變應(yīng)原免疫治療進(jìn)展-20160327

變應(yīng)原免疫治療研究進(jìn)展

TheprogressofAllergenImmunotherapyresearch

重慶新橋醫(yī)院程曉明Mar27th2016重慶變應(yīng)性疾病-如影相隨GuptaR,etal.BMJ.2003Nov15x;327(7424):1142-3NinanTK,etal.BMJ.1992Apr4;304(6831):873-5歷史變遷LarchéM,etal.NatRevImmunol.2006;6(10):761-71VonPirquet是SpecificImmunotherapy(SIT)

還是AllergenImmunotherapy(AIT)?CalderónMA,etal.Allergy.2013;68(7):825-8AIT的機(jī)制是什么？AkdisCA,etal.WorldAllergyOrganJ.2015;8(17):1-12.Mechanismsofallergen-specificimmunotherapyandimmunetolerancetoallergens.Veryearlybasophiltolerance:EarlydecreaseinmastcellandbasophilactivityforsystemicanaphylaxisTypeIskintestreactivityEarlyincreaseinspecificIgEfollowedbyalatedecreaseinspecificIgEIncreaseinspecificIgG4andinsomestudiesIgAandIgG1DecreasednumbersoftissuemastcellsandeosinophilsandreleaseoftheirmediatorsinnasalmucosalbiopsiesofallergicrhinitispatientsDecreasedskinlate-phaseresponseinparalleltodecreasedlymphocyteandeosinophilinfiltrationInductionofTregandBregcellssuppressionofTh2-Th1cellsAIT可能的推手-Treg和BregAkdisCA,etal.WorldAllergyOrganJ.2015;8(17):1-12.Mechanismsofallergen-specificimmunotherapyandimmunetolerancetoallergens.PharmacotherapyAllergenavoidanceAllergenimmunotherapyPatienteducation變應(yīng)性疾病綜合治療方案BousquetJ,etal.JAllergyClinImmunol.1998;102(4Pt1):558-62Allergenimmunotherapy:therapeuticvaccinesforallergicdiseases.AWHOpositionpaper.內(nèi)容建議推薦強(qiáng)度環(huán)境因素那些明確因環(huán)境變應(yīng)原致病的患者應(yīng)避免接觸已知變應(yīng)原或進(jìn)行環(huán)境控制（不養(yǎng)寵物、使用過(guò)濾系統(tǒng)、防螨罩或殺螨劑）可選SeidmanMD,etal.OtolaryngolHeadNeckSurg.2015;152(1Suppl):S1-43GINA和NAEPP關(guān)于環(huán)境控制的建議GINA2014NEnglMed2009;360:1862-9AIT對(duì)蜂毒過(guò)敏反應(yīng)、過(guò)敏性鼻炎/結(jié)膜炎，過(guò)敏性哮喘有效免疫治療是唯一可以影響變應(yīng)性疾病自然病程的治療方法，它還可阻止變應(yīng)性鼻炎發(fā)展為哮喘成功的免疫治療取決于標(biāo)準(zhǔn)化的、可持續(xù)生產(chǎn)的高質(zhì)量變應(yīng)原疫苗BousquetJ,etal.JAllergyClinImmunol.1998;102(4Pt1):558-6210200620112012歐美AIT現(xiàn)狀BurksAW,etal.JAllergyClinImmunol.2013;131(5):1288-96變應(yīng)原配方療效：由于研究設(shè)計(jì)的多樣性，使得比較困難總結(jié)：只給患者接種引起癥狀的變應(yīng)原NelsonHSetal.JAllergyClinImmunol.2009;123:763-769脫敏途徑-SCIT或SLIT歐洲：SLIT占AIT的45%，區(qū)域差別大（北歐限新EMA注冊(cè)變應(yīng)原，德國(guó)25%，南歐80%）美國(guó)：2014年4月FDA批準(zhǔn)3種舌下片劑

傳統(tǒng)治療：SCIT對(duì)AIT療效的共識(shí)-過(guò)敏性疾病修飾劑CommitteeforMedicinalProductsforHumanUse(CHMP)andEfficacyWorkingParty(EWP)預(yù)防變應(yīng)性鼻炎并發(fā)哮喘預(yù)防對(duì)新變應(yīng)原過(guò)敏停用后保持長(zhǎng)期臨床效果真實(shí)世界

AIT對(duì)預(yù)防鼻炎進(jìn)展為哮喘的肯定作用

-6年回顧性研究SchmittJ,etal.JAllergyClinImmunol.2015Dec;136(6):1511-6RA患者進(jìn)行AIT發(fā)生哮喘的危險(xiǎn)顯著低于非AITSCIT的預(yù)防作用顯著天然提取物制備的變應(yīng)原作用顯著3年和更久的治療作用顯著對(duì)AIT現(xiàn)狀的共識(shí)-適應(yīng)癥適應(yīng)癥：同時(shí)罹患哮喘和鼻炎變應(yīng)性鼻炎藥物不能控制癥狀嚴(yán)重藥物不良反應(yīng)不愿長(zhǎng)期用藥

對(duì)AIT現(xiàn)狀的共識(shí)-操作指南適應(yīng)癥禁忌癥治療后觀察30mins妊娠期AITβ-阻滯劑的使用人員培訓(xùn)醫(yī)療器械準(zhǔn)備醫(yī)療文件準(zhǔn)備對(duì)AIT現(xiàn)狀的共識(shí)-低估AIT的治療價(jià)值盡管均認(rèn)為AIT是唯一對(duì)哮喘和鼻炎起到修飾作用的治療，目前僅5%患者接受AIT療效證據(jù)不充分支出-獲益比不明