Allergic rhinitis (AR) is still often trivialized, but there is no reason for this: It is a major chronic respiratory disease with high prevalence and impact on quality of life, and it is also considered a risk factor for asthma. A new study shows how the disease can affect performance. In allergen-specific immunotherapy, there are new approaches using monoclonal IgG antibodies. An expert provided insight into studies and therapy developments.
In England, A-level examinations typically take place exactly at the time of the pollen flight, introduced Prof. Dr. Martin Wagenmann, Head of Rhinology, Allergology and Endoscopic Skull Base Surgery, ENT Clinic, University Hospital Düsseldorf (D) [1]. Students who want to take A-levels on the island (A-level graduation) are therefore at higher risk of doing poorly if they are allergy sufferers, according to observational studies. In order to investigate this relationship in more detail, scientists at Lund University in Sweden initiated a study that looked specifically at the impairment of cognitive performance associated with pollen counts [2].
Cognitive function tests were performed in children and adolescents as part of the study. Patients with allergic rhinitis (n=43) and a control group (n=26) were compared within and outside the allergen season. The result: Out-of-season scores on Spatial Working Memory – a score that measures how many mistakes you make – did not differ between the allergy sufferers and the controls. However, when the pollen flies, the allergy sufferers actually made more mistakes, i.e. displayed a reduction in cognitive performance. The more pronounced the symptoms were, the longer the reaction time was. The good news is that previous studies have shown that this limitation can be largely reversed with adequate therapy.
LTRAs lose importance
The state of the art in drug therapy for allergic rhinitis is treatment with intranasal steroids. Set below and less effective are the antihistamines, either intranasally or orally administered, and oral leukotriene receptor antagonists (LTRA). The most effective therapy is considered to be the fixed combination of an intranasal antihistamine and intranasal steroid (Fig. 1). However, in a recent American update, LTRA 2020 was deleted – all other drugs remained in the same grouping [3]. The background to this are findings from data according to which neuro-psychiatric side effects of LTRA were repeatedly found in children, Prof. Wagenmann explained. “On the other hand, because the leukotriene receptor antagonists offer no advantage over the antihistamines, they have been removed from the short list of therapeutic options.”
According to Prof. Wagenmann, the central problem in the treatment of allergic rhinitis is that there are simply far too many allergy sufferers. As a specialist, it is therefore impossible to take care of all these patients, with the result that a large proportion of these people are already diagnosed and treated before an allergist or ENT specialist sees them, namely by general practitioners and pharmacists. In addition, there are the patients themselves – their participation, opinions and attitudes have a significant impact on therapy adherence. For all these groups, Prof. Wagenmann therefore recommended the use of a therapy algorithm (Fig. 2), on the basis of which – depending on the severity of the symptoms – the forms of therapy including immunotherapy can be derived [4]. “In such an algorithm, patients who say from the beginning, for example, that they want a sustained effect can also be helped to move more quickly toward immunotherapy.”
AIT with monoclonal IgG antibodies
In allergen-specific immunotherapy (AIT), the expert presented a new therapeutic approach in which patients can be injected with monoclonal IgG antibodies against the allergens themselves [5]. “The thinking behind this is that by binding these antibodies to the allergens, you can prevent cross-linking of the IgG receptors on the effector cells, so the allergic reaction can be suppressed.” The foundation for this is a phase 1 study with IgG antibodies against Bet v1 (major allergen birch). Included were 64 patients with allergic rhinitis who underwent nasal allergen provocation and skin testing. Each subject received a single subcutaneous injection with the mix of antibodies.
As a result, the antibody group showed a significantly lower response to nasal allergen provocation versus the placebo group, and skin test responses were also significantly reduced compared to placebo, with very good tolerability in each case. (Fig. 3). “It is remarkable that the effect apparently lasts for more than two months after a single injection,” Prof. Wagenmann said. This has also led to Phase 3 studies with monoclonal antibodies for birch (results are still pending), and studies are currently underway for cat.
Source: Wagenmann M: Allergology/Immunotherapy. 15th ENT Update Seminar, 11/27/2021.
Literature:
- Wagenmann M: Allergology/immunotherapy. 15th ENT Update Seminar, 11/27/2021.
- Papapostolou G, Kiotseridis H, Romberg K, et al: Cognitive dysfunction and quality of life during pollen season in children with seasonal allergic rhinitis. Pediatr Allergy Immunol 2021; 32: 67-76; doi: 10.1111/pai.13328.
- Dykewicz MS, Wallace DV, Amrol DJ, et al: Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol 2020; 146: 721-767; doi: 10.1016/j.jaci.2020.07.007.
- Hellings PW, Scadding G, Bachert C, et al: EUFOREA treatment algorithm for allergic rhinitis. Rhinology J 2020; 58: 618-622; doi: 10.4193/rhin20.376.
- Gevaert P, De Craemer J, De Ruyck N, et al: Novel antibody cocktail targeting Bet v 1 rapidly and sustainably treats birch allergy symptoms in a phase 1 study. J Allergy Clin Immunol 2022; 149: 189-199; doi: 10.1016/j.jaci.2021.05.039.
InFo PNEUMOLOGY & ALLERGOLOGY 2022; 4(3): 42-43.
