Can Epinephrine Coated Syringe for Subcutaneous Immunotherapy (SCIT) Reduce Large Local Reaction?

Allergen immunotherapy is effective in the management of allergic asthma, allergic rhinitis/conjunctivitis, and stinging insect hypersensitivity. The most common side effect of subcutaneous allergen specific immunotherapy (SCIT) is local reactions (LR). Although some studies indicated that LR did not predict systemic reaction (SR), patients with higher frequency of large local reaction (LLR) were reported to have higher risk for SR. Epinephrine may decrease LLR due to its vasoconstrictive effect . The objective of this study was to compare the size of LLR in patients receiving SCIT with epinephrine or normal saline coated syringe. The patients who complained of frequent LLR despite pre-medication and local treatment were recruited.

Study Overview

• Status: Completed
• Conditions: Injection Reactions Site; Systemic Reactions
• Intervention / Treatment: Drug: Epinephrine or normal saline

Detailed Description

Allergen immunotherapy (AIT) is an immune mediated treatment which modifies T helper (Th) 2-directed response through the interplay between regulatory T and B cells, blocking IgG4 antibodies and tissue effector-mediated mechanisms. Aeroallergen immunotherapy is recommended for patients with allergic rhinitis, allergic conjunctivitis or allergic asthma whose symptoms were not adequately controlled by antigen avoidance and pharmacotherapy. AIT could reduce symptoms and medication usage in respiratory allergy. In children, AIT prevented the progression from allergic rhinitis to asthma and prevented new onset of allergen sensitization in monosensitized patients. The administration of allergen by subcutaneous injection (SCIT) is a common practice among allergists.

The benefits of SCIT must be weighed against the risks of side effects which can be mild or life threatening. Adverse allergic reactions to SCIT were classified as either local (LR) or systemic reactions (SR).6 Large local reactions (LLR) are defined as erythema and/or swelling (> 25 mm) at the site of injection. The timing of adverse reactions were categorized into immediate (occurring within 30 min) and late reactions (occurring > 30 min after injection). LR associated with SCIT ranged from 26-72% of patients and 0.7-4% of injections. SR were reported to occurred in 3.7% of patients and 0.3% of injection. Recent prospective study in pediatric patients who received SCIT showed immediate LR in 54.6%, delayed LR in 56.1%, immediate SR in 2.2% and delayed SR in 7.4% of the patients. Severe SR were seen in 0.03% of all treatments which appeared within 30 minutes after the injections. The author concluded that children had similar rates of LR compared to adult patients but had lower rates of severe SR.

Several studies indicated that individual LR did not predict subsequent SR. The rate of SR were not change despite the dose adjustment after a LR. However, patients with greater frequency of LLR might be at an increased risk for future SR. Recognizing the significance of frequent LLRs is important for designing safer protocols for successful SCIT.

In the Division of Allergy and Clinical Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, we performed SCIT in approximately 100 patients and 2000 injections per year. The LR associated SCIT were complained in 75% of the patients. Of the patients who experienced LR, 80% had LR more than 25 mm which was considered LLR.

Many strategies to prevent or minimize LR were reported. Oral antihistamines, leukotriene receptor antagonist (LTRA) or anti-IgE could reduce LR during the built-up phase. Cold compression or topical steroid were used to reduce the LR without any strong evidence. To our knowledge, the benefit of epinephrine coated syringe prior to drawing the allergen extract for SCIT in patients with frequent LLR has never been explored in any controlled trial.

The objective of this study is to compare the size of LR in patients with frequent LLR who receive SCIT by coating syringe with epinephrine or placebo prior to drawing allergen extract.

• Study Type: Interventional
• Enrollment (Actual): 17
• Phase: Phase 2; Phase 1

Contacts and Locations

Study Locations

• Thailand
  • Bangkok, Thailand, 10700
    • Orathai Piboonpocanun

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 6 years to 40 years (ADULT, CHILD)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients older than 6 years old who received SCIT at Pediatrics allergy departments at Siriraj hospital
• Patients who develops larges local reactions(mean wheal diameter > 25 mm.) during SCIT.
• Patients who received SCIT in maintenance phase.

Exclusion Criteria:

• Patients who develops systemic reactions (more than grade 1) during SCIT.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: CROSSOVER
• Masking: QUADRUPLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
ACTIVE_COMPARATOR: Coated syringe with epinephrine; Epinephrine was coated syinge before drawing the allergen to filled in.	Drug: Epinephrine or normal saline; epinephreine or normal saline coated syringe before drawing allergen for injection.; Other Names: Adrenaline or normal saline
PLACEBO_COMPARATOR: placebo; Normal saline was coated syinge before drawing the allergen to filled in.	Drug: Epinephrine or normal saline; epinephreine or normal saline coated syringe before drawing allergen for injection.; Other Names: Adrenaline or normal saline

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Epinephrine coated syringe for SCIT changed sized of large local reactions compared with placebo	We measured the sized of local reactions after injected SCIT coated with epinephrine or placebo for 30 minutes at clinic then 2 hours, 4 hours and 6 hours at home.	30 minutes, 2 hours, 4 hours, 6 hours

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Epinephrine coated syringe for SCIT changed systemic reactions compared with placebo.	We measured the systemic reactions after injected SCIT coated with epinephrine or placebo for 30 minutes at clinic then 2 hours, 4 hours and 6 hours at home.	30 minutes, 2 hours, 4 hours, 6 hours

Collaborators and Investigators

• Sponsor: Mahidol University
• Investigators: Principal Investigator: Orathai Piboonpocanun, MD, Siriraj Hospital

Publications and helpful links

General Publications

• Roy SR, Sigmon JR, Olivier J, Moffitt JE, Brown DA, Marshall GD. Increased frequency of large local reactions among systemic reactors during subcutaneous allergen immunotherapy. Ann Allergy Asthma Immunol. 2007 Jul;99(1):82-6. doi: 10.1016/S1081-1206(10)60626-6.
• Calabria CW, Stolfi A, Tankersley MS. The REPEAT study: recognizing and evaluating periodic local reactions in allergen immunotherapy and associated systemic reactions. Ann Allergy Asthma Immunol. 2011 Jan;106(1):49-53. doi: 10.1016/j.anai.2010.10.025.

Study record dates

Study Major Dates

• Study Start (ACTUAL): October 24, 2018
• Primary Completion (ACTUAL): August 25, 2019
• Study Completion (ACTUAL): September 1, 2019

Study Registration Dates

• First Submitted: May 22, 2019
• First Submitted That Met QC Criteria: May 23, 2019
• First Posted (ACTUAL): May 24, 2019

Study Record Updates

• Last Update Posted (ACTUAL): February 20, 2020
• Last Update Submitted That Met QC Criteria: February 19, 2020
• Last Verified: February 1, 2020

More Information

Terms related to this study

• Keywords: Large local reaction; adrenaline, epinephrine
• Additional Relevant MeSH Terms: Chemically-Induced Disorders; Pathologic Processes; Drug-Related Side Effects and Adverse Reactions; Extravasation of Diagnostic and Therapeutic Materials; Injection Site Reaction; Physiological Effects of Drugs; Adrenergic Agents; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Autonomic Agents; Peripheral Nervous System Agents; Adrenergic alpha-Agonists; Adrenergic Agonists; Bronchodilator Agents; Anti-Asthmatic Agents; Respiratory System Agents; Adrenergic beta-Agonists; Sympathomimetics; Vasoconstrictor Agents; Mydriatics; Epinephrine
• Other Study ID Numbers: 393/2561(EC3)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

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