Immunotherapy and biologic therapies
Question:
2/10/2017
I am seeing an increasing number of patients referred from other specialists for allergen immunotherapy but who are already taking a biologic with immune properties in particular Tecfidera, abetacept, and products like Enbrel, Humira etc. I’m not clear that immunotherapy will work as well long term in some of these patients and don't want to tell them it will if I am wrong. Do we have any studies that sort this out?
Answer:
I have asked Dr. Tom Casale to assist in answering your question.
His response is as follows:
"Allergen immunotherapy works in part by inducing the production of multiple suppressors of T2 immunity especially IL-10 and TGF-b. Importantly there is also induction of Tregs. However, TNF may also induce IgG4 vs IgE and inhibitors of TNF might impair this response to AIT. Inhibition of CTLA4 could affect T cell responses necessary for AIT. However, these are only theoretical concerns since I am aware of no data exploring changes in efficacy of AIT in patients treated with MAbs except omalizumab which there is additional efficacy in patients treated with both AIT and Omalizumab."
Additionally, a related question was asked in April of 2016. I am also including Dr. Dennis Ledford's response to the prior question:
4/11/2016
Are there any contraindications for allergy testing and immunotherapy when a patient is receiving Orencia injections?
"Abatacept is a fusion protein of cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), also designated CD152, and human IgG1. Abatacept binds to CD80 and CD86 on antigen presenting cells interfering with antigen specific T-cell activation via CD28, which also binds CD80 and CD86 resulting in a stimulatory signal to the T cell. The result is an immunosuppression that is useful in treating autoimmune diseases such as rheumatoid arthritis. This effect would not affect allergy skin testing or measurement of specific-IgE in vitro. To my knowledge there is no information with respect to allergen immunotherapy. Since specific T-cell regulatory stimulation is necessary for the benefits from immunotherapy, there is a theoretical argument that therapy with abatacept could reduce the effectiveness of the treatment. However, I do not see a reason that SCIT would be contraindicated with abatacept therapy. In summary, in my opinion abatacept (Orencia) therapy is not a contraindication for allergen testing or allergen immunotherapy."
I concur with the opinions of Dr. Casale and Dr. Ledford. Overall, there are theoretical reasons that the biologic agents you've discussed could impact response to allergy immunotherapy. However, there is no data that I am aware of that provides clear evidence in this regard. I hope that you find this information helpful.
Kind Regards,
Daniel Jackson, MD