Balancing efficacy against safety in sublingual immunotherapy with inhalant allergens: what is the best approach?

Abstract

Over the last 20 years, studies and clinical trials have demonstrated efficacy, safety and cost–effectiveness of sublingual immunotherapy (SLIT) for respiratory allergic diseases. Nevertheless, it seems to be mostly used as a second-line therapeutic option, and adherence to treatment is not always optimal. Selective literature research was done in Medline and PubMed, including guidelines, position papers and Cochrane meta-analyses concerning SLIT in adult patients. The most recent reviews confirm SLIT as viable and efficacious treatment especially for allergic rhinitis, even if the optimal dosage, duration, schedule are not clearly established for most of the products. Despite an optimal safety profile, tolerability and patient-reported outcomes concerning SLIT have received poor attention until now. Recently, new tools have been specifically developed in order to investigate these aspects. Regular assessment of tolerability profile and SLIT-related patient-reported outcomes will allow balancing efficacy with tolerability and all the other patient-related variables that may affect treatment effectiveness beyond its efficacy.

Keywords::

• adherence
• effectiveness
• efficacy
• patient-reported outcomes
• safety
• sublingual immunotherapy
• tolerability

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Sublingual immunotherapy (SLIT) is a viable efficacious and safe treatment for allergic rhinitis.

• • Further research is needed in order to strengthen the evidence of SLIT efficacy for asthma.

• • High heterogeneity in SLIT indications, age groups, allergen preparations, schedule and duration of treatment can weaken the final data about efficacy.

• • An ideal surrogate marker that correlates with real clinical end points and that leads to a tailored immunotherapy treatment is still not available.

• • Tolerability and patient-reported outcomes are crucial determinants of adherence and treatment effectiveness.

• • Recognizing, grading and managing SLIT local adverse effects may enhance adherence to treatment.

• • Operative protocols about the management of SLIT local side effects according to their severity are needed.

• • Patient-reported outcomes, and in particular patient satisfaction, should be regularly assessed through appropriate tools in order to improve treatment effectiveness beyond its efficacy.