Allergen immunotherapy: does it work and, if so, how and for how long?

Background. Pollen immunotherapy is effective in selected patients with IgE-mediated seasonal allergic rhinitis, although it is questionable whether there is long-term benefit after the discontinuation of treatment. Methods. We conducted a randomised, double-blind, placebo-controlled trial of the discontinuation of immunotherapy for grass pollen allergy in patients in whom three to four years of this treatment had previously been shown to be effective. During the three years of this trial, primary outcome measures were scores for seasonal symptoms and the use of rescue medication. Objective measures included the immediate conjunctival response and the immediate and late skin responses to allergen challenge. Cutaneous biopsy specimens obtained 24 hours after intradermal allergen challenge were examined for T cell infiltration and the presence of cytokine-producing T helper cells (Th2 cells) (as evidenced by the presence of interleukin-4 messenger RNA). A matched group of patients with hay fever who had not received immunotherapy was followed as a control for the natural course of the disease. Results. Scores for seasonal symptoms and the use of rescue antiallergic medication, which included short courses of prednisolone, remained low after the discontinuation of immunotherapy and there was no significant difference between patients who continued immunotherapy and those who discontinued it. Symptom scores in both treatment groups (median areas under the curve in 1995, 921 for continuation of immunotherapy and 504 for discontinuation of immunotherapy, p=0.60) were markedly lower than those in the group that had not received immunotherapy (median value in 1995, 2863). Although there was a tendency for immediate hypersensitivity to allergen to return late after discontinuation, there was sustained reduction in the late skin response and associated CD3+ T cell infiltration and interleukin-4 messenger RNA expression. Conclusions. Immunotherapy for grass pollen allergy for three to four years induces prolonged clinical remission accompanied by a persistent alteration in immunologic reactivity. (N Engl J Med 1999;341:468–75)