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Low dose sublingual therapy in patients with allergic rhinitis due to house dust mite

Clinical allergy provides a forum for the publication of papers on all aspects of clinical and experimental allergy. Provided the studies are scientifically sound and of contemporary interest, they are likely to be accepted even if the subject matter is controversial. Readers will then be able to make their own critical evaluation of a particular presentation and perhaps engage the authors in a healthy exchange of views through the Journal's correspondence section. With these sentiments in mind, the paper by Scadding and Brostoff in the current issue should arouse considerable comment. Their study has demonstrated most unexpectedly favourable responses to low dose sublingually administered house dust mite extract in patients with mild allergic perennial rhinitis. The double-blind cross-over trial was completed in only eighteen individuals with extremely short, 2-week, treatment periods and only a 2-week washout phase. Responses were monitored by subjective assessment, twice daily nasal peak inspiratory flow (NPIF), nasal allergen challenge, and total and house dust mite specific IgE. Subjectively and by nasal provocation, significantly more patients improved in the active treatment phase but not surprisingly there was no change in IgE levels. Overall the NPIF did not improve but subjective improvement was to some extent correlated with an increase in the morning NPIF, though changes were very small. This study is based on a 'low zone tolerance' using the Miller method of intradermal testing to determine the therapeutic allergen dose [1]. Many authorities would reject this procedure as being unproven with no known immunological mechanism which could account for the phenomenon [2]. Furthermore, orally administered allergen therapy has an equally chequered history [3]. Thus the background justification for the trial may well be unsound, though Noon [4] and Freeman introduced subcutaneous hyposensitization on a similar unsound theory with some success, though controversy persists as to how much [5]. The very short duration of the therapeutic response is difficult to explain by an immunological theory and an effect on allergen-induced late reactions seems highly improbable. Claims for efficacy of low dose sublingual therapy abound in the literature. This is one of the first double-blind assessments and must be applauded as such. However allergic diseases are very variable and much longer studies on a larger number of patients with more severe disease are required before this approach can be considered as a serious therapeutic option.