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Review
. 2007 Jan 24;2007(1):CD001936.
doi: 10.1002/14651858.CD001936.pub2.

Allergen injection immunotherapy for seasonal allergic rhinitis

M A Calderon  1 , B Alves, M Jacobson, B Hurwitz, A Sheikh, S Durham
Affiliations
Review

Allergen injection immunotherapy for seasonal allergic rhinitis

M A Calderon et al. Cochrane Database Syst Rev. .

Abstract

Background: Allergic rhinitis is the most common of the allergic diseases. Despite improved understanding of the pathophysiology of allergic rhinitis and advances in its pharmacological treatment, its prevalence has increased worldwide. For patients whose symptoms remain uncontrolled despite medical treatment, allergen injection immunotherapy is advised. An allergen-based treatment may reduce symptoms, the need for medication and modify the natural course of this disease.

Objectives: To evaluate the efficacy and safety of subcutaneous specific allergen immunotherapy, compared with placebo, for reducing symptoms and medication requirements in seasonal allergic rhinitis patients.

Search strategy: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1 2006), MEDLINE (1950 to 2006), EMBASE (1974 to 2006), Pre-MEDLINE, KOREAMED, INDMED, LILACS, PAKMEDINET, Scisearch, mRCT and the National Research Register. The date of the last search was February 2006.

Selection criteria: All studies identified by the searches were assessed to identify randomised controlled trials involving participants with symptoms of seasonal allergic rhinitis and proven allergen sensitivity, treated with subcutaneous allergen specific immunotherapy or corresponding placebo.

Data collection and analysis: Two independent authors identified all studies reporting double-blind, placebo controlled randomised trials of specific immunotherapy in patients with seasonal allergic rhinitis due to tree, grass or weed pollens. Two authors independently performed quality assessment of studies. Data from identified studies were abstracted onto a standard extraction sheet and subsequently entered into RevMan 4.2.8. Analysis was performed using the Standardised Mean Difference (SMD) method and a random-effects model; P values < 0.05 were considered statistically significant. The primary outcome measures were symptom scores, medication use, quality of life and adverse events.

Main results: We retrieved 1111 publications of which 51 satisfied our inclusion criteria. In total there were 2871 participants (1645 active, 1226 placebo), each receiving on average 18 injections. Duration of immunotherapy varied from three days to three years. Symptom score data from 15 trials were suitable for meta-analysis and showed an overall reduction in the immunotherapy group (SMD -0.73 (95% CI -0.97 to -0.50, P < 0.00001)). Medication score data from 13 trials showed an overall reduction in the immunotherapy group (SMD of -0.57 (95% CI -0.82 to -0.33, p<0.00001)). Clinical interpretation of the effect size is difficult. Adrenaline was given in 0.13% (19 of 14085 injections) of those on active treatment and in 0.01% (1 of 8278 injections) of the placebo group for treatment of adverse events. There were no fatalities.

Authors' conclusions: This review has shown that specific allergen injection immunotherapy in suitably selected patients with seasonal allergic rhinitis results in a significant reduction in symptom scores and medication use. Injection immunotherapy has a known and relatively low risk of severe adverse events. We found no long-term consequences from adverse events.

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Conflict of interest statement

The Department of Upper Respiratory Medicine, National Heart & Lung Institute, London, UK, headed by Professor Durham, has received financial support from ALK‐Abelló, Horsholm, Denmark ‐ manufacturers of allergen extracts.

Figures

1
1
1.1
1.1. Analysis
Comparison 1 Active versus placebo, Outcome 1 Symptom score.
1.2
1.2. Analysis
Comparison 1 Active versus placebo, Outcome 2 Medication score.
1.3
1.3. Analysis
Comparison 1 Active versus placebo, Outcome 3 Symptom and medication.
1.4
1.4. Analysis
Comparison 1 Active versus placebo, Outcome 4 Nasal symptom.
1.5
1.5. Analysis
Comparison 1 Active versus placebo, Outcome 5 Bronchial symptom.
1.6
1.6. Analysis
Comparison 1 Active versus placebo, Outcome 6 Ocular symptom.
1.7
1.7. Analysis
Comparison 1 Active versus placebo, Outcome 7 IgG.
1.8
1.8. Analysis
Comparison 1 Active versus placebo, Outcome 8 IgG‐4.
1.9
1.9. Analysis
Comparison 1 Active versus placebo, Outcome 9 Rhinoconjunctivitis Quality of Life score.
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References

References to studies included in this review

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Garcia Gonzalez 2002 {published data only}
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Klimek 1999a {published data only}
    1. Klimek L, Dormann D, Jarman ER, Cronwell O, Reichelmann H, Reske‐Kunz AB. Short‐term preseasonal birch pollen allergoid immunotherapy influences symptoms, specific nasal provocation and cytokine levels in nasal secretions, but not peripheral T‐cell responses, in patients with allergic rhinitis. Clinical and Experimental Allergy 1999;29:1326‐35. - PubMed
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Nakano 2002 {published data only}
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Sandstrom 2001 {published data only}
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    1. Wuthrich B, Storck H. Desensitization results in pollen allergic patients with allpyral and aqueous extracts [Desensibilisierungresulate bei Pollenallergikern mit Allpyral und mit wasserigen Extrakten]. Schweizerische Medizinische Wochenschrift. Journal Suisse de Medecine 1968;98(17):653‐8. - PubMed
Wuthrich 1977 {published data only}
    1. Wuthrich B. Immunotherapy of pollinosis: results of a 2‐year study with a new allergen preparation (novo‐helisen depot) (author's transl) [Zur spezifischen Hyposensibilisierung der Pollinosis. Ergebnisse einer zweijahrigen Studie mit einem neuen Allergen‐Praparat (Novo‐Helisen Depot)]. Schweizerische Rundsdchau fur Medizinische Praxis 1977;66(9):260‐6. - PubMed
Wuthrich 1980 {published data only}
    1. Wuthrich B, Hafner G. Pollinosis. II. Specific hyposensitization: indications and results of treatment. A study with the allergen preparation Stallergenes‐Depot in the pollen season of 1976, 1977 and 1978 [Pollinosis. II. Spezifische Hyposensibilisierung: Indikation und Behandlungsergebnisse Eine Studie mit dem Allergen‐Praparat Stallergenes‐Depot in der Pollensaison 1976, 1977 und 1978]. Schweizerische Medizinische Wochenschrift. Journal Suisse de Medecine 1980;110(8):281‐90. - PubMed
Yariktas 2002 {published data only}
    1. Yariktas M, Unlu M, Doner F, Sahin U. Comparison of Leukotriene Receptor Antagonist and Antihistamine Therapy in Seasonal Allergic Rhinitis [Mevsimsel Allerjik Rinitte Lökotrien Reseptör Antagonisti ile Antihistaminik Tedavisinin Karsilastirilmasi]. Turkish Archives of Otolaryngology 2002;40(4):252‐6.

References to studies awaiting assessment

Frank 2001 {published data only}
    1. Frank E, Williams A, Cromwell O, Atkinson P, Rajakulasingam K. Effectiveness of a pre‐seasonal allergoid immunotherapy in patients with seasonal allergic rhinitis due to grass pollen. Journal of Allergy and Clinical Immunology 2001;107(2 (Pt 2)):S260.
Szymanski 1996 {published data only}
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References to ongoing studies

Rajakulasingam 2006 {published data only}
    1. Rajakulasingam, K. Study for evaluation of safety and efficacy of a pre‐seasonal immunotherapy with an allergoid preparation of an extract of a 6 grass pollen mixture in pts with a clinically relevant grass pollen sensitivity. National Research Register 2006.

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