Updated immunotherapy could be ‘game changer’ for allergy sufferers

Film and TV production student James Clegg grew up with allergies, knowing each autumn and winter of his childhood heralded asthma attacks and that hay fever of late spring and summer would bring nasal misery, which could trigger his asthma.

“I have had asthma since about the age of four. I was born with eczema and when that was leaving me the asthma developed.” Over the autumn months it would begin to get worse.

“There was one Halloween that I ended up in hospital for over a week. I was probably about eight or nine then. There were other years that I didn’t end up in hospital but I had a nebuliser in the house and I would be hooked up to that all day long for about a week.”

Although it had a big impact on his childhood, it was also his normal. “It was just who I was, part of my life, it wasn’t a big deal to me. When I was younger, whenever I had an asthma attack I would be reassuring other people I would be okay.”

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Now aged 22 and in his final year at Dundalk Institute of Technology, he recalls how at the beginning of every year in primary school he would introduce himself to his new teacher saying: "Hi, I'm James and I have asthma – here's a spare inhaler in case something happens."

Nearly every day he would have the beginnings of an asthma attack if playing chasing around the yard, he says, which would mean he would have to sit out and use his inhaler for a while. “Obviously me not knowing anything else, it was all normal for me. I would see other kids without asthma but I was running around with them as much as I could as well, it’s just every now and then I would have to take a bit of a break.”

However, he stopped playing certain sports because he had to adapt and opt for “more stationary stuff”. He took up sailing with his father and, from about the age of 14, also started doing clay pigeon shooting with him. “I would have tried every kind of sport when I was younger: football, basketball, cricket, tennis – all kinds of stuff but, because the seasons go into the winter months, I wasn’t able to keep them up.”

There was little reprieve in the summer because James, who lives in Malahide, Co Dublin, is one of the estimated 300,000-plus people in Ireland who has both asthma and hay fever.

"My nose was at me during the summer when the pollen was high. I couldn't cut the grass really, I would have to be careful. Playing football out on the green with my friends for a little bit, I would get the sniffles. Because that's all to do with breathing, it would affect my asthma. It all comes back to that."But maybe for not much longer. James has started a programme of sublingual immunotherapy, which he is hoping will desensitise him to his two most troublesome allergens. Rather than just addressing the symptoms, as allergy medications do, sublingual immunotherapy aims to modify patients' immune response to their allergies – although the process takes two to three years.

We are still waiting on big, big trials so that we can, hands on heart, say this treatment is fantastic

Allergen immunotherapy, using injections of tiny, modified amounts of allergens to build up a person’s tolerance, has been a proven treatment for 100 years but it wasn’t without risks. Those being treated for their allergy to, say, a bee or wasp sting, could go into anaphylactic shock.

Dr Dermot Nolan, a GP and asthma specialist in Co Waterford, explains how after immunotherapy attracted some red flag warnings about being used in hospital settings only, it "went out of fashion" in the UK and Ireland. But with the updated version of the treatment which involves large doses of certain allergens in tablet or liquid form under the tongue, it is emerging as an effective option for sufferers of hay fever and asthma.

Sublingual immunotherapy has become "a real game changer", says Dr Nolan of Tramore Medical Centre, who runs a regional asthma clinic. He has been using it "really successfully" for patients with uncontrolled rhinitis and hay fever for the past seven or eight years.

“Some of these patients suffered really badly. Their summers were destroyed, they often couldn’t work, or students couldn’t study, and their lives were pure misery for many months, despite multiple medications. The only thing that worked was oral immunotherapy.”

The two drugs that he has been prescribing to desensitise the allergic response to pollen are reimbursable under the HSE’s medical card or drugs payment schemes. A corresponding one for the house dust mite is yet to be included on that list.

The house dust mite is one of the main drivers of asthma in Ireland, with about 50 per cent of asthma patients being allergic to it, says Nolan, who works closely with the Asthma Society of Ireland. "We are still waiting on big, big trials so that we can, hands on heart, say this (sublingual) reatment is fantastic. We have got some evidence but we don't have brilliant evidence."

However, the guidelines of the Global Initiative for Asthma, which used to recommend it only for extreme patients, has now said it could be considered for “moderate” asthma patients, he reports. “So I think you are going to see more of it in the next little while. I think you are going to see more of it in younger people.”

The house dust mite immunotherapy drug is licensed for children (over 12 years) as well as adults but, as it is a three-year treatment, the child has to co-operate and parents have to buy into it, Nolan observes.

“It is a relatively new drug so we will be monitoring responses and review. We are still learning about this but I think in time we will be able to target this treatment to a more exact cohort of asthmatic patients.”

A survey conducted by the Asthma Society of Ireland last April found that the most common allergies among asthma/chronic obstructive pulmonary disease (COPD) sufferers were to pollen (63 per cent) or house dust mites (56 per cent). More than 33 per cent of respondents reported a diagnosis of allergy to pet or animal hair, while a fifth had confirmed allergies to certain foods.

Nolan believes more patients should, and are, opting for immunotherapy, as heath literacy and awareness improves among the public. However, there are barriers to it in Ireland, he acknowledges, not least of which is the lack of immunology services in secondary care and the cost of private treatment. The very limited number of immunologists means in public allergy care it is people with severe, anaphylactic reactions who are generally prioritised for treatment.

“Nobody is going to die of hay fever,” remarks Nolan. But nearly one person a week in the Republic does suffer a fatal asthma attack.

The public clinical immunology department in St James’s Hospital, Dublin, which includes venom desensitisation and desensitisation treatment (allergic rhinitis – grass and house dust mite only) among its services, has a waiting list of up to 24 months for routine cases.

“This is an ongoing problem,” it says on its website. “The single most important factor is that there are not enough clinical immunology doctors available to provide the increasing breadth of service required for an increasing number of patients.

“We believe that this is a major unmet need across the health service,” it adds.

Patients attending St James’s immunology department must be referred by a GP or some other healthcare professional, whereas private clinics that offer allergen immunotherapy will usually take self-referrals.

James  takes a little tablet under his tongue at home each day, building up his tolerance to the allergen, and has periodic check-ups with the consultant

As we approach allergy season, the Asthma Society is advising patients to get their allergies under control in a newly launched allergy awareness campaign, supported by ALK. “Now is the time for people who regularly experience allergy symptoms, where they are not controlled on current medications and it has an impact on their life, to seek a medical diagnosis and take appropriate measures, such as using other available treatment options to get their allergies under control,” says a society spokeswoman. “For more information, reach out to your GP.”

As a young adult, James heard about allergy testing and decided to go to the Allergy Clinic, which has a number of centres, including one in the Blackrock Clinic, Co Dublin. It takes adult self-referrals but children must be referred. He describes getting the allergen test as "a pivotal moment" because "the best way to fight off something and manage something is to know exactly what it is".

The testing involved the drawing of grids on both his arms and the administering of droplets of different liquidised allergens into each numbered square. After his skin was pricked at each allergen site, the results showed he had the biggest reaction to grass pollen and the house dust mite, and he was referred to a respiratory physician, also in Blackrock Clinic.

“I am on immunotherapy for my grass pollen allergy right now and I have been on it for about eight months.” He takes a little tablet under his tongue at home each day, building up his tolerance to the allergen, and has periodic check-ups with the consultant.

While it takes a few months for the treatment to kick in, James says he can feel the difference it has made: “less sniffles, less stuffy nose. I used to get a nasal drip down the back of my throat – all of that has cleared up.” He also attributes his improvements to the physician changing his inhaler and prescribing steroids to shrink nasal polyps, which had reoccurred after he had them removed by surgery at the age of 14.

James is hopeful that immunotherapy will eliminate his grass pollen allergy in time and also that he can start immunotherapy for his house dust mite allergy very soon too.

After suffering the effects of these allergies his whole life so far, “I am going to be midway through my 20s and these allergies are going to be gone,” he says confidently.

James hopes sharing his story will help fellow allergy sufferers to find an avenue to go down to get this kind of medication. “There are a few hurdles to jump with the referrals and things like that,” he adds. “I think it is important for people to know this is an option and how to get there as well.”