ABSTRACT
BACKGROUND: Allergen immunotherapy (AIT) has a longstanding history and still remains the only disease-changing treatment for allergic rhinitis and asthma. Over the years 2 different schools have developed their strategies: the United States (US) and the European. Allergen extracts available in these regions are adapted to local practice. In other parts of the world, extracts from both regions and local ones are commercialized, as in Mexico. Here, local experts developed a national AIT guideline (GUIMIT 2019) searching for compromises between both schools. METHODS: Using ADAPTE methodology for transculturizing guidelines and AGREE-II for evaluating guideline quality, GUIMIT selected 3 high-quality Main Reference Guidelines (MRGs): the European Academy of Allergy, Asthma and Immunology (EAACI) guideines, the S2k guideline of various German-speaking medical societies (2014), and the US Practice Parameters on Allergen Immunotherapy 2011. We formulated clinical questions and based responses on the fused evidence available in the MRGs, combined with local possibilities, patient's preference, and costs. We came across several issues on which the MRGs disagreed. These are presented here along with arguments of GUIMIT members to resolve them. GUIMIT (for a complete English version, Supplementary data) concluded the following. RESULTS: Related to the diagnosis of IgE-mediated respiratory allergy, apart from skin prick testing complementary tests (challenges, in vitro testing and molecular such as species-specific allergens) might be useful in selected cases to inform AIT composition. AIT is indicated in allergic rhinitis and suggested in allergic asthma (once controlled) and IgE-mediated atopic dermatitis. Concerning the correct subcutaneous AIT dose for compounding vials according to the US school: dosing tables and formula are given; up to 4 non-related allergens can be mixed, refraining from mixing high with low protease extracts. When using European extracts: the manufacturer's indications should be followed; in multi-allergic patients 2 simultaneous injections can be given (100% consensus); mixing is discouraged. In Mexico only allergoid tablets are available; based on doses used in all sublingual immunotherapy (SLIT) publications referenced in MRGs, GUIMIT suggests a probable effective dose related to subcutaneous immunotherapy (SCIT) might be: 50-200% of the monthly SCIT dose given daily, maximum mixing 4 allergens. Also, a table with practical suggestions on non-evidence-existing issues, developed with a simplified Delphi method, is added. Finally, dissemination and implementation of guidelines is briefly discussed, explaining how we used online tools for this in Mexico. CONCLUSIONS: Countries where European and American AIT extracts are available should adjust AIT according to which school is followed.
ABSTRACT
BACKGROUND: In Mexico, allergen immunotherapy (AIT) and immunotherapy with hymenoptera venom (VIT) is traditionally practiced combining aspects of the European and American school. In addition, both types of extracts (European and American) are commercially available in Mexico. Moreover, for an adequate AIT/VIT a timely diagnosis is crucial. Therefore, there is a need for a widely accepted, up-to-date national immunotherapy guideline that covers diagnostic issues, indications, dosage, mechanisms, adverse effects and future expectations of AIT (GUIMIT 2019). METHOD: With nationwide groups of allergists participating, including delegates from postgraduate training-programs in Allergy/Immunology-forming, the guideline document was developed according to the ADAPTE methodology: the immunotherapy guidelines from European Academy of Allergy and Clinical Immunology, German Society for Allergology and Clinical Immunology, The American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma, and Immunology were selected as mother guidelines, as they received the highest AGREE-II score among international guidelines available; their evidence conforms the scientific basis for this document. RESULTS: GUIMIT emanates strong or weak (suggestions) recommendations about practical issues directly related to in vivo or in vitro diagnosis of IgE mediated allergic diseases and the preparation and application of AIT/VIT and its adverse effects. GUIMIT finishes with a perspective on AIT modalities for the future. All the statements were discussed and voted on until > 80 % consensus was reached. CONCLUSIONS: A wide and diverse group of AIT/VIT experts issued transculturized, evidence-based recommendations and reached consensus that might improve and standardize AIT practice in Mexico.
Antecedentes: En México, la inmunoterapia con alérgenos (ITA) y con veneno de himenópteros (VIT) se practica tradicionalmente combinando criterios de las escuelas europea y estadounidense; los dos tipos de extractos están comercialmente disponibles en México. Para una ITA adecuada es crucial un diagnóstico oportuno. Objetivo: Presentar GUIMIT 2019, Guía Mexicana de Inmunoterapia 2019, de base amplia, actualizada, que abarca temas de diagnóstico, indicaciones, dosificación, mecanismos, efectos adversos de la ITA y expectativas con esta modalidad de tratamiento. Método: Con la participación de múltiples grupos mexicanos de alergólogos, que incluían los centros formadores universitarios en alergia e inmunología, se desarrolló el documento de la guía según la metodología ADAPTE. Las guías de inmunoterapia de la European Academy of Allergy and Clinical Immunology, The American Academy of Allergy, Asthma and Immunology, German Society for Allergology and Clinical Immunology y del American College of Allergy, Asthma, and Immunology se seleccionaron como guías fuente, ya que recibieron la puntuación AGREE-II más alta entre las guías internacionales disponibles; su evidencia conforma la base científica de GUIMIT 2019. Resultados: En GUIMIT 2019 se emiten recomendaciones fuertes o débiles (sugerencias) acerca de temas directamente relacionados con el diagnóstico in vivo o in vitro de las enfermedades alérgicas mediadas por IgE, la preparación y aplicación de ITA o VIT y sus efectos adversos; se incluye la revisión de las modalidades de ITA para el futuro. Todos los argumentos que se exponen fueron discutidos y votados con > 80 % de aprobación. Conclusión: Un grupo amplio y diverso de expertos en ITA y VIT emitió recomendaciones transculturizadas basadas en evidencia, que alcanzaron consenso; con ellas se pretende mejorar y homologar la práctica de la inmunoterapia en México.
Subject(s)
Hypersensitivity/diagnosis , Hypersensitivity/therapy , Immunoglobulin E , Immunotherapy/standards , Humans , Hypersensitivity/immunology , Immunoglobulin E/immunologyABSTRACT
BACKGROUND: Food allergy diagnosis is performed by a double blind placebo controlled challenge; however, in a lot of patients, it is only based on clinical history, skin prick tests, or parents' perception. There is a high frequency of elimination diets without an adequate approach. OBJECTIVES: To analyze the results of diagnostic tests in a group of children with elimination diet-based on suspected food allergy and verify such studies with double blind placebo-controlled test challenge. MATERIAL AND METHOD: An observational, analytical and prospective study was done in a group of patients with elimination diet for suspected food allergy. We performed prick test, Prick-to-Prick test and patch test and the positive ones were verified by double-blind placebo-controlled challenge. RESULTS: Fourty-three patients were included within a total of 1,935 tests. Both approach for immediate and late sensitivity had not statistically significant relationship between a positive test and the elimination of food. Until now, we had 4 (8%) positive challenges out of 50. CONCLUSIONS: The frequency of allergy proved by double-blind placebo-controlled test in 50 challenges was of 8% (4/50), thus, in the preliminary report we found a high frequency of elimination diets without adequate support. It is very important that food allergy diagnosis is accurate and based on an appropriate approach; since the implementation of an elimination diet in pediatric population can have a negative influence on their growth and development.
Antecedentes: el diagnóstico de alergia alimentaria se realiza idealmente con reto doble ciego controlado con placebo; sin embargo, en muchas ocasiones sólo se basa en la historia clínica, en las pruebas cutáneas o, incluso, en la percepción de los padres. Con gran frecuencia se prescriben dietas de eliminación sin el abordaje adecuado. Objetivos: analizar los resultados de las pruebas diagnósticas de alergia alimentaria en un grupo de niños con dieta de eliminación y verificar esos estudios con la prueba de reto doble ciego. Material y método: estudio observacional, analítico, prospectivo, efectuado en un grupo de pacientes con dieta de eliminación por sospecha de alergia alimentaria. Se realizaron pruebas por punción, Prick-to-Prick y de parche a todos los pacientes y posteriormente se verificó la positividad de esas pruebas mediante reto doble ciego controlado con placebo. Resultados: se incluyeron 43 pacientes con un total de 1,935 pruebas. En el abordaje para sensibilidad inmediata y tardía no se encontró ninguna relación estadísticamente significativa entre la positividad de la prueba y la eliminación del alimento. Al momento se han realizado 50 retos, de los que 4 fueron positivos (8%). Conclusiones: la frecuencia de alergia comprobada por reto doble ciego controlado con placebo en 50 retos fue de 8% (4/50), por lo que en este reporte preliminar encontramos una alta frecuencia de eliminación de alimentos sin el sustento adecuado. Es muy importante que el diagnóstico de alergia alimentaria sea acertado y se base en el abordaje adecuado, porque la implementación de una dieta de eliminación en una población muy vulnerable, como los pacientes pediátricos, es de suma importancia y puede influir de manera negativa en su crecimiento y desarrollo.
