Long-Term Effects of Sublingual Grass Therapy

A Randomized, Double-blind, Single-center, Placebo Controlled Study of Sublingual Immunotherapy and Subcutaneous Immunotherapy in Adults With Seasonal Allergic Rhinitis (ITN043AD)

The purpose of this research study is to investigate whether sublingual immunotherapy (SLIT, grass pollen tablets under the tongue) has long term effects in severe hay fever.

Study Overview

• Status: Completed
• Conditions: Rhinitis, Allergic, Seasonal
• Intervention / Treatment: Biological: Subcutaneous immunotherapy (SCIT); Other: Placebo; Biological: Sublingual immunotherapy (SLIT)

Detailed Description

This is a randomized, double-blind, single-center, placebo-controlled, three-arm study comparing SLIT with placebo and SCIT with placebo. The main comparison will be between SLIT and placebo.

Individuals with severe grass pollen hay fever, with or without associated seasonal asthma, will be recruited during the pollen season of March through September 2011. Eligible participants will be randomized to one of the following three treatment arms administered in a double-blind (masked), double-dummy fashion in a 1:1:1 ratio:

• SLIT + SCIT placebo
• SCIT + SLIT placebo
• SLIT placebo + SCIT placebo

Participants will receive treatment over a 2-year period followed by a 1-year blinded (masked) withdrawal phase. Participants will be provided with anti-allergic rescue medications (antihistamine, topical intranasal corticosteroids, and short-acting beta agonists) throughout the study. Clinical endpoint assessments will be performed at prior to initiating their assigned treatment, after 1 and 2 years of treatment, and after the 1-year withdrawal period at 3 years.

• Study Type: Interventional
• Enrollment (Actual): 106
• Phase: Phase 2

Contacts and Locations

Study Locations

• United Kingdom
  • London, United Kingdom, SW3 6LY
    • Royal Brompton Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• A clinical history of grass pollen-induced allergic rhinoconjunctivitis for at least 2 years with peak symptoms in May, June, or July;
• A clinical history of moderate to severe rhinoconjunctivitis symptoms interfering with usual daily activities or with sleep as defined according to the Allergic Rhinitis and its Impact on Asthma (ARIA) classification of rhinitis;
• A clinical history of rhinoconjunctivitis for at least 2 years requiring treatment with either antihistamines or nasal corticosteroids during the grass pollen season;
• Positive skin prick test response, defined as wheal diameter greater than or equal to 3 mm, to Phleum pratense (e.g., Timothy grass);
• Positive specific IgE, defined as greater than or equal to IgE class 2 (0.7 kU/L), against Phleum pratense;
• A positive response to nasal allergen challenge with Phleum pretense, defined as an increase in TNSS greater than or equal to 7 points above baseline;
• For women of childbearing age, a willingness to use an effective form of contraception for the duration of the trial; and
• The ability to give informed consent and comply with study procedures.

Exclusion Criteria:

• Prebronchodilator forced expiratory volume at 1 second (FEV1) less than 70% of predicted value at either screening or baseline visit;
• A clinical history of moderate to severe allergic rhinitis, according to the ARIA classification, due to tree pollen near or overlapping the grass pollen season;
• A clinical history of persistent asthma and/or requiring regular inhaled corticosteroids for > 4 weeks per year outside of the grass pollen season;
• A clinical history of moderate- severe allergic rhinitis, according to the ARIA classification, caused by an allergen to which the participant is regularly exposed;
• History of emergency visit or hospital admission for asthma in the previous 12 months;
• History of chronic obstructive pulmonary disease;
• History of significant recurrent acute sinusitis, defined as 2 episodes per year for the last 2 years, all of which required antibiotic treatment;
• History of chronic sinusitis, defined as a sinus symptoms lasting greater than 12 weeks that includes 2 or more major factors or 1 major factor and 2 minor factors. Major factors are defined as facial pain or pressure, nasal obstruction or blockage, nasal discharge or purulence or discolored postnasal discharge, purulence in nasal cavity, or impaired or loss of smell. Minor factors are defined as headache, fever, halitosis, fatigue, dental pain, cough, and ear pain, pressure, or fullness.
• At randomization, current symptoms of, or treatment for, upper respiratory tract infection, acute sinusitis, acute otitis media, or other relevant infectious process; serous otitis media is not an exclusion criterion. Participants may be re-evaluated for eligibility after symptoms resolve.
• Any tobacco smoking within the last 6 months or a history of ≥ 10 pack years;
• Previous treatment by immunotherapy with grass pollen allergen within the previous 5 years.
• Any history of grade 4 anaphylaxis due to any cause as defined by the World Allergy Organization (WAO) grading criteria for immunotherapy;
• History of bleeding disorders or treatment with anticoagulation therapy;
• History of anti-IgE monoclonal antibody treatment;
• Ongoing systemic immunosuppressive treatment;
• History of intolerance to the study therapy, rescue medications, or their excipients;
• For women of childbearing age a positive serum or urine pregnancy test with sensitivity of less than 50 mIU/mL within 72 hours before the start of study therapy;
• The use of any investigational drug within 30 days of the screening visit; or
• The presence of any medical condition that the investigator deems incompatible with participation in the trial.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: SCIT + Placebo; Subcutaneous immunotherapy (SCIT) + sublingual immunotherapy (SLIT) placebo	Biological: Subcutaneous immunotherapy (SCIT); Participants randomized to receive subcutaneous injection immunotherapy with placebo tablets. Subcutaneous immunotherapy was included as a positive control.; Other Names: Alutard SQ Grass Pollen®; Other: Placebo; Participants randomized to double-placebo tablets and injections. This group was included as a negative control.
Experimental: SLIT + Placebo; Sublingual immunotherapy (SLIT) + subcutaneous immunotherapy (SCIT) placebo	Other: Placebo; Participants randomized to double-placebo tablets and injections. This group was included as a negative control.; Biological: Sublingual immunotherapy (SLIT); Participants randomized to receive sublingual allergen tablet immunotherapy with placebo injections.; Other Names: Grazax®
Placebo Comparator: Placebo + Placebo; Sublingual immunotherapy (SLIT) placebo + subcutaneous immunotherapy (SCIT) placebo	Other: Placebo; Participants randomized to double-placebo tablets and injections. This group was included as a negative control.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Nasal Response to Allergen Challenge	Defined as the average of the Total Nasal Symptom Score (TNSS) area under the curve (AUC) measured at 0 to 1 hours and the AUC measured at 1 to 10 hours after allergen challenge. The primary outcome consists of the comparison of SLIT + SCIT placebo versus SLIT placebo + SCIT placebo.	3 years

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Skin Late Phase Response (LPR) to Intradermal Testing	Recorded as the mean diameter of the swelling measured at the specified time points after allergen challenge at 1, 2, and 3 years. The analysis of this outcome will compare the mean diameter of the swelling at 1, 2, and 3 years separately, adjusting for baseline diameter using ANCOVA at the 0.05 level of significance.	Baseline (Time 0) and 1,-2, and -3 years
Skin Early Phase Response (EPR) to Intradermal Testing	Recorded as the mean diameter of the swelling measured at the specified time points after allergen challenge at 1, 2, and 3 years. The analysis of this outcome will compare the mean diameter of the swelling at 1, 2, and 3 years separately, adjusting for baseline diameter using ANCOVA at the 0.05 level of significance.	Baseline (Time 0) and 1, -2, and -3 years
Nasal LPR	Defined as the TNSS AUC over the specified time periods after allergen challenge at 1, 2, and 3 years. The analysis of these this outcome will compare the mean TNSS AUC at 1, 2, and 3 years separately, adjusting for baseline LPR using ANCOVA at the 0.05 level of significance.	Baseline (Time 0) and 1, -2, and -3 years
Nasal EPR	Defined as the TNSS AUC over the specified time periods after allergen challenge at 1, 2, and 3 years. The analysis of these this outcome will compare the mean TNSS AUC at 1, 2, and 3 years separately, adjusting for baseline EPR using ANCOVA at the 0.05 level of significance.	Baseline (Time 0) and 1, -2, and -3 years
Peak Total Nasal Symptom Score (TNSS) EPR	Maximum TNSS score measured between 0 and 1 hour after challenge.	Baseline (Time 0) and 1, -2, and -3 years
Peak Nasal Inspiratory Flow (PNIF) LPR	Defined as PNIF AUC over the specified time periods after allergen challenge at 1, 2 and 3 years. The analyses for this outcome will compare the mean PNIF AUC at 1, 2, and 3 years separately, adjusting for baseline PNIF using ANCOVA at the 0.05 level of significance.	Baseline (Time 0) and 1, -2, and -3 years
Peak Nasal Inspiratory Flow (PNIF) LPR Area Under the Curve (AUC)	Defined as PNIF AUC over the specified time periods after allergen challenge at 1, 2 and 3 years. The analyses for this outcome will compare the mean PNIF AUC at 1, 2, and 3 years separately, adjusting for baseline PNIF using ANCOVA at the 0.05 level of significance.	Baseline (Time 0) and 1, -2, and -3 years
Peak Nasal Inspiratory Flow (PNIF) EPR Area Under the Curve (AUC)	Defined as PNIF AUC over the specified time periods after allergen challenge at 1, 2 and 3 years. The analyses for this outcome will compare the mean PNIF AUC at 1, 2, and 3 years separately, adjusting for baseline PNIF using ANCOVA at the 0.05 level of significance. AUC measured hourly between 1 and 10 hours after challenge.	Baseline (Time 0) and 1, -2, and -3 years
Skin Prick Test Endpoint Titration	Assessed as the mean wheal diameters (mm) in response to skin prick tests in duplicate with 1000 SQ, 10,000 SQ and 100,000 SQ units of grass pollen allergen.	Baseline (Time 0) and 1, -2, and -3 years
Use of Rescue Medications During the Pollen Season	A composite rescue medication score will be derived using a pre-defined scoring algorithm.	1, -2, and -3 years
Mini Rhinoconjunctivitis Quality-of-Life Questionnaire Score	Mini Rhinoconjunctivitis Quality-of-Life Questionnaire (MiniRQLQ) scores will be collected pre-, peak-, and post-pollen season at 1, 2, and 3 years.	1, -2, and -3 years
Hay Fever Severity Score	Measured at the end of each pollen season at 1, -2, and -3 years.	1, 2 and 3 years
Weekly Visual Analog Symptom (VAS) Scores	Weekly Visual Analogue Scale scores will be summarized descriptively by group and year.	1, -2, and -3 years
EXPLORATORY: Mechanistic Assessments of Local Immune Responses	Measured in the nasal mucosa before and after nasal allergen challenge. Nasal secretions will be assayed for inflammatory mediators and local antibodies.	1, 2, and 3 years
EXPLORATORY: Mechanistic Assessments of Peripheral Blood Subsets	Peripheral blood mononuclear cells (PBMCs) samples will be analyzed.	1, 2, and 3 years

Collaborators and Investigators

• Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)
• Collaborators: Imperial College London; Immune Tolerance Network (ITN)
• Investigators: Study Chair: Stephen Durham, MD, Imperial College London

Publications and helpful links

General Publications

• Cox LS. Sublingual Immunotherapy for Allergic Rhinitis: Is 2-Year Treatment Sufficient for Long-term Benefit? JAMA. 2017 Feb 14;317(6):591-593. doi: 10.1001/jama.2017.0128. No abstract available. Erratum In: JAMA. 2017 Mar 21;317(11):1179.
• Scadding GW, Calderon MA, Shamji MH, Eifan AO, Penagos M, Dumitru F, Sever ML, Bahnson HT, Lawson K, Harris KM, Plough AG, Panza JL, Qin T, Lim N, Tchao NK, Togias A, Durham SR; Immune Tolerance Network GRASS Study Team. Effect of 2 Years of Treatment With Sublingual Grass Pollen Immunotherapy on Nasal Response to Allergen Challenge at 3 Years Among Patients With Moderate to Severe Seasonal Allergic Rhinitis: The GRASS Randomized Clinical Trial. JAMA. 2017 Feb 14;317(6):615-625. doi: 10.1001/jama.2016.21040.

Helpful Links

• Division of Allergy, Immunology, and Transplantation (DAIT)
• National Institute of Allergy and Infectious Disease (NIAID)
• Immune Tolerance Network (ITN)
• Immune Tolerance Network (ITN) TrialShare: open public access to participant-level data available for this trial
• University of California, San Francisco (UCSF)
• Imperial College London

Study record dates

Study Major Dates

• Study Start: March 1, 2011
• Primary Completion (Actual): February 1, 2015
• Study Completion (Actual): February 1, 2015

Study Registration Dates

• First Submitted: April 8, 2011
• First Submitted That Met QC Criteria: April 12, 2011
• First Posted (Estimate): April 14, 2011

Study Record Updates

• Last Update Posted (Actual): June 2, 2017
• Last Update Submitted That Met QC Criteria: May 31, 2017
• Last Verified: May 1, 2017

More Information

Terms related to this study

• Keywords: sublingual immunotherapy; subcutaneous immunotherapy
• Additional Relevant MeSH Terms: Infections; Respiratory Tract Infections; Respiratory Tract Diseases; Immune System Diseases; Hypersensitivity, Immediate; Otorhinolaryngologic Diseases; Respiratory Hypersensitivity; Hypersensitivity; Nose Diseases; Rhinitis; Rhinitis, Allergic; Rhinitis, Allergic, Seasonal; Physiological Effects of Drugs; Immunologic Factors
• Other Study ID Numbers: DAIT ITN043AD; 2010-023536-16 (EudraCT Number)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes
• IPD Plan Description: Participant level data and additional relevant materials are available to the public in TrialShare, the Immune Tolerance Network (ITN) Clinical Trials Research Portal. ITN TrialShare makes data from the consortium's clinical trials publicly available.

Study Data/Documents

1. Individual Participant Data Set
   Information identifier: ITN043AD
   Information comments: TrialShare is a clinical trials research portal developed by the Immune Tolerance Network (ITN) that makes data from the consortium's clinical trials publicly available without charge.Creating an account for ITN TrialShare is free and allows for searching studies of interest.
2. Synopsis, Adverse Events, -Data and Reports, -Schedule of Assessments
   Information identifier: ITN043AD
   Information comments: TrialShare is a clinical trials research portal developed by the Immune Tolerance Network (ITN) that makes data from the consortium's clinical trials publicly available without charge.Creating an account for ITN TrialShare is free and allows for searching studies of interest.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No