The EAACI guideline highlights- HDM AIT and general asthma management,contraindications and precautions, and risk management of HDM AIT.

The guidelines can help clinicians make decisions for prescribing allergan immunotherapy(AIT) to patients of house dust mite(HDM)-induced asthma. The aim was to introduce AIT as an additional treatment for general asthma for those who suffer from HDM-driven allergy asthma. According to GINA, if asthma in a patient is allergy-driven, AIT can prove to be beneficial. Supporting trials provide evidence that HDM AIT can be integrated into the general management of allergic asthma.

Safety, precautions and contraindications

The following safety measures, precautions and contraindications should be kept in mind while considering integrating HDM AIT in the management of HDM-induced asthma, depending upon the level of asthma control:

• There is only limited data available about the possible adverse situations in patients with moderate or severe allergic asthma
• Uncontrolled asthma is a major risk in terms of fatal adverse reactions and hence, a significant contraindicator for HDM SCIT and SLIT
• Select cases of patients with severe but controlled HDM-driven asthma can be considered eligible for HDM AIT but only under careful supervision
• The summary of product characteristics (SmPC) should also be reviewed to derive product-specific precautions and contraindications arising from the difference in preparations
  • HDM AIT is definitely not safe for patients with uncontrolled asthma
  • HDM SLIT-tablet may be considered for patients with controlled asthma but with adequate caution
  • HDM AIT for patients of partially controlled asthma may show improved asthma control and quality of life
  • HDM SLIT-tablet for adults, whose asthma is not well controlled by ICS or combination products, does not increase the risk of adverse events
  • AIT should not be started in pregnancy, however, it can be continued during pregnancy
  • AIT should not be initiated in patients with active or uncontrolled autoimmune disorders or any active malignancies
  • AIT is not recommended for asthma patients also suffering from immune deficiencies, active infections and infestations, and uncontrolled diseases such as diabetes, inflammatory bowel disease, gastric ulcer, etc.
  • Caution must be practiced if AIT has to be considered for asthma patients under treatment with beta‐blockers (BB) or ACE inhibitors (ACEI); the clinician should ensure it is given in specialised settings only, as it can cause increased refractoriness to treatment of anaphylaxis with epinephrine

Recommendations for risk management of HDM AIT

Common recommendations

1. Ensure you have provided correct and necessary information and have a sign for patient’s/guardian’s consent
2. Administration of HDM SCIT should be done under the supervision of a healthcare professional (HCP), who is also trained in assessing patients with allergic asthma while they are in a setting that facilitates proper management of the therapy and its evaluation, too.
3. The patient should be kept under observation for at least 30 minutes after giving the injection

Recommendations specific to HDM SCIT

1. Evaluate the patient’s current health to determine any changes that may make it necessary to consider reviewing AIT therapy
2. The patient and/or guardians of the patient should be provided education in management of HDM SLIT therapy at home and for events of late reporting of reactions

Recommendations specific to HDM SLIT

1. Patients and/or guardians of patients must be provided education and written information on identifying fatal reactions, contacting the HCP about adverse reactions, missed doses, gaps in treatment or anything that can hamper the course of treatment.
2. Patients and/or guardians of patients should be informed of when to discontinue SLIT; i.e in case of oral inflammation, such as mouth ulcers, lichen planus, stomatitis aphthous, or dental extractions. And that the treatment can be continued only a few hours after the reaction, such as gum bleeding, has subsided.
3. In case of any dental procedure, the patient should wait for up to 24 hours before resuming SLIT.
4. Information on when to withhold a SLIT dosage should be provided. For example, when there can be a systemic allergic reaction to a situation; the potential situations and the advice of withholding SLIT should be clearly mentioned.
5. Regular follow-ups should be made mandatory to ensure safety.

To read the first part of this guideline, click, Allergen Immunotherapy treatment for house dust mite-induced asthma: EAACI recommendations