Grass pollen immunotherapy for treatment of allergic rhinitis.

A 33 year old female teacher presented with a history of troublesome allergic rhinoconjunctivitis and seasonal asthma. Since her teens, from May through to August she had experienced sneezing, nasal congestion, rhinorrhoea, itchy red eyes, and occasional breathlessness. In previous summers, her general practitioner had prescribed daily intranasal budesonide, oral cetirizine, and cromoglicate eye drops, together with inhaled salbutamol as needed. Although she had experienced a modest improvement with this treatment, symptoms continued to impair her concentration in the classroom and her quality of sleep. Her general practitioner referred her for consideration of “desensitisation.” Grass pollen immunotherapy involves repeated administration of high doses of grass pollen allergen with the aim of inducing clinical and immunological tolerance in the recipient. Immunotherapy formulations contain an extract of one or more species of grass pollen and are administered either as a course of subcutaneous injections (“subcutaneous immunotherapy”) or as daily sublingual drops or dissolving tablets (“sublingual immunotherapy”) for three years. Experience with subcutaneous immunotherapy, first described more than 100 years ago,1 is extensive; experience with sublingual immunotherapy is less so. In the United Kingdom, grass pollen immunotherapy is indicated in selected patients whose allergic rhinitis remains highly bothersome despite conventional medical treatment with intranasal corticosteroid sprays and oral or topical antihistamines.2 The clinical effect is believed to derive from induction of T cells that produce interleukin 10 (regulatory T cells) and B cells that produce allergen specific IgG antibodies.3 Interleukin 10 has multiple anti-inflammatory properties, and grass pollen specific IgG blocks some of the actions of IgE, which largely mediates the immediate hypersensitivity reaction. Side effects mainly occur as IgE mediated reactions to the vaccines. Many clinical guidelines support use of immunotherapy for treatment of refractory allergic rhinitis that affects quality of life, sleep, work, or social activities. A Cochrane …