Diapositiva 1

SLIT nel bambino:
più efficace,
più sicura?
G. B. Pajno
Dipartimento di Pediatria – U.O. di Allergologia Pediatrica
Università di Messina
Milano,
31 Gennaio – 1-2 Febbraio 2008
PREMESSA
Prevenzione e terapia non farmacologica
delle malattie allergiche
 Probiotici
 Profilassi ambientale
 Dietoterapia
Authors’ conclusions
There is insufficient evidence to recommend the addition of probiotics to infant feeds for
prevention of allergic disease or food hypersensitivity. Although there was a reduction in
clinical eczema in infants, this effect was not consistent between studies and caution is advised
in view ofmethodological concerns regarding included studies. Further studies are required to
determine whether the findings are reproducible.
Probiotics in infants for prevention of allergic disease and food hypersensitivity (Review)
Copyright © 2007 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd
Therefore from these studies, it is
reasonable to conclude that in real-life
circumstances it is not possible to
reduce the exposure to house dust
mite in such a way that it has clinically
relevant consequences for asthmatic
patients.
J Allergy Clin Immunol 2007;119:1323-8.
Trattamento farmacologico
Effetti del Montelukast dopo
la sospensione
Effects of montelukast treatment and withdrawal on fractional exhaled nitric oxide and lung function
in children with asthma.
Montuschi P, Mondino C, Koch P, Ciabattoni G, Barnes PJ, Baviera G.
Department of Pharmacology, Faculty of Medicine, Catholic University of the Sacred Heart, Largo F. Vito, 1, 00168 Rome, Italy.
Chest. 2007 Dec;132(6):1876-81.
BACKGROUND: Leukotriene receptor antagonists (LTRAs) reduce fractional exhaled nitric oxide (Feno)
concentrations in children with asthma, but the effect of LTRA withdrawal on Feno and lung function is unknown. We
aimed to study the effect of treatment and withdrawal of montelukast, a LTRA, on airway inflammation as reflected by
Feno and lung function in children with asthma.
METHODS: A double-blind, randomized, placebo controlled, parallel group study was undertaken in 14 atopic children
with mild persistent asthma who were treated with oral montelukast (5 mg/d for 4 weeks) and 12 atopic children with
mild persistent asthma who received matching placebo. A follow-up visit was performed 2 weeks after montelukast or
placebo withdrawal.
RESULTS: Montelukast reduced Feno concentrations by 17% (p = 0.067), an effect that was more pronounced (35%) [p
= 0.0029] when children with seasonal atopy who were exposed to relevant allergens during the treatment phase were
excluded from analysis (n = 3). Compared to those at the end of treatment, Feno concentrations were increased 2 weeks
after montelukast withdrawal (p = 0.023) concomitant with a reduction in absolute FEV(1) values (p = 0.011), FEV(1)
percentage of predicted values (p = 0.006), FEV(1)/FVC ratio (p = 0.002), and forced expiratory flow at 25% to 75% of
FVC values (p = 0.021). These changes were not observed in the placebo group.
CONCLUSIONS: LTRAs reduce Feno concentrations in children with asthma, and withdrawal can result in increased
Feno values and worsening of lung function in children with asthma.
G.B. Pajno
Allergens
Exposure
Birth
Food Allergens
Inhalant Allergens
TH2 polarized
Immunity
Persistent
Persistent Wheeze Allergic
Atopic Dermatitis
Diseases
Hay Fever
Food Allergy
S
L
Increasing post-natal
I
T
Hampering
age
the progression and
worsening of IgE
mediated disorders
J Allergy Clin Immunol 2007;119:796-801.
PIÙ EFFICACE?
Rispetto alla farmacoterapia la SLIT è un
approccio differente.
Initial Trial
Current Trial
Durham S.R. et al.
Long-Term Clinical Efficacy of Grass-Pollen Immunotherapy.
N Eng J Med 1999; 341: 468-475
Novembre E et al J Allergy Clin Immunol 2004:114:851-7
PIÙ EFFICACE?
SLIT versus SCIT
Symptom reduction with SCIT -0.73
(OR-0.97, -0.50) compared with
SLIT -0.42 (OR -0.69, -0.15) and
Medication reduction with SCIT
-0.57 (OR -0.82, -0.33) compared
with SLIT -0.43 (OR -0.63, -0.23).
“…The findings suggest that SLIT
efficay
may
require
a
longer
duration of treatment. …”
Nella
maggioranza
letteratura
inizia
dopo
dei
l’efficacia
il
primo
lavori
della
anno
di
SLIT
di
trattamento.
Cox L. Current Allergy and Asthma Reports 2007;7:410-420.
While new pharmacological avenues
seem to be leading mostly to blind
alleys, do you think that there is
hope that other approaches, such as
sublingual
thermal
immunotherapy
bronchoplasty,
useful in clinical practice?
may
and
be
SLIT:
È PIÙ SICURA DELLA SCIT?
I PUNTI CONTROVERSI
 Dosaggio ed omogeneità degli estratti
 Cause di inefficacia
I PUNTI CONTROVERSI
 Dosaggio ed omogeneità degli estratti
 Cause di inefficacia
(J Allergy Clin Immunol 2007;119:796-801.)
I PUNTI CONTROVERSI
 Dosaggio ed omogeneità degli estratti
 Cause di inefficacia
IL FUTURO CLINICO DELLA SLIT
 Almeno tre anni di terapia
 “Richiamo” al bisogno, soprattutto per le
pollinosi
CONCLUSIONI 1
CONCLUSIONI 2
“... We Will leave by Messina ...”
Riccardo I Cuor di Leone III Crociata