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Sublingual immunotherapy: from proven prevention to putative rapid relief of allergic symptoms

Allergen-specific immunotherapy (SIT) for the treatment of allergic rhinitis and asthma was first introduced in 1911. Although millions of patients have received this form of treatment, it has remained a controversial therapy since its inception. The vast majority of randomized double-blind, placebo-controlled trials have only been performed since the 1960s and standardized allergen vaccines have only been available for the past 25 years. It is now recognized that subcutaneous SIT using appropriate doses, high-quality allergen vaccines and an appropriate indication is effective in rhinitis and asthma caused by pollens and mites (1). However, although sublingual immunotherapy (SLIT) using high-dose vaccines is widely used in many European countries (2), it is still controversial (3) and this form of therapy has gained little acceptance in the US. Evidence-based medicine (EBM) is an increasingly important concept which has become a new paradigm in medicine. It is the ability to track down, critically appraise (for its validity and usefulness) and incorporate the information obtained from randomized trials to establish the clinical bases for diagnosis, prognosis and therapeutics (4). The increasing influence of EBM is due partly to the work of the Cochrane Collaboration which has led the way in setting new standards for preparing systematic reviews (5). Cochrane reviews are, on average, more systematic and less biased than systematic reviews published in paper journals. However, they have not yet all been perfected as errors and biases also occur in Cochrane reviews (6). For SLIT, there was, however, no pivotal controlled trial nor has a meta-analysis yet been published. An evidence-based evaluation was therefore impossible. In this issue of the journal, Wilson et al. (7) publish the Cochrane Collaboration meta-analysis of SLIT in rhinitis. Twenty-two trials involving 979 patients were included in the analysis. There were six trials of SLIT for house dust mite allergy, five for grass pollen, five forParietaria, two for olive pollen and one each for, ragweed pollen, cat dander, and Cupressus pollen. Four studies exclusively tested children. The authors concluded that SLIT is a safe treatment which significantly reduces symptoms and medication requirements in allergic rhinitis. The size of this benefit compared to that of other available therapies, particularly injection immunotherapy, is not clear, having been assessed directly in very few studies. Further research is required concentrating on optimizing allergen dosage and patient selection. This study therefore confirms the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines (1) which proposed that SLIT is one of the treatment options for allergic rhinitis in adults. However, more information is required on SLIT. Although the same conclusions will probably be arrived at, more data are needed to confirm the efficacy of SLIT in asthma and in children. The safety of SLIT in asthma and in children is now ascertained (8). Moreover, we need more data to find the relative indications of SLIT and subcutaneous SIT (9). So, what may be the next step for SLIT? As SLIT is a safe treatment with doses currently administered, rush SLIT can be performed without the risk of serious systemic reactions observed with subcutaneous SIT. Can these high doses then be effective within minutes after J. Bousquet Clinique des Maladies Respiratoires, University Hospital and INSERM U454, H pital Arnaud de Villeneuve, CHU Montpellier, France