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Compromising between European and US allergen immunotherapy schools: Discussions from GUIMIT, the Mexican immunotherapy guidelines.

ABSTRACT: Background: Allergen immunotherapy (AIT) has a longstanding history and still remains the only disease-changing treatment for allergic rhinitis and asthma. Over the years 2 different schools have developed their strategies: the United States (US) and the European. Allergen extracts available in these regions are adapted to local practice. In other parts of the world, extracts from both regions and local ones are commercialized, as in Mexico. Here, local experts developed a national AIT guideline (GUIMIT 2019) searching for compromises between both schools.

Methods: Using ADAPTE methodology for transculturizing guidelines and AGREE-II for evaluating guideline quality, GUIMIT selected 3 high-quality Main Reference Guidelines (MRGs): the European Academy of Allergy, Asthma and Immunology (EAACI) guideines, the S2k guideline of various German-speaking medical societies (2014), and the US Practice Parameters on Allergen Immunotherapy 2011. We formulated clinical questions and based responses on the fused evidence available in the MRGs, combined with local possibilities, patient's preference, and costs. We came across several issues on which the MRGs disagreed. These are presented here along with arguments of GUIMIT members to resolve them. GUIMIT (for a complete English version, Supplementary data) concluded the following.

Results: Related to the diagnosis of IgE-mediated respiratory allergy, apart from skin prick testing complementary tests (challenges, in vitro testing and molecular such as species-specific allergens) might be useful in selected cases to inform AIT composition. AIT is indicated in allergic rhinitis and suggested in allergic asthma (once controlled) and IgE-mediated atopic dermatitis. Concerning the correct subcutaneous AIT dose for compounding vials according to the US school: dosing tables and formula are given; up to 4 non-related allergens can be mixed, refraining from mixing high with low protease extracts. When using European extracts: the manufacturer's indications should be followed; in multi-allergic patients 2 simultaneous injections can be given (100% consensus); mixing is discouraged. In Mexico only allergoid tablets are available; based on doses used in all sublingual immunotherapy (SLIT) publications referenced in MRGs, GUIMIT suggests a probable effective dose related to subcutaneous immunotherapy (SCIT) might be: 50-200% of the monthly SCIT dose given daily, maximum mixing 4 allergens. Also, a table with practical suggestions on non-evidence-existing issues, developed with a simplified Delphi method, is added. Finally, dissemination and implementation of guidelines is briefly discussed, explaining how we used online tools for this in Mexico.

Conclusions: Countries where European and American AIT extracts are available should adjust AIT according to which school is followed.

SUBMITTER: Larenas-Linnemann D

PROVIDER: S-EPMC7451623 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Compromising between European and US allergen immunotherapy schools: Discussions from GUIMIT, the Mexican immunotherapy guidelines.

Larenas-Linnemann Désirée D Rodríguez-Pérez Noel N Luna-Pech Jorge A JA Rodríguez-González Mónica M Blandón-Vijil María Virginia MV Del-Río-Navarro Blanca E BE Costa-Domínguez María Del Carmen MDC Navarrete-Rodríguez Elsy Maureen EM Macouzet-Sánchez Carlos C Ortega-Martell José Antonio JA Pozo-Beltrán César Fireth CF Estrada-Cardona Alan A Arias-Cruz Alfredo A Rodríguez Galván Karen Guadalupe KG Brito-Díaz Herson H Canseco-Raymundo María Del Rosario MDR Castelán-Chávez Enrique Emanuel EE Escalante-Domínguez Alberto José AJ Gálvez-Romero José Luis JL Gómez-Vera Javier J González-Díaz Sandra Nora SN Guerrero-Núñez María Gracia Belinda MGB Hernández-Colín Dante Daniel DD Macías-Weinmann Alejandra A Mendoza-Hernández David Alejandro DA Meneses-Sánchez Néstor Alejandro NA Mogica-Martínez María Dolores MD Moncayo-Coello Carol Vivian CV Montiel-Herrera Juan Manuel JM O'Farril-Romanillos Patricia María PM Onuma-Takane Ernesto E Ortega-Cisneros Margarita M Rangel-Garza Lorena L Stone-Aguilar Héctor H Torres-Lozano Carlos C Venegas-Montoya Edna E Wakida-Kusunoki Guillermo G Partida-Gaytán Armando A López-García Aída Inés AI Macías-Robles Ana Paola AP Ambriz-Moreno María de Jesús MJ Azamar-Jácome Amyra Ali AA Beltrán-De Paz Claudia Yusdivia CY Caballero-López Chrystopherson C Fernández de Córdova-Aguirre Juan Carlos JC Fernández-Soto José Roberto JR Lozano-Sáenz José Santos JS Oyoqui-Flores José Joel JJ Osorio-Escamilla Roberto Efrain RE Ramírez-Jiménez Fernando F Rivero-Yeverino Daniela D Martínez Infante Eric E Medina-Ávalos Miguel Alejandro MA

The World Allergy Organization journal 20200821 8

<h4>Background</h4>Allergen immunotherapy (AIT) has a longstanding history and still remains the only disease-changing treatment for allergic rhinitis and asthma. Over the years 2 different schools have developed their strategies: the United States (US) and the European. Allergen extracts available in these regions are adapted to local practice. In other parts of the world, extracts from both regions and local ones are commercialized, as in Mexico. Here, local experts developed a national AIT gu ...[more]

PMID: 32884611

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Project description:ImportanceHome aeroallergen exposure is associated with increased asthma morbidity in children, yet little is known about the contribution of school aeroallergen exposures to such morbidity.ObjectiveTo evaluate the effect of school-specific aeroallergen exposures on asthma morbidity among students, adjusting for home exposures.Design, setting, and participantsThe School Inner-City Asthma Study was a prospective cohort study evaluating 284 students aged 4 to 13 years with asthma who were enrolled from 37 inner-city elementary schools in the northeastern United States between March 1, 2008, and August 31, 2013. Enrolled students underwent baseline clinical evaluations before the school year started and were then observed clinically for 1 year. During that same school year, classroom and home dust samples linked to the students were collected and analyzed for common indoor aeroallergens. Associations between school aeroallergen exposure and asthma outcomes during the school year were assessed, adjusting for home exposures.ExposuresIndoor aeroallergens, including rat, mouse, cockroach, cat, dog, and dust mites, measured in dust samples collected from inner-city schools.Main outcomes and measuresThe primary outcome was maximum days in the past 2 weeks with asthma symptoms. Secondary outcomes included well-established markers of asthma morbidity, including asthma-associated health care use and lung function, measured by forced expiratory volume in 1 second.ResultsAmong 284 students (median age, 8 years [interquartile range, 6-9 years]; 148 boys and 136 girls), exposure to mouse allergen was detected in 441 (99.5%) of 443 school dust samples, cat allergen in 420 samples (94.8%), and dog allergen in 366 samples (82.6%). Levels of mouse allergen in schools were significantly higher than in students' homes (median settled dust level, 0.90 vs 0.14 µg/g; P < .001). Exposure to higher levels of mouse allergen in school (comparing 75th with 25th percentile) was associated with increased odds of having an asthma symptom day (odds ratio, 1.27; 95% CI, 1.05-1.54; P = .02) and 4.0 percentage points lower predicted forced expiratory volume in 1 second (95% CI, -6.6 to -1.5; P = .002). This effect was independent of allergic sensitization. None of the other indoor aeroallergens were associated with worsening asthma outcomes.Conclusions and relevanceIn this study of inner-city students with asthma, exposure to mouse allergen in schools was associated with increased asthma symptoms and decreased lung function. These findings demonstrate that the school environment is an important contributor to childhood asthma morbidity. Future school-based environmental interventions may be beneficial for this important public health problem.

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Compromising between European and US allergen immunotherapy schools: Discussions from GUIMIT, the Mexican immunotherapy guidelines.

Publications

Compromising between European and US allergen immunotherapy schools: Discussions from GUIMIT, the Mexican immunotherapy guidelines.

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