Rhinitis, sinusitis, and upper airway disease
Efficacy of subcutaneous and sublingual immunotherapy with grass allergens for seasonal allergic rhinitis: A meta-analysis–based comparison

https://doi.org/10.1016/j.jaci.2012.08.012Get rights and content

Background

Subcutaneous (SCIT) and sublingual (SLIT) immunotherapy are the 2 most prescribed routes for administering allergen-specific immunotherapy. They were shown to be effective in control of symptoms and in reducing rescue medication use in patients with allergic diseases, but their effectiveness has to be balanced against side effects. In recent years, SLIT has been increasingly prescribed, instead of SCIT, because of improved safety and easy administration.

Objective

We assessed which route is the most effective in the treatment of patients with seasonal allergic rhinitis to grass pollen.

Methods

An indirect meta-analysis–based comparison between SCIT and SLIT was performed. Treatment efficacy was determined as the standardized mean difference (SMD) in symptom and medication scores obtained with active treatment, SCIT or SLIT, compared with placebo. Studies were included if they were double-blind randomized controlled trials comparing SCIT or SLIT with placebo. Thirty-six randomized controlled trials (3014 patients; 2768 controls) were analyzed.

Results

The overall effect size of SCIT for symptom score (SMD, −0.92; 95%CI, −1.26 to −0.58) was significantly higher than SLIT, both administered via drops (SMD, −0.25; 95% CI, −0.45 to −0.05) and tablets (SMD, −0.40; 95%CI, −0.54 to −0.27). Similar results were reported for medication score (SCIT: SMD, −0.58; 95% CI, −0.86 to −0.30. SLIT drops: SMD, −0.37; 95% CI, −0.74 to −0.00. SLIT tablets SMD, −0.30; 95% CI, −0.44 to −0.16).

Conclusions

Our results provide indirect but solid evidence that SCIT is more effective than SLIT in controlling symptoms and in reducing the use of antiallergic medications in seasonal allergic rhinoconjuntivitis to grass pollen.

Section snippets

Selection of randomized trials

The primary source of the reviewed studies was MEDLINE with the following medical subject headings: rhin* (which covers rhinitis, rhinopathy, rhinosinusitis, and rhinoconjuntivitis), grass, sublingual, subcutaneous, and immunotherapy. The computer search was supplemented with manual searches of reference lists for all available review articles, primary studies, and abstracts from conferences. We selected 38 randomized controlled trials (RCTs),9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22

Features of RCTs

The main features of the studies included in the meta-analysis are shown in Table I. The 36 RCTs9, 10, 11, 12, 13, 14, 15, 16, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47 (22 for SLIT9, 10, 11, 12, 13, 14, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 14 for SCIT15, 16, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47) included a total of 3014 patients treated with immunotherapy and 2768 controls who

Discussion

This meta-analysis of data from 36 RCTs, representing a pooled total of 3014 patients treated with immunotherapy and 2768 controls who received placebo, provides indirect evidence that, in patients with seasonal allergic rhinoconjunctivitis to grass, SCIT is more effective than SLIT in the control of symptoms and in the reduction of antiallergic medication use. The evidence has to be considered indirect because it is based on trials that compared immunotherapy with placebo, not on a direct

References (57)

  • S.R. Durham et al.

    Sublingual immunotherapy with once-daily grass allergen tablets: a randomized controlled trial in seasonal allergic rhinoconjunctivitis

    J Allergy Clin Immunol

    (2006)
  • A. Didier et al.

    Optimal dose, efficacy, and safety of once-daily sublingual immunotherapy with a 5-grass pollen tablet for seasonal allergic rhinitis

    J Allergy Clin Immunol

    (2007)
  • C. Ortolani et al.

    Grass pollen immunotherapy: a single year double-blind, placebo-controlled study in patients with grass pollen-induced asthma and rhinitis

    J Allergy Clin Immunol

    (1984)
  • J. Bousquet et al.

    Double-blind, placebo-controlled immunotherapy with mixed grass-pollen allergoids. Comparison of the safety and efficacy of two dosages of a high-molecular-weight allergoid

    J Allergy Clin Immunol

    (1990)
  • H.P. Zenner et al.

    Short-term immunotherapy: a prospective, randomized, double-blind, placebo-controlled multicenter study of molecular standardized grass and rye allergens in patients with grass pollen-induced allergic rhinitis

    J Allergy Clin Immunol

    (1997)
  • M. Jutel et al.

    Allergen-specific immunotherapy with recombinant grass pollen allergens

    J Allergy Clin Immunol

    (2005)
  • A.J. Frew et al.

    Efficacy and safety of specific immunotherapy with SQ allergen extract in treatment-resistant seasonal allergic rhinoconjunctivitis

    J Allergy Clin Immunol

    (2006)
  • R. DerSimonian et al.

    Meta-analysis in clinical trials

    Controlled Clin Trials

    (1986)
  • G.W. Canonica et al.

    Recommendations for standardization of clinical trials with Allergen Specific Immunotherapy for respiratory allergy. A statement of a World Allergy Organization (WAO) taskforce

    Allergy

    (2007)
  • J. Bousquet et al.

    Development and implementation of guidelines in allergic rhinitis – an ARIA-GA2LEN paper

    Allergy

    (2010)
  • S.R. Durham et al.

    Long-term clinical efficacy of grass-pollen immunotherapy

    N Engl J Med

    (1999)
  • T. Quirino et al.

    Sublingual versus injective immunotherapy in grass pollen allergic patients: a double blind (double dummy) study

    Clin Exp Allergy

    (1996)
  • M.S. Khinchi et al.

    Clinical efficacy of sublingual and subcutaneous birch pollen allergen-specific immunotherapy: a randomized, placebo-controlled, double-blind, double-dummy study

    Allergy

    (2004)
  • R. Mösges et al.

    Sublingual immunotherapy in pollen-induced seasonal rhinitis and conjunctivitis: a randomized controlled trial

    Acta Dermatovenerol Alp Panonica Adriat

    (2007)
  • U. Wahn et al.

    Efficacy and safety of 5-grass-pollen sublingual immunotherapy tablets in pediatric allergic rhinoconjunctivitis

    J Allergy Clin Immunol

    (2009)
  • H. Ott et al.

    Efficacy of grass pollen sublingual immunotherapy for three consecutive seasons and after cessation of treatment: the ECRIT study

    Allergy

    (2009)
  • A. Bufe et al.

    Safety and efficacy in children of an SQ-standardized grass allergen tablet for sublingual immunotherapy

    J Allergy Clin Immunol

    (2009)
  • F. Horak et al.

    Implementation of pre-seasonal sublingual immunotherapy with a five-grass pollen tablet during optimal dosage assessment

    Clin Exp Allergy

    (2009)

    • Cited by (0)

    No support was received from the pharmaceutical and diagnostic industry.

    Disclosure of potential conflict of interest: The authors declare that they have no relevant conflicts of interest.

    View full text
    Copyright © 2012 American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc. All rights reserved.