Original Article
Interventions
Physicians' experience and opinion on contraindications to allergen immunotherapy: The CONSIT survey

https://doi.org/10.1016/j.anai.2017.02.012Get rights and content

Abstract

Background

Allergen immunotherapy (AIT) is the only disease-modifying treatment in allergy but several contraindications limit its use.

Objective

To collect the outcome of using AIT in theoretically contraindicated situations in real patients in the Contraindications to Specific ImmunoTherapy (CONSIT) survey.

Methods

The CONSIT is an electronic European Academy of Allergy and Clinical Immunology survey conducted to gather the safety outcomes of patients undergoing subcutaneous, sublingual, or venom AIT and the opinions of physicians on each of 17 selected conditions: children younger than 5 years; starting AIT during pregnancy; controlled severe asthma; arrhythmias; coronary disease; cancer; autoimmune disease; bone marrow and solid organ transplantation; human immunodeficiency virus and acquired immunodeficiency syndrome; previous anaphylaxis during AIT; use of β-blockers, angiotensin-converting inhibitors, cyclosporine, and methotrexate; and inability to communicate. Safety using AIT was reported in a 3-point scale: 1, “no problems”; 2, “minor problems” (requiring only dose modifications); and 3, “major problems” (AIT not tolerated). Each physician was asked about the degree of contraindication that each condition should have: no contraindication (score 1), relative contraindication (score 2), or absolute contraindication (score 3).

Results

Five hundred twenty physicians (75% Europeans, 89% allergists) reported on approximately 45,000 patients undergoing AIT with any of these conditions. Major problems were infrequent, occurring more frequently in patients with asthma (9.9%) and with previous anaphylaxis from AIT (9.5%). Regarding opinions, experienced physicians scored a significantly lower mean for all conditions than non-experienced physicians for all routes.

Conclusion

Major problems were infrequent and experienced physicians were less likely to be restrictive in the use of AIT.

Introduction

Allergen immunotherapy (AIT) is the hallmark in the treatment of respiratory and venom allergy.1 AIT has been greatly advanced in standardization, dosage, understanding the underlying mechanisms for its clinical effects, improvement in administration routes, and widened indications2 (food allergy[3], [4], [5], [6] and atopic dermatitis7). However, clinical contraindications for AIT remain diffuse; a general consensus has not been reached among physicians; and clinical contraindications to AIT are not usually discussed in detail in current guidelines.

Most current clinical contraindications lack a strong evidence base and are based on assumptions. These contraindications refer to (1) existing comorbidities, (2) possible pharmacologic negative effects of drugs taken by the patient, (3) possible interactions of those drugs with emergency treatment of adverse reactions, and (4) a theoretical negative interaction of AIT with the immunologic background of the patient's disease.

Within the framework of the European Academy of Allergy and Clinical Immunology (EAACI) Interest Groups for Immunotherapy and Venom Immunotherapy, a task force on contraindications to AIT was created. An extensive review of the literature and worldwide guidelines on AIT was performed to evaluate clinical contraindications, and an EAACI position paper was published.8 During this process, limited information on the day-to-day experience of practitioners performing AIT was identified. Therefore, it was decided to conduct an electronic survey among EAACI members to collect first-hand information on clinical situations considered contraindications to AIT.

The use of online tools to gather information from large medical groups has been successfully used in medicine[9], [10] and in clinical allergy,[11], [12] especially at the EAACI.[13], [14], [15] Indeed, surveys on the number of adverse events during AIT in real life[16], [17], [18] provided sensitive information on this topic and the evidence generated was seriously considered.

Therefore, an electronic survey was designed to assess the opinions of EAACI members performing AIT regarding clinical contraindications to subcutaneous immunotherapy (SCIT), sublingual immunotherapy (SLIT), and venom immunotherapy (VIT) in adults and children. The level of personal experience with prescribing AIT to patients with certain medical conditions and the actual experience of the number of patients treated with AIT and VIT having those clinical conditions were examined.

Section snippets

Methods

An open invitation to take part in this e-survey was e-mailed through the EAACI's mailing list to all EAACI members. No incentives were offered to the participants. The e-survey was first launched on January 23, 2013, and 2 reminders were sent out during the following 2 weeks.

The SurveyMonkey19 online survey instrument was used, and all data were stored and protected by an enhanced security system (secure sockets layer) in a centralized database. Users with the same internet protocol could not

Results

Of 7,124 members approached (eFig 1), 631 (8.7%) responded at least to the first question; of these, 522 (7.33%) completed the questionnaire (clicked the “submit” button), leading to a “completion rate” of 82.7%. However, 2 physicians requested to be excluded from analysis. A final dataset of 520 questionnaires (7.3%) was used in the analysis.

Discussion

Allergen immunotherapy has proved its efficacy in treating allergic rhinitis,[22], [23] conjunctivitis,24 asthma,[3], [25], [26], [27], [28] and venom allergy.29 However, one of its major drawbacks, particularly SCIT, is its safety profile.[16], [17], [30] To hinder its use in certain patients and conditions, many contraindications were established with no solid evidence based. The intention of this survey was to collect information on the experience of physicians performing AIT for patients

Acknowledgments

We thank all participants for their anonymous contribution to this survey by disclosing their experience and opinion. We thank Stallergenes for supporting the advice of a medical writer. We also express our gratitude to Prof David Bernstein who generously shared with the group information concerning this survey. We thank the EAACI for its support with a grant for this project.

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  • Cited by (0)

    Disclosures: Dr Pfaar reports honoraria for consultancy and/or advisory board and/or lectures from ALK-Abelló, Allergopharma, Anergis, Allergy Therapeutics/Bencard, HAL-Allergy, LETI Pharma, Lofarma, and Stallergenes-Greer; and research grants from ALK-Abelló, Allergopharma, Allergy Therapeutics/Bencard, Circassia, HAL-Allergy, and Stallergenes-Greer. Dr Gawlik received honoraria for lectures from Astra-Zeneca, Allergopharma, and HAL-Allergy. Dr Larenas-Linnemann received honoraria for lectures from MSD, Pfizer, UCB, Astra-Zeneca, and Boehringer Ingelheim; received support for asthma guideline from GSK, Novartis, TEVA, Astra-Zeneca, and Boehringer Ingelheim; serves as the Chair Immunotherapy for the Colegio Mexicano de Inmunologia Clinica y Alergia; and is a member of the World Allergy Organization. Dr Demoly reported lecturing and serving on the board for Stallergenes-Greer and ALK; lecturing for Allergopharma; and serving as an investigator for Stallergenes-Greer and Circassia. Dr Calderon reported honoraria for lectures from ALK, Merck, Stallergenes-Greer, Allergopharma and HAL-Allergy, and honoraria as Advisor from ALK, Stallergenes-Greer and HAL-Allergy. Drs Rodríguez del Río, Pitsios, Tsoumani, Paraskevopoulos and Valovirta have no relevant financial interests to disclose.

    Funding Sources: Grants from the European Academy of Allergy and Clinical Immunology.

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