Frew.qxp 7/8/09 4:07 pm Page 48
Allergic Rhinoconjunctivitis
Conclusions courses or lower doses. In the longer term, there is a need for more
SIT is a useful treatment for allergic rhinoconjunctivitis that offers a general immunomodulatory therapies, which would be particularly
logical approach to dealing with the underlying immunological advantageous for those patients sensitised to multiple allergens. ■
problem rather than simply suppressing the symptoms. When used
appropriately, SIT is effective and acceptably safe, but care is needed
Anthony J Frew is a Professor of Allergy and
to recognise and treat adverse reactions. Despite a century of use, the
Respiratory Medicine at Brighton and Sussex Medical
precise mechanisms of action of SIT remain uncertain. Current School, a position he has held since 2005, and also
emphasis on the role of regulatory T cells is driving attempts to
has a busy clinical practice in allergy, respiratory
medicine and acute general medicine. His main
simplify SIT regimes and reduce the risks. Future directions in SIT
research interests are air pollution and trials of
include improvements in allergen standardisation and the use of allergen immunotherapy. He graduated from
recombinant allergens, both of which should improve the safety profile
Cambridge University in 1980 and then undertook
post-graduate training in Nottingham, Oxford, London
of SIT. In parallel, the use of adjuvants may improve the efficiency and
and Stoke-on-Trent. He trained in allergy and research at the Royal Brompton
scope of SIT. This may lead to increased efficacy in those who already Hospital and in Vancouver, Canada, before joining the academic respiratory group
respond, the achievement of some efficacy in non-responders and the
in Southampton in 1992.
attainment of current levels of efficacy and durability with shorter
1. Freeman J, Vaccination against hay fever: report of results more, Allergy, 2006;61:796–807. testing: 1990–2001, J Allergy Clin Immunol, 2004:113:1129–36.
during the first three years, Lancet, 1914;1:1178. 6. Frew AJ, Powell RM, Corrigan CJ, Durham SR, Efficacy and 12. Wilson DR, Lima MT, Durham SR, Sublingual
2. Iliopoulos O, Proud D, Adkinson NF, et al., Effects of safety of specific immunotherapy with SQ allergen extract immunotherapy for allergic rhinitis: systematic review and
immunotherapy on the early, late and rechallenge nasal in treatment-resistant seasonal allergic rhinoconjunctivitis, meta-analysis, Allergy, 2005;60:4–12.
reaction to provocation with allergen: changes in J Allergy Clin Immunol, 2006;117:319–25. 13. Frew AJ, Sublingual immunotherapy, N Engl J Med,
inflammatory mediators and cells, J Allergy Clin Immunol, 7. Durham SR, Walker SM, Varga EM, et al., Long-term clinical 2008;358:2259–64.
1991;87:855–66. efficacy of grass pollen immunotherapy, N Engl J Med, 14. Jutel M, et al., Allergen-specific immunotherapy with
3. Durham SR, Ying S, Varney VA, et al., Grass pollen 1999;341:468–75. recombinant grass pollen allergens, Allergy, 2006;61:
immunotherapy inhibits allergen-induced infiltration of 8. Horak F, Manifestation of allergic rhinitis in latent 796–807.
CD4+ T-lymphocytes and eosinophils in the nasal mucosa sensitised patients. A prospective study, Eur Arch 15. Senti G, Prinz-Vavricka B, Erdmann I, et al., Intralymphatic
and increases the number of cells expressing mRNA for Otorhinolaryngol, 1985;242:242–9. allergen administration renders specific immunotherapy
interferon-gamma, J Allergy Clin Immunol, 1996;97:1356–65. 9. Niggemann B, Jacobsen L, Dreborg S, et al., Five-year shorter and safer, Allergy, 2007;62(S83):34.
4. Ebner C, Siemann U, Bohle B, et al., Immunological follow-up on the PAT study: specific immunotherapy and 16. Corrigan CJ, Kettner J, Doemer C, et al., Efficacy and safety
changes during specific immunotherapy of grass pollen long-term prevention of asthma in children, Allergy, of preseasonal-specific immunotherapy with an
allergy: reduced lymphoproliferative responses to allergen 2006;61:855–9. aluminium-adsorbed six-grass pollen allergoid, Allergy,
and shift from Th2 to Th1 in T-cell clones specific for Phl 10. Bousquet J, Lockey RF, Malling H-J, Allergen 2005;60:801–7.
p1, a major grass pollen allergen, Clin Exp Allergy, immunotherapy: therapeutic vaccines for allergic 17. Puggioni F, Durham SR, Francis JN, Monophosphoryl Lipid
1997;27:1007–15. diseases, J Allergy Clin Immunol, 1998;102:558–62. A (MPL) promotes allergen-induced immune deviation in
5. Jutel M, Akdis M, Blaser K, Akdis CA, Mechanisms of 11. Bernstein DI, Wanner M, Borish L, Liss GM, Twelve-year favour of Th1 responses, Allergy, 2005;60:678–84.
allergen specific immunotherapy -T-cell tolerance and survey of fatal reactions to allergen injections and skin
By the Same Author
Is Structured Allergy History Sufficient When Assessing Practice of Venom Immunotherapy in the United
Patients with Asthma and Rhinitis in General Practice? Kingdom: A National Audit and Review of Literature
Smith HE, Hogger C, Lallemant C, Crook D, Frew AJ, Pain, 2009;142(1–2):68–74. Diwakar L, Noorani S, Huissoon AP, Frew AJ, Krishna MT, Clin Exp Allergy,
This article provides an overview of a study on patients with
2008;38(10):1651–8.
asthma and rhinitis who are allergic, but in primary care few This article focuses on venom immunotherapy (VIT) as the only
diagnostic and management decisions are made with formal effective treatment for prevention of serious allergic reactions
allergy assessment. knowing a patient’s atopic status might be to bee and wasp stings in sensitised individuals. However,
helpful in distinguishing the cause of disease and in selecting controversies exist relating to diagnosis, indications for treatment
appropriate treatments. The study’s objective was to estimate the and treatment schedules. This article discusses current practice of
extent to which a formal allergy assessment (a structured allergy VIT in the UK to evaluate adherence to international guidelines. A
history and skin prick tests to five common aeroallergens) would study with an online questionnaire was sent to all clinicians
improve the precision of allergy diagnosis compared with a practising immunotherapy identified on the British Society of
patient’s self-report or the structured allergy history alone. Allergy Allergy and Clinical Immunology website. The study concluded
status based on the patient’s opinion and on structured allergy that skin-prick tests (SPTs) and serum venom-specific IgE (SSIgE)
history alone was compared with formal allergy assessment. were equally preferred as first-line investigations.
Assessments were validated by an independent allergy specialist
reviewing the files. Patients were given written advice specific to The article concludes that currently there is considerable variation
their allergies and followed up three months later to assess in the diagnosis and management of hymenoptera venom allergy
satisfaction, recall and effect on health and behaviour. The article in the UK. This audit has demonstrated that the current
concludes that skin-prick testing improves the accuracy of international guidelines for the diagnosis and management
assessment of allergic status based on patient opinion or a of hymenoptera venom allergy are not being followed by UK
structured allergy history alone. ■ allergy practitioners. ■
48 EUROPEAN RESPIRATORY DISEASE
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