Immunotherapy as a Preventive Treatment for Allergic Diseases

Immunotherapy as a Preventive Treatment for Allergic Diseases

Cristina Russo, Riccardo Polosa
European Respiratory Disease 2007 - Issue I
Published: October 2008
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Allergen immunotherapy is currently the only immune-modifying treatment for allergic disease and it is indicated for the treatment of allergic rhinitis, asthma and venom hypersensitivity. The notion that rhinitis and asthma are manifestations of a common syndromic entity, and that rhinitis may be an important risk factor for the development of new-onset asthma, has important implications for the management of these common illnesses. In particular, there is now emerging evidence that it is possible to prevent the development of new allergen sensitisations and to lower the risk of incident asthma cases by modulating the immune and clinical response with allergen immunotherapy.

The Link Between Upper and Lower Respiratory Disease
A clinical, functional, pathogenic and immunological association between upper and lower respiratory-airway disorders has been repeatedly documented, leading to the concept of the ‘united airways disease’.1,2 The existence of the so-called united airways disease was first inferred from epidemiological studies, which indicated a close association between rhinitis and asthma; as many as 40% of patients with rhinitis have asthma, and nasal allergy symptoms occur in up to 80% of patients with asthma.3,4

Several studies have suggested that allergic rhinitis usually precedes asthma and that rhinitis may be an important risk factor for the development of asthma. In a proportion of allergic rhinitic individuals, bronchial challenge with histamine or methacholine may reveal bronchial hyper-responsiveness (BHR), even in the absence of any asthmatic symptoms,5,6 and this may be a reflection of subclinical inflammatory changes in the lower airways.7-9 Rhinitic subjects with documented BHR are known to be at risk for asthma progression.10-12 In addition, a number of epidemiological surveys in adults suggest that allergic rhinitis may be a precursor to airway symptoms related to asthma.13-16 However, these epidemiological surveys rely mostly on postal questionnaires for the diagnosis of allergic rhinitis and asthma. In the authors’ recent clinicbased retrospective cohort study, they were able to substantiate these views since a medical diagnosis of allergic rhinitis at the start of the study was highly predictive of development of new-onset asthma after 10 years, with 46.1% of those with rhinitis at baseline developing asthma symptoms by the end of follow-up (odds ratio (OR) 10.3).17

It is unclear why a large proportion of individuals with atopy and rhinitis eventually progress to bronchial asthma. Irrespective of the putative causes, little effort has been made towards developing a therapeutic strategy designed to interfere with disease progression. Given that allergen immunotherapy is currently the only immune-modifying treatment for allergic disease, it has been theorised that allergen immunotherapy should be introduced early to prevent progression to more advanced and irreversible types of allergic disease such as asthma.

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