1. Dr Narayana pradeep Consultant Pulmonologist Carewell hospital KasaragodKERALA

2. Sublingual immunotherapy Sublingual immunotherapy for allergic diseases Sublingual immunotherapy for allergic diseases Cochrane review Cochrane review ( Wilson DR, Torres Lima M, Durham SR) ( Wilson DR, Torres Lima M, Durham SR)

3. Back ground Allergic dissease can impair QOL Allergic dissease can impair QOL Injection immunotherapy associated with more systemic reactions Injection immunotherapy associated with more systemic reactions Interest in alternative routes of delivery Interest in alternative routes of delivery

4. objectives To evaluate the efficacy of sublingual immunotherapy ( SLIT) compared with palcebo, for reductions in symptoms and medication requirements To evaluate the efficacy of sublingual immunotherapy ( SLIT) compared with palcebo, for reductions in symptoms and medication requirements

5. Search strategy The cochrane controlled trails register, MEDLINE ( 1966 – 2002), EMBASE ( 1974 to 2002) and Scisearch were searched upto 2002 using terms (Rhin* or Hey fever and immunotherap* or desentitisation and subingual) The cochrane controlled trails register, MEDLINE ( 1966 – 2002), EMBASE ( 1974 to 2002) and Scisearch were searched upto 2002 using terms (Rhin* or Hey fever and immunotherap* or desentitisation and subingual)

6. Selection criteria All studies identified by searches were assessed by the reviewers to identify randomised controlled trials involving participants with symptoms of allergic rhinitis and proven allergen skin sensitivity treated with SLIT or corresponding placebo All studies identified by searches were assessed by the reviewers to identify randomised controlled trials involving participants with symptoms of allergic rhinitis and proven allergen skin sensitivity treated with SLIT or corresponding placebo

7. Data collection and analysis Data from identified studeis were abstracted onto a standard extraction sheet and subsequently entered into RevMan 4.1. Data from identified studeis were abstracted onto a standard extraction sheet and subsequently entered into RevMan 4.1. Analysis was performed by the method of standard mean difference (SMD ) Analysis was performed by the method of standard mean difference (SMD ) Subgroup anaysis was according to allergen administered, age of participant,and duration of treatment Subgroup anaysis was according to allergen administered, age of participant,and duration of treatment

8. Main results 22 trails involving 979 patients were included 22 trails involving 979 patients were included 6 trails for house dust mite allergy, 5 for grass pollen, 5 for parietaria, 2 for olive and 1 each for Ragweed, cat, tree, and cupressus 6 trails for house dust mite allergy, 5 for grass pollen, 5 for parietaria, 2 for olive and 1 each for Ragweed, cat, tree, and cupressus 17 studies administered the allergen by sublingual drops subsequently swallowed, 3 by drops subsequently spat out, 2 by sublingual tablets 17 studies administered the allergen by sublingual drops subsequently swallowed, 3 by drops subsequently spat out, 2 by sublingual tablets

9. .. 8 studies involved treatment 12 months 8 studies involved treatment 12 months All included studies were double blind placebo controlled trails of parallel group design All included studies were double blind placebo controlled trails of parallel group design

10. … Overall, after SLIT Overall, after SLIT significant reduction in both significant reduction in both 1.symptoms ( SMD -0.34, 95% confidence interval -0.63 to -0.15: p= 0.002 ) 1.symptoms ( SMD -0.34, 95% confidence interval -0.63 to -0.15: p= 0.002 ) 2. medication requirements 2. medication requirements ( SMD -0.43, p=0.00003) ( SMD -0.43, p=0.00003)

11. .. Subgroup analysis failed to identify a disproportionate benefit of treatment according to allergen administered Subgroup analysis failed to identify a disproportionate benefit of treatment according to allergen administered Increasing duration of treatment does not clearly increase efficacy Increasing duration of treatment does not clearly increase efficacy The total dose of allergen administered may be important but insufficient data were available to analyse this The total dose of allergen administered may be important but insufficient data were available to analyse this

12. Reviewerers conclusion SLIT is safe treatment which significantly reduces symptoms and medication requirements in allergic rhinitis SLIT is safe treatment which significantly reduces symptoms and medication requirements in allergic rhinitis The size of this benefit compared to that of other available therapies, particularly injection immunotherapy is not clear, having been assessed directly in very few centres The size of this benefit compared to that of other available therapies, particularly injection immunotherapy is not clear, having been assessed directly in very few centres

13. Future…… Further research is required concentrating on optimising allergen dosage and patient selection Further research is required concentrating on optimising allergen dosage and patient selection