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Errata
The following errors appeared in the comparative effectiveness review, “Allergen-Specific Immunotherapy for the Treatment of Allergic Rhinoconjunctivitis and/or Asthma: Comparative Effectiveness Review.” These errors did not affect the overall conclusions of the report.
- In the Methods section, the definition of single and multiple allergen was missing. It should read:
“In this review, multiple allergen immunotherapy was defined as the use of extracts containing more than one allergen species, including cross-reacting allergens. Single allergen immunotherapy was defined by the use of a single allergen species, and not by a class of allergens.
Allergists may apply different definitions of single and multiple allergen immunotherapies to our findings. Multiple allergen immunotherapies can be defined as the use of extracts containing more than one allergen class, whereas single allergen immunotherapy can refer to the use of closely related allergens within the same class. For example, a study using a grass mix allergen (or tree mix, or 2 dust mite species) could be considered a single allergen study, whereas a multiple allergen study could use different classes of allergens, such as tree and grass.” - In Table 27 (Body of evidence for sublingual immunotherapy affecting rhinitis/rhinoconjunctivitis symptoms), the direction of change for Tseng 2008 and deBot 2011 appears as positive when these two studies, in fact, showed a negative direction of change.
- In the Results section of the executive summary, in the section regarding subcutaneous versus sublingual immunotherapy, for Key Question 1, the strength of evidence was reported as “low that subcutaneous immunotherapy is superior to sublingual immunotherapy for control of allergic rhinitis and conjunctivitis symptoms.” This was an error since the strength of evidence for this outcome is moderate as stated in the tables referring to this outcome in the full report. The error has been corrected in the report available on this page.
Again, these errors did not affect the overall conclusions of the report.
Structured Abstract
Objectives
Allergic rhinitis is highly prevalent in North America, affecting 20 to 40 percent of the population. Nearly 9 percent of Americans suffer from asthma, with more than half having evidence of atopy. This comparative effectiveness review describes the effectiveness and safety of subcutaneous immunotherapy and sublingual immunotherapy (off-label use of subcutaneous-aqueous allergens for sublingual desensitization) compared with other therapies for treatment of allergic rhinoconjunctivitis and asthma.
Data sources
We searched the MEDLINE®, Embase, LILACS, and CENTRAL databases from the beginning of each database through May 21, 2012.
Review methods
Two reviewers independently selected randomized controlled trials according to established study inclusion criteria. Disagreements were resolved by consensus. Paired reviewers assessed the risk of bias of each study and extracted details about the population, intervention(s), and outcomes of interest. The results were summarized by immunotherapy type (sublingual or subcutaneous), allergen, and outcomes. Studies exclusively enrolling children were reviewed separately. The strength of the body of evidence was graded and summarized.
Results
We included 74 references that investigated the efficacy and safety of subcutaneous immunotherapy, 60 studies that investigated the efficacy and safety of sublingual immunotherapy, and 8 studies that compared the two modes of delivery. All 142 studies were randomized controlled studies. The majority of studies were at medium risk of bias due to design choices. The strength of evidence is high that subcutaneous immunotherapy reduces asthma symptoms, rhinitis symptoms, conjunctivitis symptoms, asthma medication use, asthma plus rhinoconjunctivitis medication use, and rhinoconjunctivitis-specific quality of life. The strength of evidence is moderate that subcutaneous immunotherapy reduces rhinoconjunctivitis medication use, relative to usual care, which includes pharmacotherapy. Likewise, the strength of evidence is high that sublingual immunotherapy reduces asthma symptoms. The strength of evidence is moderate that sublingual immunotherapy reduces rhinitis/rhinoconjunctivitis symptoms, combined symptom scores, conjunctivitis symptoms, and medication useusage relative to usual care, and improves allergy-specific quality of life. In studies comparing subcutaneous with sublingual immunotherapy, strength of evidence supporting the superiority of subcutaneous immunotherapy for reducing allergic rhinitis and conjunctivitis symptoms, and the superiority of sublingual immunotherapy for reducing medication use, is low. We identified 13 pediatric studies of subcutaneous immunotherapy, 18 pediatric studies of sublingual immunotherapy, and 3 pediatric studies comparing subcutaneous and sublingual immunotherapy. The strength of evidence is moderate that subcutaneous immunotherapy reduces asthma symptoms and rhinitis symptoms in comparison to usual care. The strength of evidence is low that subcutaneous immunotherapy reduces conjunctivitis symptoms, medication scores, combined symptom-medication scores, or improves quality of life relative to usual care. The strength of evidence is high that sublingual immunotherapy reduces asthma symptoms, and moderate that it reduces rhinitis/rhinoconjunctivitis symptoms, combined asthma plus rhinitis/rhinoconjunctivitis symptoms, conjunctivitis symptoms, and decreases medication use. While local reactions were frequent with both treatment regimens, there were rare reports of anaphylaxis in the subcutaneous immunotherapy studies, and no anaphylaxis reported in the sublingual immunotherapy studies.
Conclusions
With some variation across outcomes, the overall body of evidence consistently provides moderate to high support for the effectiveness and safety of both subcutaneous and sublingual immunotherapy for the treatment of allergic rhinitis and asthma. The evidence to support the use of immunotherapy in children is somewhat weaker than the evidence supporting its use in adults. The superiority of one route of administration over the other is not known.
