indicates that tablet and drop formulations differ in regard to physical characteristics, dosing, and strength of evidence for efficacy. Whether there are any differences in absorption and mechanism of action between the 2 formulations is currently unknown. Optimal dosing, efficacy, and safety have been established for SLIT-T. In contrast, in North America there is little support for efficacy of SLIT-D from randomized double-blind, placebo-controlled trials, and dose ranges have not been appropriately evaluated. SLIT-T treats a single allergen, whereas in the United States SLIT-D often contains multiple allergens to treat polysensitization. The safety profiles of SLIT-T and SLIT-D appear similar, and both formulations are considered safer than SCIT. CONCLUSION: Professional guidelines should make a clear distinction between SLIT-T and SLIT-D in their recommendations to minimize confusion with the umbrella term SLIT.

Perception and practice of sublingual immunotherapy among practicing allergists in the United States: A follow-up survey.

BACKGROUND: Limited information is available regarding the current perception and practice of sublingual immunotherapy (SLIT) use among US and international allergists. In light of 4 recent US Food and Drug Administration (FDA)-approved SLIT options, perceptions and practices may be changing. OBJECTIVE: To provide updated information about current allergists' practice and perception of SLIT relative to 2007 and 2011. METHODS: On behalf of the American College of Allergy, Asthma, and Immunology (ACAAI) Immunotherapy and Diagnostics Committee, an electronic survey was sent to all US and international allergists who were members of the ACAAI. Data were compared with previous surveys conducted and published in 2007 and 2011. RESULTS: Of the 305 respondents, 268 (87.9%) practiced in the United States. A total of 197 of 268 respondents (73.5%) reported experience using SLIT compared with 45 of 766 US allergists (5.9%) in 2007 and 59 of 519 US allergists (11.4%) in 2011 (P < .001). Of the 188 respondents in the United States who used SLIT in their practice, 129 (68.6%) used FDA-approved SLIT tablets only, 44 (23.4%) used both FDA-approved SLIT tablets and SLIT drops using an extract that is FDA approved for subcutaneous immunotherapy, and 15 (8.0%) reported using only SLIT drops. Limitation of only treating one allergen was the primary barrier in using SLIT among 197 of 268 respondents (73.5%). CONCLUSION: There has been a significant increase in SLIT use in the last 5 years, with 73.5% of respondents reporting experience with it. With 4 FDA-approved SLIT therapies, this likely contributes to its more widespread use. The greatest barrier to SLIT use is the limitation of only treating one allergen.