Subcutaneous and sublingual allergen-specific immunotherapy: a tale of two routes.

Summary: Specific immunotherapy is the only treatment acting on the causes and not only on symptoms of respiratory allergy. It was first introduced as subcutaneous immunotherapy (SCIT) with the aim to induce immunological tolerance to the administered allergen(s). In the 1980s, sublingual immunotherapy (SLIT) was developed, mainly to improve the safety, which was a critical issue at that time. This article reviewed the available literature, including a large number of randomized controlled trials, meta-analyses, and real-life studies as well, on the outcomes of SCIT and SLIT concerning the treatment critical issues of the two routes, that are efficacy, safety, cost-effectiveness, and compliance to treatment. The efficacy of SCIT and SLIT is similar in respiratory allergy, providing, based on the induction of typical changes in the immunologic response, an early control of symptoms that steadily increases during the treatment and its efficacy lasts after the recommended duration of three years. Such results are the reason why SCIT and SLIT have economic advantage over symptomatic drugs.

Atopic Keratoconjunctivitis: Pharmacotherapy for the Elderly.

Among the different forms of allergic conjunctivitis, atopic keratoconjunctivitis has distinct characteristics, defined by a more common onset in late adolescence or early adulthood, but also affecting the elderly, and with a higher prevalence in male individuals. However, the prevalence of atopic keratoconjunctivitis is scarcely investigated, and the data are often uncertain because other allergic nasal or respiratory disorders occur concomitantly. Mast cells, eosinophils, basophils, and T cells are involved in the pathogenesis of atopic keratoconjunctivitis. Despite its denomination as atopic, negative responses to skin tests or in-vitro immunoglobulin E tests are common. In fact, atopic keratoconjunctivitis can be attributed to a combination of T-helper-1 and T-helper-2 responses, but a higher prominence for T-helper-1 cells was found. The most common symptoms of atopic keratoconjunctivitis are bilateral ocular itching, burning, and tearing with a perennial presentation, although some patients may have seasonal exacerbations in winter or summer. Other symptoms such as photophobia, blurred vision, and mucous chewy discharge, owing to the accumulation of cells and mucin, may occur. The diagnosis of atopic keratoconjunctivitis is mainly clinical, as accepted diagnostic criteria or laboratory tests are not available. The treatment of atopic keratoconjunctivitis is aimed at controlling symptoms, decreasing relapse and exacerbations, and reducing vision loss. Therapeutic options comprise topical ophthalmic drops, including cromones, antihistamines, corticosteroids, and calcineurin inhibitors. Topical ointments are also available for corticosteroids and calcineurin inhibitors. Severe forms may require systemic medications including antihistamines, corticosteroids, and calcineurin inhibitors. Atopic keratoconjunctivitis therapy in the elderly does not differ from the adult population, but the occurrence of multi-morbidities and concomitant drug treatment, which are common in this age group, requires a careful evaluation to determine appropriate and personalized treatment.