People with allergic rhinitis or asthma who might benefit from allergen immunotherapy aren’t  getting identified and onto the long treatment pathway which could potentially be life changing, Australian experts say.

Professor Sinthia Bosnic-Anticevich, from the Woolcock Institute of Medical Research, told the limbic that while allergen immunotherapy was usually delivered by specialists, the first step was recognising those patients in the community who might benefit.

“For example, with allergic rhinitis, the person might actually be self medicating and may not even be talking to a pharmacist. Or if they do get prescribed medication, they are non adherent and living with symptoms and not even telling their GP they are not well.”

Professor Bosnic-Anticevich, a respiratory pharmacist, is one of the Australian co authors on a Pocket Guide on allergen immunotherapy, which has been made available by a joint study group of the Allergic Rhinitis and its Impact on Asthma (ARIA) initiative and the European Academy of Allergy and Clinical Immunology (EAACI).

The Guide provides care pathways for the use of sublingual and subcutaneous immunotherapy in patients with allergic rhinitis uncontrolled by symptomatic treatment, and in patients with asthma who are sensitised to house dust mites as an add-on to their regular asthma treatment.

It includes treatment algorithms for both conditions.

Precision medicine

The Guide, published in Clinical and Translational Allergy and reviewed by members from 65 countries including Australia, emphasises the importance of a precision medicine approach including patient stratification.

Professor Bosnic-Anticevich said a structured pathway was required.

“It is really potentially a very long pathway to actually get to the point where that person would be identified as a candidate. It requires someone somewhere along the line recognising that they do have a very obvious response to an aeroallergen and that they are not being sufficiently treated when they are on an appropriate dose and when they are adherent.”

“Many people are polysensitised so they are actually responding to more than one allergen. Then it’s really important to articulate which allergens they are responding to and find the one they have the biggest response to. If they are going to have immunotherapy and they are polysensitised, you can only treat with one allergen at a time.”

Professor Bosnic-Anticevich said another challenge with immunotherapy was that treatment often goes for quite a long time.

“It can be anything from 3-5 years – and so then there is the adherence issue again. People drop off,” she said.

The Guide said there were currently no in vivo or in vitro biomarkers validated for monitoring the efficacy of allergen immunotherapy.

“So there are some practical issues that have traditionally been associated with immunotherapy but for some people who manage to get there and have the treatment, it really makes a difference.”

She said additional resources were available from the Australasian Society of Clinical Immunology and Allergy (ASCIA) website.