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BACKGROUND: Aspirin-exacerbated respiratory disease (AERD) is characterized by chronic eosinophilic rhinosinusitis, nasal polyps, asthma, and respiratory sensitivity to aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). In addition to sensitivity to aspirin and NSAIDs, the majority of patients with AERD have been reported to have respiratory intolerance associated with the consumption of alcohol. METHODS: A multicenter prospective cohort study was performed. Patients with AERD confirmed by aspirin challenge were eligible to participate. Those who described themselves as able to tolerate alcohol consumption were excluded. Patients underwent aspirin desensitization following endoscopic sinus surgery. A questionnaire was distributed to patients before and after desensitization to determine pre-desensitization and post-desensitization symptoms associated with alcohol ingestion. RESULTS: Forty-five patients were enrolled and 37 patients completed the study. The most common pre-desensitization symptoms were nasal congestion (95.6%), rhinorrhea (46.7%), and wheezing (40%). Improvement in the ability to tolerate alcohol was noted in 86.5% of participants (95% confidence interval [CI], 75.5% to 97.5%) and 70.3% of participants (95% CI, 55.5% to 85.0%) described desensitization to be "very helpful" or "extremely helpful" for their ability to tolerate alcohol. CONCLUSION: The majority of patients with AERD who experience respiratory symptoms with alcohol consumption describe improvement in this domain following aspirin desensitization.

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BACKGROUND: Since 1988, numerous allergen immunotherapy guidelines (AIT-GLs) have been developed by national and international organizations to guide physicians in AIT. Even so, AIT is still severely underused. OBJECTIVE: To evaluate AIT-GLs with AGREE-II, developed in 2010 by McMaster University methodologists to comprehensively evaluate GL quality. METHODS: Allergist, from different continents, knowledgeable in AIT and AGREE-II trained were selected into the project team. The project received methodologists' guidance. AIT-GLs in any language were sought from 1980 to 2016; AIT-GLs were AGREE II-evaluated by at least 2 team members, independently; discrepancies were resolved in a second round, by team discussion or methodologists' consulting. RESULTS: We found 31 AIT-GLs (15 post-2010), ranging from local consensus reports to international position papers (EAACI, AAAAI-ACAAI, WAO). Pre-2010 GLs scored 1.6-4.6 (23%-67%) and post-2010 GLs scored 2.1-6 (30%-86%), on a 7-point Likert scale. The highest scores went to: German-Austrian-Swiss (6.0), Mexican (5.1), and the AAAAI/ACAAI AIT-GL (4.7). These were also the only 3 GLs that received "yes" of both evaluators to the item: "I would recommend this GL for use." The domains of "Stakeholder involvement" and "Rigor of Development" only scored 3/7, and "Applicability" scored the lowest. Strikingly, newer GLs only scored clearly better in "Editorial independence" and "Global evaluation." CONCLUSIONS: In AIT-GLs, there is still a lot of room for improvement, especially in domains crucial for the dissemination. For some GLs, the "Scientific rigor" domain flawed. When resources are limited, transculturizing a high-quality GL might be preferable over developing a GL from zero. Our study and AGREE-II could help to select the best candidate. CLINICAL IMPLICATIONS: We here evaluate allergen immunotherapy guideline (AIT-GL) quality. Only high-quality AIT-GLs should be consulted for AIT management decisions. In low-resource settings, transculturization of these is preferred over developing low-quality guidelines.

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BACKGROUND: Practical issues dealing with the administration of allergen immunotherapy (AIT) by European and US allergists are not well known. Several concerns are only partially covered by guidelines. OBJECTIVE: To survey AIT practice patterns among worldwide members of the American Academy of Allergy, Asthma and Immunology (AAAAI). METHODS: A web-based survey was conducted among AAAAI members on dosing, dose adjustment after missed doses, and duration of AIT. RESULTS: A total of 1,201 replies (24.7% response rate of which 10% of responses were from non-US and non-Canada members). A total of 57% to 65% of the US-Canadian dosing falls within the recommended Practice Parameter ranges (9.4%-19% too low). Dose adjustment after missed doses is based on time elapsed since the last administered dose by 77% of US-Canadian and 58% of non-US-Canadian allergists. Doses are reduced when a patient comes in more than 14 days for 5 weeks after the last administration and initial dosing restarted after more than 30 days for 12 weeks since last administration during the build-up or maintenance stage. After missing 1 to 3 doses, the dosing schedules were mostly followed (build-up phase: repeat last dose, reduce by 1 dose, reduce by 2doses; maintenance phase: reduce by 1 dose, reduce by 2 doses, reduce by 3 doses). AIT is prescribed for a median of 3 years by non-US-Canadian allergists but for a median of 5 years by 75% of US-Canadian allergists. Main reasons for continuing beyond 5 years were "after stopping, symptoms reappeared" or "patient afraid to relapse." CONCLUSION: Many patients receive less than recommended doses. Two areas in which to plan further research are establishment of an optimal dose-adjustment plan for missed applications and exploration of the maximum appropriate duration of immunotherapy.

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BACKGROUND: Sublingual immunotherapy (SLIT) has become established in Europe, and its efficacy is being evaluated in the United States. The doses used for SLIT in Europe today are difficult to evaluate, because each manufacturer expresses the potency of its extracts differently. OBJECTIVES: To compare in vitro European SLIT maintenance solutions against US licensed standardized allergenic extract concentrates and to determine the monthly SLIT doses delivered expressed in bioequivalent allergy units ([B]AU). METHODS: We studied Dermatophagoides pteronyssinus, timothy grass pollen, cat (hair) and short ragweed pollen allergen extracts. The SLIT maintenance solutions of 4 leading European manufacturers and standardized concentrate extracts of 3 US manufacturers were analyzed with the following assays: protein content, relative potency (immunoglobulin E [IgE]-binding enzyme-linked immunosorbent assay [ELISA] inhibition) and major allergen content. The relative monthly allergen dose in (B)AU was calculated for each recommended SLIT schedule. RESULTS: Relative potency was approximately 10 times higher for US concentrate standardized extracts-which are meant to be diluted-than for European SLIT maintenance solutions of D pteronyssinus and timothy grass pollen. For cat (hair) and short ragweed pollen, the difference was less. Measurements of relative potency and major allergen content correlated well. In our assays, European mite extracts contain a very low quantity of Der p 2 compared with US mites. CONCLUSION: Recommended SLIT doses in Europe vary widely among the manufacturers, but are consistently lower (Eur1) or higher (Eur4) over all four allergens tested. SLIT efficacy probably depends on additional factors apart from the exact dose. SLIT dose finding studies should be done for each product.

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BACKGROUND: In Mexico, the way allergen immunotherapy is performed has remained without changes for many years. Here we present the modifications that have been performed in the General Hospital of Mexico to make immunotherapy more effective. OBJECTIVE: To show the changes implemented to make immunotherapy faster and more effective by changing the volume of allergy vaccines from 5 or 10 mL to 3 mL, and the theoretical and practical support for the change. MATERIAL AND METHOD: The amount of protein delivered in each immunotherapy shot was computed to show how they change along the treatment. Results for schedules for 3, 5 and 10 mL were compared. RESULTS: Results showed serial rises and falls in protein amount injected every time a new vaccine flask starts to be used. However, in the case for 3 mL vaccines schedules, those changes are less pronounced. CONCLUSIONS: Due to these results we suggest a schedule of immunotherapy with 3 mL vaccines that allow getting the maintenance doses in a shorter time and at lower cost.

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BACKGROUND: There is considerable variability in how allergen extract potency is measured and reported worldwide. In Europe, where many sublingual immunotherapy studies have been conducted, manufacturers report allergen extract potency as units based on an in-house reference, making it difficult to understand the exact doses used and to compare studies. OBJECTIVES: To describe the various methods of expressing extract potency that European allergen extract manufacturers use and to gather reports on the micrograms of major allergen of the in-house units of European allergen extract manufacturers. METHODS: Information was derived from 3 sources: data on extract potency in micrograms of major allergen in articles on sublingual immunotherapy found by PubMed (references through October 2005) and in reference articles, brochures on allergen extracts from the manufacturers, and information provided by structured questionnaires e-mailed to the manufacturers. RESULTS: All but 1 of the European allergen extract manufacturers use in-house reference standards that are based on titrated skin prick testing of allergic patients. Subsequently, in vitro tests compare the potency of commercial batches with the in-house reference and potency is assigned as arbitrary units. Most manufacturers measure major allergen content of their standardized products but do not release this information with the package insert. Diversity in major allergen content was found. CONCLUSIONS: Micrograms of major allergens given in articles on sublingual immunotherapy to express the dose administered cannot be used to translate the dose to US extracts. Extract potency can only be compared if uniform test methods and reference extracts are used.

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