“Two thirds of patients forget to take their medicines,
and a third don’t feel that their medications work,” said
William E. Berger, M.D., M.B.A., a clinical professor of pediatrics
at the University of California, Irvine. “Patients basically
want a fast onset of action and long duration, prefer not to use
steroids, and want medications that are non-habit forming and that
have few adverse effects.”
“We basically have patients with a chronic disease who are
not completely happy with their present therapies, and that includes
antihistamines, decongestants, steroids and allergy immunotherapy,” he
Sublingual Immunotherapy Allergy Treatment
One of the new therapeutic paradigms discussed at the annual meeting
was sublingual immunotherapy (SLIT). SLIT is the most widely
used non-injection allergy treatment in Europe. With SLIT there
is no direct absorption of the allergen through the mucosa and
has been considered a possible alternative to allergy shots,
but, as research indicated, it does have some limitations.
“It is allergen specific so it only can be administered
for one allergen at a time, which is one of the limitations. We’re
not sure of its direct mechanism of action, but the hypothesis
is that it is absorbed into the regional lymph nodes,” Dr.
The initial dosing for a SLIT treatment is 1:1,000 dilution, and
it is placed under the tongue, kept there for two minutes and then
swallowed. For treatment of pollen allergy, it is given before
and during the season, while it is given on a continual basis for
treatment of perennial allergies.
It seems that SLIT may have some great advantages. One double-blind
placebo controlled study found that SLIT was effective, and reduced
drug consumption in patients with grass-pollen rhinitis, include
those who had mild asthma. The main advantages of SLIT is that
it is convenient to use and cost effective, but the downside is
that is has to be taken every day. Compliance is limited when medication
must be taken on a daily basis, said Dr. Berger.
Anti-IgE Allergy Treatment Therapy
Another new therapy is anti-IgE, which is a recombinant monoclonal
antibody to IgE. It inhibits binding of IgE to high affinity
IgE receptors on the surface of mast cells and basophils. The
new treatment has shown to be effective for patients with asthma
and/or seasonal allergic rhinitis. The anti-IgE drug that has
already entered the marketplace is omalizumab (Xolair), approved
for treatment of moderate-to-severe forms of allergic asthma.
Specific Immunotherapy and Anti-IgE Combination
There has also been an increased interest among medical professionals
in combining specific immunotherapy (SIT) with anti-IgE monoclonal
antibody treatment, as the two have complementary modes of action.
In a study that evaluated the effectiveness of combined SIT and
anti-IgE therapy in children and adolescents with birch and grass
allergy, combination therapy reduced the symptom load by 48 percent,
compared to SIT alone. During the grass season, SIT reduced symptoms
by 32 percent while combination therapy reduced them by 71 percent.
Second Generation Antihistamines to Treat Allergies
Second generation antihistamines are another new allergy treatment
method surfacing lately.
One of the newer medications is azelastine, an antihistamine that
is delivered as a nasal spray. It is different from other drugs
in its class in that it also exhibits anti-inflammatory activity.
It stabilizes the mast cells and reduces the triggers of inflammation.
In a recent study, which compared azelastine with oral cetirizine,
azelastine significantly improved the total nasal symptom score
(TNSS), 29.3 percent vs. 23 percent. It also began to take effect
more quickly, which is what you would expect with a nasal spray
and was associated with an improved quality of life.
Another new nasal antihistamine second generation nasal spray in
development is Olopatadine, which is currently available as eye
drops. It is non-sedating, it has anti-inflammatory activity
and will have value in treating allergic inflammation, symptoms
of allergic rhinitis.
In a study that evaluated the effect of olopatadine on human nasal
epithelial cells, the medication significantly inhibited histamine-stimulated
IL-8 in a dose dependent manner. When studied in patients with
seasonal allergic rhinitis, olopatadine significantly reduced TNSS,
as compared to placebo, from 90 minutes after taking the drug to
12 hours afterwards.
Ciclesonide, a new inhaled corticosteroid nasal spray, has also
shown to be effective in the treatment of seasonal allergic rhinitis.
The parent compound is converted locally in airways by esterases
to produce the active metabolite desisobutyrl-ciclesonide (DES-CIC),
said Dr. Berger, and it only works in area of respiratory mucosa.
DES-CIC is 99 percent protein bound and metabolized by the liver,
causing little unwanted systemic interaction. Its effects are experienced
primarily in the respiratory system. A randomized, double-blind
placebo-controlled study found that TNSS changes were significant
for ciclesonide, compared with placebo.
“The focus of treatments coming up in the future are safety,
cost-effectiveness, improving patient compliance, as well as recognizing
and treating comorbidities,” Dr. Berger said.