REBUTTAL FROM DR. BOUSQUET

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Medicine is an ever-changing science, but "the history of an illness should embody all the facts of medical significance in the life of a patient" (1). This sentence perfectly illustrates the narrow focus of Dr. Adkinson's views on specific immunotherapy (SIT) in asthma. Doctors must not treat patients because they suffer from either nose or chest symptoms but because they have both nose and chest symptoms, which often coexist in asthma (2). Thus, the global approach to the patient is the essence of clinical management. To my great surprise, Dr. Adkinson never discussed the global approach to the allergic patient, which is the major strength of SIT.

In his introduction, Dr. Adkinson wrote that "(SIT) must possess some unique advantages that can't be found elsewhere." He completely forgot my statements: "Besides anti-IgE therapy, SIT is the only current immunomodulatory treatment of allergic asthma" and "SIT is the only treatment that may alter the natural course of allergic diseases." Thus, SIT offers unique advantages and cannot be compared with any other drug that cannot modify the course of the disease, and in particular with relievers such as ₂-agonists.

The study by Adkinson and coworkers (3) of allergic asthma was extremely well carried out, but the meta-analysis by Abramson and coworkers found that all studies using multiple allergens were negative and that these cannot be used to assess the efficacy of SIT in asthma.

Moreover, Dr. Adkinson's paper is also misleading because he wrote that SIT does not protect against irritants and that there is no consistent effect on nonspecific bronchial hyperresponsiveness. In the Abramson meta-analysis reviewing 12 papers (including reference 3), which studied nonspecific bronchial hyperresponsiveness, the ² Z score is 2.58 in favor of immunotherapy over placebo; I do not know any other controller treatment of asthma that has such an important effect. Moreover, newer studies have confirmed such a positive effect (4, 5).

Thus, Dr. Adkinson's views are probably biased by his own study, which was unfortunately planned a long time ago. He should have more modern views on the global approach to the allergic patient, including the global management of asthma and rhinitis.

	References

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1. Fauci A, Braunwald E, Isselbacher K, Wilson J, Martin J, Kasper D, Hauser SL, Longo DL, editors. Clinical skills. Introduction to clinical medicine. In: Harrison's principles of internal medicine. 14th edition. New York: McGraw-Hill; 1998.

2. Leynaert B, Neukirch F, Demoly P, Bousquet J. Epidemiologic evidence for asthma and rhinitis comorbidity. J Allergy Clin Immunol 2000; 106: 201-205 [Medline].

3. Adkinson N Jr,, Eggleston PA, Eney D, Goldstein EO, Schuberth KC, Bacon JR, Hamilton RG, Weiss ME, Arshad H, Meinert CL, et al . . A controlled trial of immunotherapy for asthma in allergic children. N Engl J Med 1997; 336: 324-331 [Abstract/Free Full Text].

4. Walker SM, Pajno GB, Lima MT, Wilson DR, Durham SR. Grass pollen immunotherapy for seasonal rhinitis and asthma: a randomized, controlled trial. J Allergy Clin Immunol 2001; 107: 87-93 [Medline].

5. Gruber W, Eber E, Mileder P, Modl M, Weinhandl E, Zach MS. Effect of specific immunotherapy with house dust mite extract on the bronchial responsiveness of paediatric asthma patients. Clin Exp Allergy 1999; 29: 176-181 [Medline].