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特异性免疫治疗主要包括皮下免疫治疗(SCIT)和舌下免疫治疗(SLIT),经全世界各国医生临床研究表明是安全的。它的不良反应主要是过敏反应,常见为局部表现,但严重全身性不良反应可以威胁患者生命甚至死亡。不良反应常见于剂量递增阶段,SCIT注射后短时间内出现手心和脚底烧灼感、痒感和热感,全身荨麻疹是严重全身不良反应的前驱症状,应立即肌注或静注抗阻胺药,出现低血压症状立即肌注肾上腺素;在治疗前与患者做好沟通,遵守其说明书的要求,注意其危险因素,同时在治疗早期联合药物治疗控制患者过敏性疾病的症状,可以有效减少免疫治疗的不良反应。     

Role of sublingual immunotherapy in the treatment of asthma: An updated systematic review

Background

The purpose of the systematic review is to evaluate the efficacy and safety of sublingual immunotherapy (SLIT) for the treatment of allergic asthma.

Methods

PubMed, Embase, and CENTRAL databases were searched, updating an earlier review (January 1, 2005 through May 8, 2017). Randomized, controlled studies (RCTs) were included, which reported one of the prespecified outcomes: asthma symptoms measured by control composite scores; quality of life; medication use; pulmonary physiology; and health‐care utilization. For safety outcomes, RCTs and observational studies were included. Two independent reviewers extracted data, assessed risk of bias, and graded strength of evidence (SOE) for each outcome.

Results

Fourteen RCTs (n = 2585) assessed the efficacy of SLIT for asthma. The RCTs utilized house dust mite (HDM), birch, or grass allergen. SLIT improved asthma symptoms (high SOE), decreased use of long‐term control medication, and improved forced expiratory volume in 1 second (FEV₁) (moderate SOE). SLIT may decrease quick‐relief medication use, and improve disease‐specific quality of life (low SOE). For safety, 20 RCTs and 10 observational studies (n = 3621) were identified. Local (risk differences ranged from ?0.03 to +0.765) and systemic allergic reactions (risk differences ranged from ?0.03 to +0.06) were a common occurrence in SLIT and control groups. Life‐threatening reactions were uncommon, with 3 cases of anaphylaxis and no deaths reported.

Conclusion

There is moderate‐to‐high strength evidence that SLIT improves allergic asthma symptoms, reduces long‐term control medication use, and improves FEV₁ based on studies of HDM, birch, and grass. SLIT rarely is associated with life‐threatening adverse events.

     

Single vs multiallergen sublingual immunotherapy in the polysensitized patient: a pilot study

Background

Sublingual immunotherapy (SLIT) has emerged as an effective and exceptionally safe method of treatment of the atopic patient. However, the optimal number of allergens that should be included in the SLIT treatment regimen for the polysensitized patient is not known and practices vary widely. This study aims to compare the efficacy of single‐allergen SLIT with pauci‐allergen vs multiallergen aqueous SLIT in polysensitized patients.

Methods

Sixteen subjects sensitized to 6+ allergens were enrolled in the study. Subjects were blinded and randomized to SLIT treatment groups that included 1 (single), 3 (pauci), or all sensitized allergens (multi). Allergens selected were those to which the patient was most sensitized and correlated with history. Primary outcomes included daily allergy medication use, weekly Rhinoconjunctivitis Symptom Score (RCSS), and the mini–Rhinoconjuncitivitis Quality of Life Questionnaire (m‐RQLQ). All metrics were measured at baseline, 6 weeks, 3 months, 6 months, and 9 months.

Results

There were significant decreases from baseline in RCSS and m‐RQLQ scores in all study groups at each interval after beginning SLIT (p < 0.05). There was no significant decrease in number of daily allergy medications used regardless of number of allergens in patient's treatment vial (p = 0.50). No significant differences emerged based on number of allergens used.

Conclusion

Single‐antigen, pauci‐antigen, and multiantigen aqueous SLIT significantly improved allergy symptoms. There was no significant difference observed in efficacy of single‐allergen SLIT vs pauci‐allergen or multi‐allergen SLIT in polysensitized patients.

     

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特异性免疫治疗(SIT)是惟一可能影响变应性疾病自然进程的治疗方式,对过敏性鼻炎、哮喘等Ⅰ型变态反应性疾病的治疗效果已得到世界卫生组织(WHO)和世界变态反应组织(WAO)的充分肯定,现结合国内外SIT的临床实践,探讨SIT适应证、禁忌证及疗效评估方法。     

舌下特异性免疫治疗对过敏性哮喘的临床疗效分析

目的探讨舌下特异性免疫治疗（SLIT）对过敏性哮喘的临床疗效。方法对57例舌下含服粉尘螨滴剂治疗的过敏性哮喘患者随访观察26周,比较患者治疗前后的症状评分、视觉模拟评分（VAS）、哮喘控制问卷（ACQ）评分、哮喘控制测试（ACT）评分、呼气峰值流速占正常预计值的百分比（PEF%）及对症治疗药物积分。结果治疗后患者日、夜间哮喘症状评分、VAS评分及对症治疗药物积分均明显降低（P〈0.05）;PEF%明显升高（P〈0.05）;ACQ评分及ACT评分均有显著改善（P〈0.05）。结论舌下特异性免疫治疗能明显改善过敏性哮喘患者的临床症状及患者自觉症状,减少患者用药量,提高患者的疾病控制水平和生活质量。     

舌下免疫治疗的免疫学机制

舌下免疫治疗(sublingual immunotherapy,SLIT)通过舌下途径给予变应原诱导变态反应性疾病患者产生变应原特异性免疫耐受,其疗效和安全性已得到广泛认同。然而,目前对SLIT确切机制的认识仍然有限。一般认为SLIT与皮下免疫治疗(subcutaneous immunotherapy,SCIT)相似,可降低患者体内特异性IgE水平并诱导产生保护性IgG4;同时能抑制患者皮肤黏膜局部炎症效应细胞的募集及活性。SLIT的另一个重要作用是将患者体内Th2型为主的免疫反应转变为Th1型反应。目前越来越多的证据显示调节性T淋巴细胞(regulatory T cell,Treg)参与变态反应性疾病的控制,虽然尚缺乏确切证据,但Treg可能在SLIT中起重要作用。更多Treg与变应原外周免疫耐受之间关系的研究,将有助于SLIT机制的进一步阐明。     

舌下含服粉尘螨滴剂治疗多重过敏的过敏性哮喘的临床评价

目的观察标准化粉尘螨滴剂舌下特异性免疫治疗(SLIT)对多重过敏的过敏性哮喘(AS)的疗效及安全性。方法收集接受规则治疗2年且随访资料完整的轻、中度AS患者141例,按皮肤点刺试验结果及患者治疗意愿,分为单一尘螨过敏免疫治疗组(单一免疫组)41例、多重过敏免疫治疗组(多重免疫组)51例和多重过敏常规治疗组(多重常规组)49例。3组均应用小至中等剂量的吸入型糖皮质激素+长效β2受体激动剂,免疫组在此基础上给予粉尘螨滴剂SLIT,进行2年的随访观察,评价疗效。结果治疗2年后,多重免疫组的症状评分、用药评分显著低于多重常规组,ACT评分显著高于多重常规组(P0.05)。治疗2年后,多重免疫组的各项指标与单一免疫组比较差异均无统计学意义(P0.05)。多重免疫组与SLIT有关的不良反应发生率为9.80%,与单一免疫组类似(9.76%)。结论标准化粉尘螨滴剂综合药物治疗多重过敏的AS患者,较常规药物更能明显改善哮喘症状,减少药物使用,提高哮喘控制水平,可达到单一过敏患者的相似的治疗效果,未发生严重不良反应。     

Efficacy of sublingual immunotherapy in children with asthma and rhinitis: a double-blind, placebo-controlled study.

To evaluate the efficacy of specific sublingual immunotherapy (SLIT), we enrolled 15 children with asthma and rhinitis (7 girls, 8 boys, mean +/- SD age of 11.7 +/- 3.3) allergic to house dust mite (HDM) into a double-blind, placebo-controlled study. After a run-in period, patients were randomized to receive either placebo (n = 7) or SLIT (n = 8) with a standardized Dermatophagoides pteronyssinus (D. pteronyssinus) + Dermatophagoides farinea (D. farinea) 50/50 extract. They received increasing doses up to 100 index units of reactivity (IR) every day for 4 weeks, then 100 IR/day for another 4 weeks, followed by maintenance therapy consisting of 20 drops 2 times a week for 4 months. Efficacy was assessed at the end of 6 months of therapy according to symptom and medication scores, serum total IgE levels, results of lung function tests, methacholine provocation tests, and skin prick tests. Daily means for the asthma score and use of inhaled beta-2-mimetics decreased significantly in the SLIT group (P = 0.05, P = 0.028, respectively), whereas no such difference was observed in the placebo group. At the end of follow-up, mean daily doses of intranasal steroids needed for control of rhinitis symptoms decreased significantly in the SLIT group (P = 0.04). Baseline skin sensitivity to D. pteronyssinus and D. farinea was not significantly different between in the two groups, whereas end-point wheal diameter obtained with D. pteronyssinus extract was significantly less in the SLIT vs. the placebo group (P = 0.026). At the end of 6 months, peak expiratory flow (PEF) values in the placebo group was significantly lower than in the SLIT group (P = 0.049). Throughout the treatment period, the SLIT group was found to have less asthma exacerbations than the placebo group (P = 0.007). The provocation concentration causing a 20% drop in forced expired volume in 1 sec did not change throughout the treatment period in either groups. None of the patients reported local or systemic side effects from SLIT. Results of this study suggests that SLIT may be a useful alternative or additional therapy in the treatment of children with asthma/rhinitis due to HDM.