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Epicutaneous allergen-specific immunotherapy ameliorates grass pollen–induced rhinoconjunctivitis: A double-blind, placebo-controlled dose escalation study

Published:October 14, 2011DOI:https://doi.org/10.1016/j.jaci.2011.08.036

      Background

      Epicutaneous allergen administration using a patch may be an alternative to subcutaneous or sublingual immunotherapy.

      Objective

      To optimize treatment dose and to demonstrate the efficacy and safety of epicutaneous immunotherapy.

      Methods

      This monocentric, placebo-controlled, double-blind trial included 132 patients with grass pollen–induced rhinoconjunctivitis. In February 2008, patients were randomly allocated to receive placebo or 3 different doses of allergen. Before and during the pollen season 2008, patients received 6 weekly patches. Efficacy was assessed 4 to 5 months later (n = 110) and during the pollen season of the treatment-free follow-up year in 2009 (n = 93). The primary outcome was patient-reported changes in hay fever symptoms assessed by a visual analog scale. Secondary outcome measures were weekly visual analog scale symptom scores during pollen season, use of rescue medication, changes in conjunctival and skin reactivity, as well as safety.

      Results

      Hay fever symptoms during the pollen season were reduced by more than 30% in 2008 and by 24% in 2009 in the high-dose group as compared with that in the placebo group, and the alleviation of symptoms in the follow-up year was dependent on the treatment dose. Higher allergen doses were associated with drug-related adverse events (AEs), predominantly manifested by pruritus, erythema, wheal, or eczema. Eleven systemic AEs of grades 1 to 2 required treatment and led to study exclusion. The dropout rate due to AEs was 8.3%. No drug-related serious AE was recorded.

      Conclusion

      Epicutaneous immunotherapy is safe and efficacious in a dose-dependent manner after 6 patches only.

      Key words

      Abbreviations used:

      AE (Adverse event), CPT (Conjunctival provocation test), EPIT (Epicutaneous allergen-specific immunotherapy), HEP (Histamine equivalent prick), SIT (Allergen-specific immunotherapy), SPT (Skin prick test), VAS (Visual analog scale)
      Despite insufficient symptom control with pharmacotherapy,
      • Nathan R.A.
      The burden of allergic rhinitis.
      only 5% of patients suffering from allergic rhinoconjunctivitis undergo allergen-specific immunotherapy (SIT),
      • Cox L.S.
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      • Nolte H.
      • Weldon D.
      • Finegold I.
      • Nelson H.S.
      Sublingual immunotherapy: a comprehensive review.
      • Cox L.
      • Calderon M.A.
      Subcutaneous specific immunotherapy for seasonal allergic rhinitis: a review of treatment practices in the US and Europe.
      which is the only disease-modifying treatment.
      • Frew A.J.
      Allergen immunotherapy.
      • Holgate S.T.
      • Polosa R.
      Treatment strategies for allergy and asthma.
      The requirement for numerous visits to a medical office and allergen-associated adverse events (AEs) limit the broad application of subcutaneous allergen-specific immunotherapy. Tremendous effort has been put into developing self-administrable and more patient-convenient treatment routes.
      • Canonica G.W.
      • Passalacqua G.
      Noninjection routes for immunotherapy.
      • Passalacqua G.
      • Compalati E.
      • Canonica G.W.
      Advances in allergen-specific immunotherapy.
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      • Lockey R.
      • Malling H.J.
      Allergen immunotherapy: therapeutic vaccines for allergic diseases. A WHO position paper.
      With the consensus approval of sublingual allergen-specific immunotherapy in 1998, a new area was initiated.
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      • Casale T.
      • Lockey R.F.
      • Baena-Cagnani C.E.
      • Pawankar R.
      • et al.
      Sub-lingual immunotherapy: World Allergy Organization Position Paper 2009.
      Thanks to the excellent safety profile, sublingual allergen-specific immunotherapy can be self-administered and represents an increasing percentage of SIT treatments in Europe.
      • Cox L.
      • Jacobsen L.
      Comparison of allergen immunotherapy practice patterns in the United States and Europe.
      However, up to 75% of patients report oral and gastrointestinal AEs.
      • Cox L.S.
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      • Finegold I.
      • Nelson H.S.
      Sublingual immunotherapy: a comprehensive review.
      Treatment duration is not reduced but may require daily application of high-allergen doses for several years, with considerable costs.
      • Cox L.S.
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      • Nolte H.
      • Weldon D.
      • Finegold I.
      • Nelson H.S.
      Sublingual immunotherapy: a comprehensive review.
      Also, treatment compliance with sublingual allergen-specific immunotherapy is low.
      • Senna G.
      • Lombardi C.
      • Canonica G.W.
      • Passalacqua G.
      How adherent to sublingual immunotherapy prescriptions are patients? The manufacturers’ viewpoint.
      The high density and immune-surveillance function of antigen-presenting Langerhans cells in the epidermis
      • Kupper T.S.
      • Fuhlbrigge R.C.
      Immune surveillance in the skin: mechanisms and clinical consequences.
      makes the skin an attractive route for the administration of SIT. Also, the epidermis lacks vascularization, thus minimizing the risk for inadvertent intravascular allergen injection and systemic allergic side effects. We therefore proposed epicutaneous allergen-specific immunotherapy (EPIT) as a needle-free and potentially self-administrable treatment route for SIT using a patch to apply allergen to the skin, and efficacy was demonstrated in a double-blind, placebo-controlled pilot trial.
      • Senti G.
      • Graf N.
      • Haug S.
      • Ruedi N.
      • von Moos S.
      • Sonderegger T.
      • et al.
      Epicutaneous allergen administration as a novel method of allergen-specific immunotherapy.
      The earliest reports of EPIT date back to Besredka in 1917 and then Patrizel and Blamoutier in the 1950s who introduced a scarification method for SIT (as reviewed in Senti et al).
      • Senti G.
      • von Moos S.
      • Kundig T.M.
      Epicutaneous allergen administration: is this the future of allergen-specific immunotherapy?.
      We replaced scarification with adhesive tape stripping, physical removal of stratum corneum being important not only to enhance antigen penetration but also to activate keratinocytes that interact with Langerhans cells.
      • Kupper T.S.
      • Fuhlbrigge R.C.
      Immune surveillance in the skin: mechanisms and clinical consequences.
      • Frerichs D.M.
      • Ellingsworth L.R.
      • Frech S.A.
      • Flyer D.C.
      • Villar C.P.
      • Yu J.
      • et al.
      Controlled, single-step, stratum corneum disruption as a pretreatment for immunization via a patch.
      In the present study, we tested the effect of EPIT on hay fever symptoms in patients with grass pollen allergy in a double-blind, placebo-controlled dose escalation study. The results implicate that EPIT is safe, convenient, and efficacious.

      Methods

       Trial population

      In total 157 persons were screened, and 132 patients aged between 18 and 65 years with a history of grass pollen allergic rhinoconjunctivitis and with positive skin prick test (SPT) and conjunctival provocation test (CPT) results signed informed consent. Exclusion criteria were eczema on upper arms, perennial allergic rhinitis, infectious rhinitis within the last 14 days, surgery within the last 30 days, pregnancy or nursing, hypertension, history of HIV/AIDS, mastocytosis, malignancy, active infectious disease, significant cardiovascular, pulmonary, renal, hepatic, hematologic, autoimmune, neurological, or psychiatric disease, moderate to severe asthma, intake of antihistamines with long half-life within the last 2 weeks or corticosteroids within the last 5 days, intake of beta-blockers, angiotensin-converting enzyme/antgiotensin II receptor antagonists, or tricyclic antidepressants, and participation in another clinical trial within the last 60 days. The study was approved by the institutional review board and the Swiss authorization agency Swissmedic (ClinicalTrials.gov NCT00719511).

       Clinical trial design and study procedures

      This single-center phase I/II randomized, placebo-controlled, double-blind study was designed to test the effective dose range, tolerability, safety, and the sustained treatment effect of EPIT. On the basis of a random-number table, 132 patients with grass pollen allergy were allocated to the placebo group (n = 33), the low-dose treatment group (10 histamine equivalent prick [HEP], n = 33), the medium-dose treatment group (50HEP, n = 33), or the high-dose grass-extract treatment group (100HEP, n = 33).
      The study was performed between February 2008 and November 2009 at the University Hospital Zurich. The trial design is outlined in Table I. At the screening visit, consenting patients received a brief physical examination and SPT and CPT were performed. At least 4 weeks before start of the 2008 pollen season, patients received the first of 6 patches. The application was prepared by tape stripping a site on the upper arm 6 times with scotch tape (3M Company, St Paul, Minn). Then, the patch was applied and the patient was observed for 30 minutes. All patients received an emergency set containing corticosteroids (prednisone [Streuli, Uznach, Switzerland]) and antihistamines (Semprex [GlaxoSmithKline, Brentford, United Kingdom]). After 8 hours, the patch was removed by the patient. To assess local reactions, all patients were contacted by phone 48 hours after the application of the first patch. With the start of the pollen season, the 5 following patches were administered in weekly intervals (allowed range 5 days to 2 weeks). Each patch was administered at a different location on the upper extremity. If a local reaction occurred, patients were asked to take a photograph of the site and to contact the study nurse or the clinician. During the entire pollen season, the severity of hay fever symptoms was recorded weekly and the use of rescue medication was assessed daily. This study was conducted according to International Conference on Harmonisation guidelines on Good Clinical Practice (ICH-GCP) and the Declaration of Helsinki.
      Table IStudy outline
      Visit/timeIntervention/analysis
      February/March 2008Newspaper advertisement and telephone recruitment
      Screening (March-April 2008)Medical history and examination, CPT, SPT, severity assessment of rhinoconjunctivitis with VAS
      Visit 1 (March-April 2008)First patch application

      Follow-up call after 48 h for record of local AEs
      Visit 2 (April-May 2008)Second patch application, AE records
      Visits 3-6 (May-July 2008)(Bi-) weekly patch application, AE records, weekly VAS symptom diary, medication diary
      Visit 7 (August-September 2008)Medical examination, CPT, SPT, AE records, recording of improvement/deterioration VAS
      Visit 8 (March-May 2009)AE records
      Pollen season 2009Weekly VAS symptom diary, medication diary
      Visit 9 (September-November 2009)Medical examination, CPT, SPT, AE records, recording of improvement/deterioration on VAS

       Allergen patch system

      The patches were prepared with the grass-allergen extract derived from the pollen of Holcus lanatus, Dactylis glomerata, Lolium perenne, Phleum pratense, Poa pratensis, and Festuca elatior (MG51 Mezcal 6 Graminees, Inmunotek, Madrid, Spain). Patches with different biological activity (10 HEP: total protein content using Bradford method was 76 μg, major allergen content was 3 μg Phl p 5 equivalents; 50 HEP: 378 μg protein, 15 μg Phl p 5 equivalents; 100 HEP: 757 μg protein, 30 μg Ph p 5 equivalents) were produced by the Cantonal Pharmacy, Canton of Zurich (Zurich, Switzerland). The allergen grass-extract was dissolved in glycerol (50%), phenol (4 mg/mL), NaCl (0.15 mol/L), and phosphate buffer (10 mmol/L), at pH 7.2, and integrated into a patch system provided by Medanz Medical GmbH (Starnberg, Germany). The patch was 95 mm × 95 mm in size containing a centered 50 mm × 30 mm polyester web with the adsorbed allergen extract.

       Patient-reported treatment outcome: Hay fever symptoms on visual analog scales

      After the pollen seasons of 2008 (visit 7) and 2009 (visit 9), patients were asked to compare the seasonal hay fever symptoms to the symptoms experienced in previous years and to rate the general improvement or deterioration on a 200-mm visual analog scale (VAS) ranging from −100 (worst conceivable symptom deterioration) over 0 (unchanged symptoms) to +100 (total symptom relief).

       Symptom and medication diary

      The patients were asked to record the severity of nasal itching, sneezing, nasal obstruction, rhinorrhea, itchy eyes, lacrimation, itchy ears, itchy palate, and lung symptoms during the pollen seasons of 2008 and 2009 on a 100-mm VAS ranging from 0 (no symptoms) to 100 (most severe symptoms) on a weekly basis. To assess the average weekly symptom scores, the sum of all symptoms (except lung symptoms) was calculated and divided by the total number of symptoms. Concomitantly, the daily use of provided rescue medication was assessed: desloratidine tablets (Aerius 5 mg from Essex, Luzern, Switzerland), olopatadin eye drops (Opatanol 1 mg/mL from Alcon, Hünenberg, Switzerland), mometasone furoate nasal corticosteroid (Nasonex 50 μg per dose from Essex), and budenoside inhalation corticosteroids (Symbicort 200 μg from AstraZeneca, Zug, Switzerland). The start and end of the grass pollen season (April 28 to July 29, 2008 and May 4 to July 5, 2009, 9 weeks each) was determined according to the seasonal development of the pollen load as measured by the Swiss federal office for meteorology and climatology MeteoSwiss.

       Conjunctival provocation test

      Reactivity in CPT was tested at baseline and after the pollen seasons of 2008 (visit 7) and 2009 (visit 9). Patients were adapted to room temperature for 10 minutes. Unspecific hyperresponsiveness was excluded by the administration of a 50-μL diluent. Subsequently, 50 μL of increasing concentrations of the grass pollen extract (MG 51 6 Graminees, Inmunothek, Spain, Madrid) was administered into the lower conjunctival sac every 10 minutes, alternating between the 2 eyes. The CPT was stopped when the total symptom score reached 3 or more. Conjunctival redness, tearing, itching, burning, and swelling of the eyelids were assessed and graded according to Abelson et al.
      • Abelson M.B.
      • Chambers W.A.
      • Smith L.M.
      Conjunctival allergen challenge: a clinical approach to studying allergic conjunctivitis.

       Skin prick test

      Reactivity in SPT was tested at baseline and after the pollen seasons of 2008 (visit 7) and 2009 (visit 9). The patients were pricked with different concentrations of the grass pollen extract—0.05HEP, 0.5HEP, 5HEP, and 50HEP (MG51 Mezcal 6 Graminees, Inmunotek)— on the volar forearm. At the screening visit, polysensitization was tested by performing SPT for mugwort, hazel, birch, alder, ash, cat hair, dog hair, Dermatophagoides pteronyssinus, and Dermatophagoides farinae (Stallergènes, Antony, France). Histamine hydrochloride and normal saline (Stallergènes) were used as positive and negative control, respectively. SPT results were assessed according to the Joint Task Force on Practice Parameters, considering a wheal of diameter at least 3 mm more than that of the diluent control as a positive reaction.
      • Bernstein I.L.
      • Li J.T.
      • Bernstein D.I.
      • Hamilton R.
      • Spector S.L.
      • Tan R.
      • et al.
      Allergy diagnostic testing: an updated practice parameter.

       Safety assessment

      AEs and serious AEs were defined according to the ICH-GCP guidelines. Systemic side effects related to EPIT were graded according to the guideline of the World Allergy Organization (WAO).
      • Cox L.
      • Larenas-Linnemann D.
      • Lockey R.F.
      • Passalacqua G.
      Speaking the same language: the World Allergy Organization Subcutaneous Immunotherapy Systemic Reaction Grading System.
      Grade 1: symptoms of 1 organ system (cutaneous, upper respiratory tract, conjunctival, other); grade 2: symptoms of more than 1 organ system present or lower respiratory tract (<40% drop in peak expiratory flow [PEF] or FEV1), gastrointestinal; grade 3: lower respiratory tract (40% drop in PEF or FEV1), upper respiratory tract (laryngeal, tongue edema); grade 4: respiratory or cardiovascular failure.

       Statistical analysis

      Sample size calculation was performed assuming a mean self-reported improvement of 29% (SD = 27%) in the placebo group and a mean self-reported improvement of 52% (SD = 27%) in at least 1 treatment arm. Thus, to yield a statistically significant result with a power of 82% (2-sided analysis with α = 0.025) and an expected dropout rate of 10%, a sample size of 33 per arm (total, 132) was calculated.
      Scores from the VAS for the improvement or deterioration in hay fever symptoms were analyzed using Mann-Whitney multiple testing with Hochberg procedure adjustment. For the evaluation of seasonal VAS symptom scores, the area under the curve, assessed out of the average weekly VAS scores, was calculated for each patient. Simultaneous upper 1-sided 97.5% confidence limits for the ratios to placebo were calculated to identify the minimum effective dose to achieve a 30% improvement (ratio = 0.7) in the average VAS symptom score compared with placebo. For clinically beneficial values, the upper 1-sided limits should thus be smaller than 1. Daily medication use was compared between the groups by using the Kruskal-Wallis test. Equal distribution of local side effects at the patch application site with increasing patch number was tested by using the χ2 test. All patients with at least 1 application of the patch were evaluated for efficacy in an intention-to-treat analysis. Similarly, all subjects receiving at least 1 patch were included in the safety analysis.

      Results

       Patient flow and characteristics

      An overview of the participant flow is provided in Fig 1. From February to March 2008, 157 persons were screened for eligibility and 132 patients with allergy to grass pollen were enrolled in the study and signed informed consent. Three patients with wheal diameters of only 2.5 mm more than those of diluent controls were also enrolled (inclusion criteria ≥ 3 mm). Thirty-three patients were randomly allocated to each of the 4 treatment arms. A total of 124 patients were analyzed for efficacy, and out of these, 111 patients (89.5%) received all 6 patches. The mean treatment duration including the 4 weeks from the initial to the second patch and including the 13 patients who did not receive all 6 patches was 74 ± 13 days. In the placebo group, 30 patients received at least 1 patch during the pollen season 2008 and were therefore included in the intention-to-treat analysis. Similarly, 31 patients each of the 10HEP and 100HEP and 32 patients of the 50HEP group received treatment during 2008 and were analyzed for treatment efficacy (2008, n = 110 in total). Several patients did not attend the follow-up visits in 2009: 1 patient in the 10HEP group was excluded for the use of prednisone against asthma, and 1 patient in the 100HEP group was excluded for starting antihypertensive treatment with an angiotensin-converting enzyme inhibitor. Thus, a total of 22 patients each of the placebo group and the 10HEP treatment group as well as a total of 25 and 24 patients of the 50HEP group and the 100HEP group, respectively, were included in the efficacy analysis for the evaluation of sustained treatment effect in 2009 (n = 93 in total).
      Figure thumbnail gr1
      Fig 1Participant flow. Flow diagram characterizing the study progress and participant flow through the different trial phases. Syst, Systemic.
      At baseline, the demographic- as well as the disease-specific characteristics were similar between the 4 treatment groups with regard to disease duration, allergic asthma, and cosensitization to other allergens. Also, the disease severity between the groups was comparable at baseline, all patients having a history of moderate to severe rhinitis according to the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines as assessed by VAS
      • Bousquet P.J.
      • Combescure C.
      • Neukirch F.
      • Klossek J.M.
      • Mechin H.
      • Daures J.P.
      • et al.
      Visual analog scales can assess the severity of rhinitis graded according to ARIA guidelines.
      (Table II).
      Table IIBaseline characteristics
      CharacteristicTreatment group
      Placebo10HEP50HEP100HEP
      Age (y), mean ± SD39 ± 10.835 ± 11.336 ± 10.236 ± 10.6
      Female, n (%)9 (27.3)14 (42.4)11 (33.3)15 (45.5)
      Duration of rhinitis (y), mean ± SD23 ± 11.621 ± 11.221 ± 10.521 ± 10.6
      Severity of rhinoconjunctivitis, mean total VAS ± SD53 ± 14.947 ± 16.750 ± 1751 ± 18.5
       Severity of nasal symptoms, mean VAS ± SD60 ± 19.856 ± 19.557 ± 24.056 ± 18.9
       Severity of ocular symptoms, mean VAS ± SD63 ± 20.152 ± 25.355 ± 19.052 ± 26.5
       Severity of oropharyngeal symptoms, mean ± SD28 ± 24.024 ± 24.231 ± 29.838 ± 26.7
      Severity of lung symptoms, mean VAS ± SD38 ±33.724 ± 31.425 ± 28.924 ± 31.2
      Seasonal asthma (%)9 (27.3)9 (27.3)12 (36.4)10 (30.3)
      Monosensitized patients7 (21.2)5 (15.2)11 (33.3)7 (21.2)
      Polysensitized patients26 (78.8)28 (84.8)22 (66.7)26 (78.8)
      Baseline CPT threshold, mean ± SD
       5BU2 ± 6.11 ± 3.01 ± 3.01 ± 3.0
       50BU5 ± 15.23 ± 9.18 ± 24.210 ± 30.3
       500BU21 ± 63.621 ± 63.619 ± 57.611 ± 33.3
       5000BU5 ± 15.28 ± 24.25 ± 15.211 ± 33.3
      Baseline SPT threshold, mean ± SD
       0.05HEP15 (45.5)11 (33.3)12 (36.4)10 (30.3)
       0.5HEP6 (18.2)11 (33.3)11 (33.3)7 (21.2)
       5HEP11 (33.3)10 (30.3)9 (27.3)8 (24.2)
       50HEP1 (3.0)1 (3.0)1 (3.0)8 (24.2)
      BU, Biological units.

       Efficacy

       Patient-reported treatment outcome

      As primary endpoint we assessed the general impact of EPIT on grass pollen allergy by determination of the subjectively experienced improvement or deterioration in hay fever symptom severity by VAS. In August/September 2008, 5 months after the application of the first patch, the patients reported an improvement in seasonal hay fever symptoms in all treatment groups, including the placebo group (Fig 2). One year later, after having received no further immunotherapy, the original placebo effect vanished, and the results revealed a clear dose-response relationship. Median improvement in the placebo group and the 10HEP group was 30.73, whereas an improvement of 53.13 and 69.79 was recorded for the treatment groups 50HEP and 100HEP, respectively (Fig 2). Symptom alleviation for the high-dose treatment group was significantly different from that in the placebo group (placebo-10HEP: P = .532; placebo-50HEP: P = .141; placebo-100-HEP: P = .017).
      Figure thumbnail gr2
      Fig 2Patient-reported treatment outcome. Patients rated the general improvement/deterioration of hay fever symptoms on a scale from −100 (worst possible deterioration) to +100 (best possible improvement) during the seasons 2008 (treatment) and 2009 (follow-up). Box plots show the median, the 10th, 25th, 75th, and 90th percentiles, and outliers. Intergroup comparison by Mann-Whitney multiple testing with Hochberg procedure adjustment. ∗P < .05.

       Weekly seasonal symptom and medication score

      Treatment with 100HEP reduced the average weekly rhinoconjunctivitis symptom score by 32% (estimate = 0.68, upper 97.5% CI = 1.09) in 2008 and as compared to placebo (Fig 3). After the treatment-free follow-up year, the 100HEP-treated patients still experienced 24% reduction in the average seasonal symptom score (estimate = 0.77, upper 97.5% CI = 1.60). A dose-response relationship was observed for the reduction in seasonal symptom scores in 2009. The use of rescue medication did not significantly differ between groups within the pollen seasons of 2008 and 2009.
      Figure thumbnail gr3
      Fig 3Mean VAS symptom score for pollen season 2008 (upper panel) and 2009 (lower panel). Mean weekly VAS symptom scores (except lung symptoms) of the 100HEP group compared with those of the placebo group (left axis). For each patient, the sum of all symptom scores was calculated and divided by the number of symptoms. The continuous line shows the weekly pollen counts in Zurich (right axis).

       Conjunctival provocation test and skin prick test

      No statistically significant difference in the degree of improvement was observed in conjunctival (CPT) or skin (SPT) tolerances between the different treatment groups (data not shown).

       Safety

      During the entire study, a total of 1566 AEs were reported (Table III), of which 825 (52.7%) were graded as likely or definitely drug related. The most frequent drug-related AEs were pruritus (417 events, 26.6% of total AEs), erythma (90 events, 5.7%), wheals (149 events, 9.5%), or eczema (138 events, 8.8%). All local AEs occurred at the patch application site. The local reactions classified as eczema were short lived. Only 2 patients reported an eczema, which lasted for 3 and 4 days, respectively; eczema was treated with topical corticosteroids. All other reported eczemas lasted for 1 day only. Pruritus, erythema, wheals, and eczema were more frequent with higher allergen treatment doses (Fig 4, A). The occurrence of local reactions significantly decreased with each patch application in all the treatment groups (P < .001; Fig 4, B). The data did not suggest a correlation between the occurrence of local reactions and the amelioration of hay fever symptoms as analyzed by using the exact Mann-Whitney test for symptoms in patients with local reactions versus no local reactions (P = .797; data not shown).
      Table IIIAdverse events
      Treatment group
      Placebo (n = 33)10HEP (n = 33)50HEP (n = 33)100HEP (n = 33)
      No. of patients with AEs, n (%)33 (100)33 (100)33 (100)33 (100)
      No. of AE episodes279409427451
      Local reactions
       Pruritus53116107141
       Erythema6222933
       Eczema14295144
       Wheal4374662
      Causality assessment
       No relation, n (%)14 (5.0)14 (3.4)18 (4.2)11 (2.4)
       Unlikely/possible relation, n (%)182 (65.2)191 (46.7)162 (37.9)148 (32.8)
       Likely/definite, n (%)82 (29.4)204 (49.9)247 (57.8)292 (64.7)
       Missing, n (%)1 (0.4)000
      Severity assessment of likely/definite drug-related AEs, n (%)
       Mild60 (76.9)135 (66.2)139 (56.3)147 (50.3)
       Moderate14 (17.9)58 (28.4)82 (33.2)115 (39.4)
       Severe4 (5.1)11 (5.4)26 (10.5)30 (10.3)
      Figure thumbnail gr4
      Fig 4Local drug-related AEs. A, Numbers of the most frequent local drug-related AEs as reported in the different treatment groups. B, Frequency of local side effects per patch sequence. Distribution of the frequency of local AEs was tested by using the χ2 test.
      Eleven patients (8.3%) stopped treatment because of a systemic allergic reaction. In these cases, patches were removed and the reaction was treated intravenously with corticosteroids (125 mg methylprednisolone) and antihistamines (4 mg clemastine). Of these 11 patients, 1 had received placebo, whereas 10 had been treated with allergen extract (Table IV). The reactions were rated as grade 1 or grade 2. All 11 patients reported cutaneous reactions such as sustained pruritus distant from the patch application site and sensation of heat, whereas 4 patients additionally suffered from rhinitis and cough originating in the upper airways, or vertigo. All systemic reactions responded to treatment with corticosteroids and antihistamines. Hospitalization or adrenaline treatment was never required.
      Table IVSystemic allergic reactions necessitating intervention
      Treated with corticosteroids and antihistamines.
      Treatment groups
      Placebo (n = 33)10HEP (n = 33)50HEP (n = 33)100HEP (n = 33)
      Systemic allergic reaction
       Grade 1, n1132
       Grade 2, n0202
       Grade 3, n0000
       Grade 4, n0000
      Treated with corticosteroids and antihistamines.

      Discussion

      The fact that allergic diseases constitute a global health problem with considerable impact on socioeconomic life
      • Nathan R.A.
      The burden of allergic rhinitis.
      underlines the need to develop a novel and convenient route for SIT with high efficacy and broad acceptance. Since the burden of allergic diseases not only goes beyond symptom scores and medication use but also affects the quality of life, we chose the patient-reported outcome measure, the primary endpoint being changes in hay fever symptoms as described by VAS. A strong placebo effect was observed during the treatment season (2008), but as this effect declined in the second year, the results revealed that EPIT with grass pollen allergens caused a dose-dependent alleviation of allergy symptoms overall. Patients treated with 100HEP reported a 70% improvement overall in hay fever symptoms, and this result was significantly different from the that in the placebo-treated group. Interestingly, a weaker placebo effect was observed when assessing the specific seasonal rhinoconjunctivitis symptom scores, with allergen-EPIT–mediated symptom improvement recorded both in the first (32%) and second (24%) years.
      Although statistical significance for self-reported symptom improvement was reached only for the high-dose treatment group, it is important to consider that statistical significance does not parallel treatment benefits under real-life conditions. Therefore, it has been proposed that every improvement of more than 30% is clinically relevant. Correspondingly, an improvement between 30% and 45% is judged as “little” treatment effect, whereas an improvement between 46% and 60% is assessed as “moderate” treatment effect and an improvement of more than 60% as a “strong” effect.
      • Pfaar O.
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      Clinical outcome measures of specific immunotherapy.
      According to such a rating, treatment effect was strong with 100HEP, moderate with 50HEP group, and absent with 10HEP. Strikingly, such clinically relevant effect was achieved through the application of merely 6 patches over a time period of only approximately 8 weeks.
      Overall, EPIT proved to be safe, but not without systemic allergic side effects, which required treatment and led to study exclusion in 8% of the treated patients. Yet, all these systemic allergic reactions were mild (grade 1 or 2) and occurred within 45 minutes after patch application. This is comparable to conventional subcutaneous allergen-specific immunotherapy where the number of systemic AEs using aeroallergens ranges from 1%
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      Non-fatal systemic reactions to subcutaneous immunotherapy: a 20-year experience comparison of two 10-year periods.
      to 29% of the patients.
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      Local reactions such as pruritus, erythema, wheal, and eczema at the patch application site were frequent; although bothersome, the appearance of eczema suggests allergen presentation to T cells.
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      • Niggemann B.
      • Rance F.
      • Vanto T.
      • Werfel T.
      EAACI/GA2LEN position paper: present status of the atopy patch test.
      T-cell involvement is a crucial mechanism in SIT and enables to redirect the pathogenic TH2 response toward a more protective TH1 or T-regulatory response.
      • Akdis M.
      • Akdis C.A.
      Therapeutic manipulation of immune tolerance in allergic disease.
      • Maggi E.
      T-cell responses induced by allergen-specific immunotherapy.
      Interestingly and over time, local reactions decreased, suggesting a reduction in allergen-specific T-cell reactivity and the development of peripheral T-cell tolerance, which is a key feature of successful SIT.
      • Akdis M.
      • Akdis C.A.
      Therapeutic manipulation of immune tolerance in allergic disease.
      • Bohle B.
      • Kinaciyan T.
      • Gerstmayr M.
      • Radakovics A.
      • Jahn-Schmid B.
      • Ebner C.
      Sublingual immunotherapy induces IL-10-producing T regulatory cells, allergen-specific T-cell tolerance, and immune deviation.
      • Jutel M.
      • Akdis M.
      • Budak F.
      • Aebischer-Casaulta C.
      • Wrzyszcz M.
      • Blaser K.
      • et al.
      IL-10 and TGF-beta cooperate in the regulatory T cell response to mucosal allergens in normal immunity and specific immunotherapy.
      • Radulovic S.
      • Jacobson M.R.
      • Durham S.R.
      • Nouri-Aria K.T.
      Grass pollen immunotherapy induces Foxp3-expressing CD4+ CD25+ cells in the nasal mucosa.
      We are currently addressing these issues in a recently initiated clinical trial with epicutaneous immunotherapy.
      The results of the present trial confirm the results and the conclusion of the previous and very first clinical trial on EPIT.
      • Senti G.
      • Graf N.
      • Haug S.
      • Ruedi N.
      • von Moos S.
      • Sonderegger T.
      • et al.
      Epicutaneous allergen administration as a novel method of allergen-specific immunotherapy.
      In the latter pilot study, the patch preparation was guided by the patch test for the diagnosis of contact dermatitis, in which the allergen extracts are applied in soft paraffin for 48 hours to pulse skin resident antigen-presenting cells.
      • Turjanmaa K.
      • Darsow U.
      • Niggemann B.
      • Rance F.
      • Vanto T.
      • Werfel T.
      EAACI/GA2LEN position paper: present status of the atopy patch test.
      • Darsow U.
      • Vieluf D.
      • Ring J.
      Atopy patch test with different vehicles and allergen concentrations: an approach to standardization.
      One problem with the paraffin-based patch was that paraffin leaked from the patch. To overcome this problem, the patches used in the present study were prepared with aqueous allergen solutions.
      Another problem in the first trial
      • Senti G.
      • Graf N.
      • Haug S.
      • Ruedi N.
      • von Moos S.
      • Sonderegger T.
      • et al.
      Epicutaneous allergen administration as a novel method of allergen-specific immunotherapy.
      was that 48 hours of allergen application caused incidents of strong local eczematic reactions. In the present study, we therefore shortened the treatment to 8 hours, assuming that a shorter application still pulsed skin resident antigen-presenting cells, but later, when T cells start infiltrating, the allergen would already be gone. In fact, while 160 eczema reactions were reported after 244 patch applications in 15 of the 21 allergen-treated patients in the original trial, only 44 and milder eczema reactions occurred after 198 patch applications in 20 of the 33 patients of the 100HEP-treated group in the current trial. In our first study, 10 of the 15 allergen-treated patients required treatment with topical corticosteroids, whereas only 2 of the 33 patients in the current trial used topical corticosteroids.
      In comparison with the original EPIT trial,
      • Senti G.
      • Graf N.
      • Haug S.
      • Ruedi N.
      • von Moos S.
      • Sonderegger T.
      • et al.
      Epicutaneous allergen administration as a novel method of allergen-specific immunotherapy.
      the number of patch applications in the current trial was reduced from 12 to 6. To compensate for this reduction, higher allergen doses were applied. In the first trial we used 300 Index of Reactivity Phleum pratense extract containing 21 μg of Phl p 5 equivalents. In the present trial, 100 HEP grass pollen extract containing 30 μg of Phl p 5 equivalents was used. Thus, the cumulative doses of Phl p 5 in the 2 trials were 252 and 180 μg of Phl p 5, respectively.
      The changes described above had no notable impact on efficacy, as both trials produced comparable symptom amelioration. In our first trial,
      • Senti G.
      • Graf N.
      • Haug S.
      • Ruedi N.
      • von Moos S.
      • Sonderegger T.
      • et al.
      Epicutaneous allergen administration as a novel method of allergen-specific immunotherapy.
      median symptom improvement in patients receiving allergen EPIT was 72% (18% with placebo), whereas in the present study, median symptom improvement with allergen EPIT was 70% (31% with placebo).
      The current trial demonstrates that higher allergen doses enhance the efficacy of EPIT. The maximal allergen doses applicable to the skin, however, are limited by safety issues. Local AEs, the most irritating being eczema, may be reduced by shortening the time period of carrying the patch. However, the application of high allergen doses to tape-stripped skin bears a significant risk of systemic allergic reactions due to the removal of the strateum corneum and, hence, disruption of the skin’s natural barrier to xenobiotics. Alternative methods of skin preparation should therefore be evaluated in terms of safety for epicutaneous or transdermal allergen application. These methods include microneedle patches, liposomal allergen formulations, hydration of the stratum corneum, or a combination of these methods. In summary, the current study provides data that suggest a dose-response relationship in the treatment of hay fever with allergen EPIT, a method that extends the growing field of needle-free vaccination methods delivering the antigen via the skin. Transcutaneous vaccination against infectious diseases such as travellers’ diarrhea
      • Frech S.A.
      • Dupont H.L.
      • Bourgeois A.L.
      • McKenzie R.
      • Belkind-Gerson J.
      • Figueroa J.F.
      • et al.
      Use of a patch containing heat-labile toxin from Escherichia coli against travellers’ diarrhoea: a phase II, randomised, double-blind, placebo-controlled field trial.
      and influenza
      • Combadiere B.
      • Vogt A.
      • Mahe B.
      • Costagliola D.
      • Hadam S.
      • Bonduelle O.
      • et al.
      Preferential amplification of CD8 effector-T cells after transcutaneous application of an inactivated influenza vaccine: a randomized phase I trial.
      are examples of this promising vaccination route. EPIT represents an easy and painless administration route that might also promote prescription of SIT in children, which is an important medical goal, since SIT has the potential to stop disease progression to asthma.
      • Jacobsen L.
      • Niggemann B.
      • Dreborg S.
      • Ferdousi H.A.
      • Halken S.
      • Host A.
      • et al.
      Specific immunotherapy has long-term preventive effect of seasonal and perennial asthma: 10-year follow-up on the PAT study.
      • Hankin C.S.
      • Cox L.
      • Lang D.
      • Bronstone A.
      • Fass P.
      • Leatherman B.
      • et al.
      Allergen immunotherapy and health care cost benefits for children with allergic rhinitis: a large-scale, retrospective, matched cohort study.
      Clinical implications
      Epicutaneous allergen-specific immunotherapy is a convenient, safe, and efficacious treatment for IgE-mediated allergies, leading to symptom relief after a single treatment season.
      We thank study nurses Mirjam Blattman, Miriam Hunziker, Andrea Nef, and Iris Häner for their support.

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