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Structured Abstract
Objectives:
To evaluate the efficacy and safety of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) in the treatment of allergic asthma.
Data Sources:
We searched PubMed, Embase, and CENTRAL through May 8, 2017.
Methods:
Two reviewers independently selected randomized controlled trials (RCTs) of the efficacy of SCIT and SLIT and RCTs, observational studies, and case series or case reports on safety. Two reviewers independently assessed the risk of bias for each study and together graded the strength of the evidence.
Results:
We identified 54 RCTs on efficacy: 31 assessed SCIT and 18 assessed SLIT and 5 on SCIT versus SLIT. We included 80 studies on safety: 26 RCTs and 18 non-RCTs for SCIT, 20 RCTs and 10 non-RCTs for SLIT and one non-RCT on SCIT versus SLIT.
SCIT reduces the use of long-term control medications [moderate strength of evidence (SOE)]. SCIT may improve quality of life, reduce the use of quick-relief medications (short-acting bronchodilators), reduce the need for systemic corticosteroids, and improve FEV1 (low SOE). There was insufficient evidence regarding the effect of SCIT on asthma symptoms and health care utilization. Local and systemic allergic reactions were frequent but infrequently required a change in treatment. We are unable to draw conclusions about whether SCIT increased risk of anaphylaxis, primarily because anaphylaxis was not directly measured (insufficient SOE). There was one case report of a death determined possibly to be caused by SCIT.
SLIT improves asthma symptoms (high SOE); decreases use of long-term control medication and improves FEV1 (moderate SOE). SLIT may decrease quick-relief medication use, and may improve quality of life (low SOE). There was insufficient evidence about the effect of SLIT on systemic corticosteroid use and health care utilization. Local and systemic allergic reactions were common but infrequently required changes in treatment. Life-threatening reactions were not commonly reported, with three case reports of anaphylaxis (insufficient SOE) and no deaths (moderate SOE) reported.
There was insufficient evidence to draw conclusions about the comparative effects of SCIT versus SLIT or for differential effects of immunotherapy based on patient age, setting of administration, or type of allergen.
Conclusions:
Overall, SLIT and SCIT were beneficial for the majority of asthma-related outcomes assessed in this report. Local and systemic allergic reactions were common but infrequently required changes in treatment. Life-threatening events (such as anaphylaxis) were reported rarely.
Contents
- Key Messages
- PREFACE
- Acknowledgements
- Technical Expert Panel
- Peer Reviewers
- Evidence Summary
- Introduction
- Methods
- Results
- Results of the Literature Search
- Key Question 1. What is the evidence for the efficacy of subcutaneous immunotherapy (SCIT) in the treatment of asthma?
- Key Question 2. What is the evidence for the safety of subcutaneous immunotherapy (SCIT) in the treatment of asthma?
- Key Question 3. What is the evidence for the efficacy of sublingual immunotherapy (SLIT), in tablet and aqueous form, for the treatment of asthma?
- Key Question 4. What is the evidence for the safety of sublingual immunotherapy (SLIT) in the treatment of asthma?
- Subcutaneous Versus Sublingual Immunotherapy
- Discussion
- Future Research Needs
- References
- Appendix A. Detailed Electronic Database Search Strategies
- Appendix B. Glossary and List of Definitions
- Appendix C. List of Excluded Articles
- Appendix D. KQ1- What is the evidence for the efficacy of subcutaneous immunotherapy (SCIT) in the treatment of asthma?
- Appendix E. KQ2- What is the evidence for the safety of subcutaneous immunotherapy (SCIT) in the treatment of asthma?
- Appendix F. KQ3- What is the evidence for the efficacy of sublingual immunotherapy (SLIT) in tablet and aqueous form, in the treatment of asthma?
- Appendix G. KQ4- What is the evidence for the safety of sublingual immunotherapy (SLIT) in tablet and aqueous form, in the treatment of asthma?
- Appendix H. Sublingual Versus Subcutaneous Immunotherapy
- Appendix I. Risk of Bias Assessment
- Appendix J. References
Suggested citation:
Lin SY, Azar A, Suarez-Cuervo C, Diette GB, Brigham E, Rice J, Ramanathan M, Gayleard J, Robinson KA. The Role of Immunotherapy in the Treatment of Asthma. Comparative Effectiveness Review No. 196 (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No.290-2015-00006-I). AHRQ Publication No. 17(18)-EHC029-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2018. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCCER196.
This report is based on research conducted by the Johns Hopkins University EPC under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00006-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians and health system leaders, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information (i.e., in the context of available resources and circumstances presented by individual patients).
This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality-enhancement tools, or reimbursement or coverage policies may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at: www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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- NLM CatalogRelated NLM Catalog Entries
- Role of sublingual immunotherapy in the treatment of asthma: An updated systematic review.[Int Forum Allergy Rhinol. 2018]Role of sublingual immunotherapy in the treatment of asthma: An updated systematic review.Lin SY, Azar A, Suarez-Cuervo C, Diette GB, Brigham E, Rice J, Ramanathan M Jr, Robinson KA. Int Forum Allergy Rhinol. 2018 Sep; 8(9):982-992. Epub 2018 Jun 9.
- Allergen-Specific Immunotherapy in the Treatment of Pediatric Asthma: A Systematic Review.[Pediatrics. 2018]Allergen-Specific Immunotherapy in the Treatment of Pediatric Asthma: A Systematic Review.Rice JL, Diette GB, Suarez-Cuervo C, Brigham EP, Lin SY, Ramanathan M Jr, Robinson KA, Azar A. Pediatrics. 2018 May; 141(5). Epub 2018 Mar 23.
- Review Allergen-specific immunotherapy for pediatric asthma and rhinoconjunctivitis: a systematic review.[Pediatrics. 2013]Review Allergen-specific immunotherapy for pediatric asthma and rhinoconjunctivitis: a systematic review.Kim JM, Lin SY, Suarez-Cuervo C, Chelladurai Y, Ramanathan M, Segal JB, Erekosima N. Pediatrics. 2013 Jun; 131(6):1155-67. Epub 2013 May 6.
- Review Effectiveness of subcutaneous versus sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis and asthma: a systematic review.[J Allergy Clin Immunol Pract. ...]Review Effectiveness of subcutaneous versus sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis and asthma: a systematic review.Chelladurai Y, Suarez-Cuervo C, Erekosima N, Kim JM, Ramanathan M, Segal JB, Lin SY. J Allergy Clin Immunol Pract. 2013 Jul-Aug; 1(4):361-9. Epub 2013 Jun 4.
- Review An evidence-based analysis of house dust mite allergen immunotherapy: a call for more rigorous clinical studies.[J Allergy Clin Immunol. 2013]Review An evidence-based analysis of house dust mite allergen immunotherapy: a call for more rigorous clinical studies.Calderon MA, Casale TB, Nelson HS, Demoly P. J Allergy Clin Immunol. 2013 Dec; 132(6):1322-36. Epub 2013 Oct 18.
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