ARIA‐EAACI care pathways for allergen immunotherapy in respiratory allergy

This Pocket Guide was developed by an ARIA and EAACI joint study group from a background paper of the ARIA-MASK guidelines on allergen immunotherapy. Bousquet J, Pfaar O, Togias A, et al. (2019). Care pathways for Allergy 2019; 74: 2087–2102. Agache, Lau S, Akdis CA, immunotherapy: house dust mite-driven allergic asthma. Allergy, 2019;74:855-73. AIT is proven therapeutic option treatment rhinitis, conjunctivitis, and/or asthma using sublingual (SLIT) or subcutaneous (SCIT) routes. However, more expensive than symptomatic treatments diseases (excluding biologicals). It justified (i) in patients with rhinitis otherwise uncontrolled (ii) as add-on to regular controlled partially-controlled asthmatic sensitised mites aiming decrease exacerbations, rescue controller medication, improve quality life. are structured multi-disciplinary care plans detailing key steps patient care. They promote translation guideline recommendations their application clinical practice. Although many international national have been produced, this first pathway AIT. pocket guide applies sub-cutaneous immunotherapy rhinitis. has revised members 65 countries (Figure 1). The decision prescribe should be based relevant symptoms during exposure, demonstration sensitisation allergens, availability good-quality extracts efficacy safety. Some approved marketing EU (list annex) some others also health agencies. For certain products, safety demonstrated appropriate studies adults children. extrapolation untested allergens different population one evaluated trial not line current there no class-effect Both monosensitised polysensitised can treated. latter case, most clinically allergen(s) used when clearly present source exposure allergy tests confirm findings. Precision medicine aims at customisation healthcare, tailored characteristics each individual patient. stratification into subpopulations basis making 2). In diseases, required to: Propose pharmacotherapy. Identify suitable candidates Reduce amount time resources needed match right optimal management programme. Optimise costs interventions necessary all patients. Patient may help patient's engagement. Precise diagnosis history, skin prick specific IgE and, if applicable, component-resolved vitro testing. cases, where above-mentioned diagnostic tools do allow precise diagnosis, provocation testing (nasal, ocular bronchial) needed. Proven indications: Allergic conjunctivitis Symptoms predominantly induced exposure. stratification: Poor control nasal despite medications according documented adherence treatment. Exceptions requiring optimum prior considering include unacceptable side effects medications. fully under medication (see HDM-AIT GL) partially asthma, facilitate achieving Good documentation product trials. (and caregiver's) views represent essential component. There currently vivo biomarkers validated monitoring although several potential being investigated. Apps used: To acquire real-world evidence situations randomised trials difficult perform. assess air index including pollen pollution. By physicians follow-up. selection pharmacotherapy AR better supported algorithms aid healthcare professionals jointly determine its step-up step-down strategy depending (shared decision-making). A simple algorithm proposed 3). case remaining symptoms, add intra-ocular effective, long-term beneficial after cessation, delay prevent onset initiated children moderate/severe that guidelines. An HDM-driven concomitant mite—with persisting low-moderate dose inhaled corticosteroids—SLIT considered, provided FEV1 >70% predicted. House mite SLIT initially considered therapy treatment, reduction controllers performed gradually supervision physician. Immunotherapy indicated acute must informed need seek medical attention immediately deteriorates suddenly 4). One strength it related allergen, Local reactions: typical reaction redness swelling injection site hours injection. Sometimes, sneezing, congestion hives occur. Systemic Serious reactions injections very rare require immediate attention. anaphylactic throat, wheezing tightness chest, nausea dizziness. serious develop within 30 min injection, advised wait doctor's surgery least Severe bronchospasm occur, especially controlled. Allergen drops tablets favourable profile injections. initial surgery, remain administration. Thereafter, administered home once given majority will experience mild local oropharyngeal passage. usually predosing antihistamine before administration SLIT. Anaphylaxis rarely described. countries, warning about possible severe reactions, adrenaline auto-injectors routinely recommended. Europe. IAgache Associate Editor CTA. CA reports grants Allergopharma, Idorsia, Swiss National Science Foundation, Christine Kühne-Center Research Education, European Commission's Horison's 2020 Framework Programme, Cure, Novartis Institutes, Astra Zeneca, scibase, advisory role Sanofi/Regeneron, Glakso Smith-Kline, scibase. IA personal fees Hikma, Roxall, Menarini, UCB, Faes Farma, Sanofi, Mundipharma, Bial, Amgen, Stallergenes. SBA TEVA, AstraZeneca, Boehringer Ingelheim, GSK, Mylan. VC ALK, Therapeutics, LETI, Thermofisher, Merck, Astrazeneca, GSK. TC PD ALK-Abello, Stallergenes-Greer, GlaxoSmithKline, Mylan, Sanofi. SD non-financial support ALK Abello, Adiga, Biomay, Anergis, Therapeutics. TH Orion Pharma. SH other ALK-Abelló, ALK-Abelló. EH Novartis, Circassia, Nestlè Purina. JCI Laboratorios Casasco Argentina, Abbott de Ecuador, EuroFarma Argentina. MJ Stallergenes, Leti, HAL, conduct study; Astra-Zeneka, Teva, Vectura, Takeda, Roche, Janssen, Medimmune, Chiesi,. LK MEDA/Mylan, LETI Pharma, Quintiles, ASIT biotech, Abelló, Lofarma, Inmunotk, Therapeut., HAL Allergie, Cassella med; Membership: AeDA, DGHNO, Deutsche Akademie für Allergologie und klinische Immunologie, HNO-BV, GPA, EAACI. PK Adamed, Berlin Chemie Lekam, Polpharma, teva. VK Dimuna, Norameda. SL DBV, Sanofi Aventis, Nutricia, Bencard. EM AstraZeneca Chiesi. JM SANOFI-GENZYME & REGENERON, NOVARTIS, ALLAKOS, MITSUBISHI-TANABE, MENARINI, ASTRAZENECA, MSD, MYLAN-MEDA URIACH Group. MO Hycor Diagnostics, Thermo Fisher Phadia. YO Torii Pharmaceutical Co., Ltd., Shionogi Co.,Ltd. OP received research Inmunotek S.L., MINECO giving scientific lectures participation Advisory Boards from: Diater, S.A, S.L, Sanofi-Genzyme NGP MENARINI/FAES FARMA, SANOFI, MYLAN/MEDA, BIOMAY, BIOTECH, Gerolymatos International SA, Capricare. Stallergenes Greer, Holding B.V./HAL Allergie GmbH, Bencard GmbH/Allergy Biotech Tools S.A., LETI/LETI Anergis Glaxo Smith Kline, Pohl-Boskamp, MEDA Pharma/MYLAN, Mobile Chamber Experts (a GA2LEN Partner), Indoor Biotechnologies, Astellas Pharma Global, EUFOREA, ROXALL Medizin, Sanofi-Aventis Sanofi-Genzyme, Med Update Europe streamedup! John Wiley Sons, AS. DPreports Pliva, Belupo, AbbVie, Chiesi, Revenio, Philips. MR board- A. Menarini - Speaker FSRreports speaker Teva Lusomedicamenta. GR payment his Institution Allergo BSreports Health Programm, grant, ASTRA, ombudsman, Centre Development, Polish Allergology Society. JS Farma. GS leds BSACI Rhinitis Guidelines lead EUFOREA Rhinitis. PSG Bencard, F2F events. ATB GSK Novartis. MJTreports Commission, SEAIC, ISCIII, Diater laboratory, Leti Aimmune MW Genzyme, Meda Teva. DW Optinose, Sanofi; past Co-Chair Joint Task Force Practice Parameters AAAAI ACAAI. Second author recently published practice parameter Aralez (Medexus), Pediapharm, Pfizer, Alk. MZ Takeda. TZ Organizational affiliations: Commitee member: WHO-Initiative “Allergic Its Impact Asthma” (ARIA). Member Board: German Society Clinical Immunology (DGAKI). Head: Foundation (ECARF). Secretary General: Global Asthma Network (GA2LEN). Member: Committee Diagnosis Molecular Allergology, World Organization (WAO). Countries Proposed Flow Medicine approach diseases. *examples exceptions: Thunderstorm-induced moderate season Treatment visual analogue scale (VAS) adolescents AIT, immunotherapy; VAS, scale. Algorithm