REBUTTAL FROM DR. ADKINSON

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Two of Dr. Bousquet's points require clarification. The first is his claim that immunotherapy improves nonspecific bronchial hyperresponsiveness. The latest update of the Cochrane meta-analysis came to this unfortunate conclusion (1), but those who bother to examine the data will not be convinced. Of 11 studies analyzed, only 2 studies involving 24 treated patients found significant improvement. The largest study, our own trial of 121 children with asthma, did not even trend toward a protective effect. Even if larger or more numerous studies add to the weight of evidence, the magnitude of the protective effect is likely to be tiny relative to the 3- to 4-fold shifts regularly seen with inhaled steroid therapy.

Another noteworthy issue raised by Dr. Bousquet is whether successful results with immunotherapy are restricted to those who are "monosensitized," that is, have a single inhalant allergy. Dr. Bousquet's group has reported that children treated with only Dermatophagoides mites developed fewer new allergic sensitivities to other aeroallergens (2). This finding has been confirmed by Pajno and coworkers in Italian children (3). What this intriguing observation means is not clear. Previous studies have shown that the effect of allergen immunotherapy is immunologically and clinically specific. Do mite extracts contain an adjuvant that can redirect allergic sensitization in general? Why should multiply sensitized patients not benefit from immunotherapy for asthma, as they do for rhinoconjunctivitis? These questions remain unanswered, and as such confound any consensus on the current indications for immunotherapy.

Dr. Bousquet and I agree that the best candidates for immunotherapy are children with mild to moderate asthma, severe perennial allergic rhinitis, and as yet few allergic sensitivities, preferably only dust mite. We participated as a study center in the CAMP study involving 1,041 North American children with mild to moderate asthma (4). Eighty-eight percent of the children had one or more positive skin tests but only 10% were "monosensitized," and of these only 43% were dust mite sensitive. Furthermore, only 12% of this unselected population of children with asthma had perennial rhinitis severe enough to require intranasal steroids year-round. Data from a comparable adult population are not available, but the prevalence of positive skin tests and perennial allergic rhinitis would surely be substantially lower. Thus, applying Dr. Bousquet's criteria, inhalant immunotherapy will be warranted in only a small fraction of patients with asthma and allergies. I rest my case.

	References

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1. Abramson MJ, Puy RM, Weiner JM. Allergen immunotherapy for asthma (Cochrane review). In: The Cochrane library, Issue 3. Oxford: Update Software; 2001.

2. Des-Roches A, Paradis L, Menardo J-L, Bouges S, Daures J-P, Bousquet J. Immunotherapy with a standardized Dermatophagoides pteronyssinus extract. VI. Specific immunotherapy prevents the onset of new sensitizations in children. J Allergy Clin Immunol 1997; 99: 450-453 [Medline].

3. Pajno G, Barbero G, De-Luca F, Morabito L, Parmiani S. Prevention of new sensitizations in asthmatic children monosensitized to house dust mites by specific immunotherapy. Clin Exp Allergy 2001; 31: 1392-1397 [Medline].

4. Childhood Asthma Management Program Research Group. Long-term effects of budesonide or nedocromil in children with asthma. N Engl J Med 2000;343:1054-1063.