[GUIMIT 2019, Mexican Guideline on Immunotherapy. Guideline on the diagnosis of IgE-mediated allergic disease and immunotherapy following the ADAPTE approach]. / GUIMIT 2019, Guía Mexicana de Inmunoterapia. Guía de diagnóstico de alergia mediada por IgE e inmunoterapia aplicando el método ADAPTE.

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.

Determinação da potência relativa de extratos alergênicos de Phleum pratense por testes cutâneos / Establishing the relative potency of Phleum pratense allergenic extracts using skin prick tests

Objetivos: Comparar a potência de extratos europeus de Phleum pratense para imunoterapia sublingual (ITSL), em relação ao extrato referência norte-americano. Métodos: Foram selecionados 15 sujeitos, com idade entre 18 e 55 anos, histórico clínico sazonal compatível e teste cutâneo com alta reatividade a gramíneas. O delineamento de estudo foi transversal, triplo cego e randômico, e comparadas as potências dos seguintes extratos alergênicos para ITSL: (A) Soluprick® (30 HEP/mL) e (B) Grazax® 75.000 SQ-T, ambos os extratos da ALK-Abelló; (C) Oralair® e (D) Staloral®, com 300 IR/mL, Stallergènes, França. O extrato de origem norteamericana (E) foi o padrão, contendo 10.000 BAU/mL. Todos os extratos foram usados em forma de concentrados e nas diluições 1:3, 1:10, e 1:30. Os testes foram aplicados em quadruplicata em dois dias não consecutivos. Os diâmetros de pápula e eritema foram registrados após 15 minutos. Resultados: Não houve diferença significativa entre os testes realizados no primeiro e segundo dias (p = 0,37) com extratos concentrados, na diluição 1:3 e também 1:10 (p = 0,20 e p = 0,33, respectivamente). No segundo dia de testes, a média obtida das pápulas do extrato A foi de 16,7 mm na diluição 1:3; de 14,3 mm na diluição 1:10; e de 9,8 mm na diluição 1:30. Houve diferenças significativas entre os extratos A, B, C, D e E na comparação entre as médias das pápulas obtidas em todas as diluições, mostrando diferença de potência entre os extratos. O diâmetro das pápulas obtidas com o material concentrado, em ordem decrescente de potência, foram C > A > E > D > B. As reações observadas com extratos concentrados mostrou que o mais potente foi Staloral, e o menos potente Grazax. Conclusões: Houve variabilidade significativa de potência nos diversos extratos comparados. Isto reforça a necessidade de padronização de extratos alergênicos para ITSL.

Objectives: To compare the potency of European Phleum pratense pollen extracts for sublingual immunotherapy (SLIT) compared to the U.S. reference extract. Methods: Fifteen subjects aged between 18 and 55 years, with compatible seasonal clinical history and skin tests highly reactive to grass, were selected. The design was cross-sectional, blind, randomized. The following extracts were compared for SLIT: (A) Soluprick® (30 HEP/mL) and (B) Grazax® 75,000 SQ-T, both from ALK-Abelló; (C) Oralair® and (D) Staloral®, with 300 IR/mL, Stallergènes, France. The American extract (E) was the standard 10,000 BAU/mL. Extracts were used in concentrate form and also diluted in 1:3, 1:10, and 1:30 ratios. Tests were applied in quadruplicate on two nonconsecutive days. Skin test reading were done after 15 minutes. Results: There were no significant differences between the tests conducted on the first and second days with the extracts in concentrate form (p = 0.37) or diluted at 1:3 or 1:10 (p = 0.20, p = 0.33, respectively). On the second day of tests, mean wheal sizes obtained with extract A were 16.7 mm with the 1:3 dilution, 14.3 mm with the 1:10 dilution, and 9.8 mm with the 1:30 dilution. There were significant differences between extracts A, B, C, D and E when comparing mean wheal sizes obtained with all dilutions, demonstrating differences in the extracts' potency. Mean wheal diameters obtained with the concentrates, in decreasing order of potency, were C > A > E > D > B. The reactions showed that the most potent extract was Staloral, and the least potent, Grazax. Conclusions: There were significant potency variations in the different extracts assessed. These results reinforce the need for standardization of allergenic extracts used for SLIT.