1. Use of Multiple Allergen Mixes in Immunotherapy Harold S. Nelson, MD Professor of Medicine National Jewish Health University of Colorado Denver School of Medicine, Denver, Colorado, USA

2. Studies of the Use of ≥ 2 Allergens in Immunotherapy Reviewed English & non-English literature 1961-2007:  4 studies with 2-allergen mixes (SCIT & SLIT): Results > placebo and = to single allergen when reported.  6 studies with > 2 allergen mixes (all SCIT): 4 showed clinical efficacy (2 asthma, 2 rhinitis. 2 failed to show clinical efficacy. HS Nelson. J Allergy Clin Immunol 2009;123:763-0

3. The Value of Hyposensitization Therapy for Bronchial Asthma in Children -A 14-year Study  Subjects: Every child with perennial bronchial asthma and positive skin tests referred to the pediatric allergy clinic of Strong Memorial Hospital between August 1953 and January 1955.  Randomly assigned to receive injections of saline, extract 10 -7, 1/5,000 or 1/250 w/v concentration of all skin test positive inhalant allergens. DE Johnstone, A Dutton Pediatrics 1968l42:793-802

4. The Value of Hyposensitization Therapy for Bronchial Asthma in Children - A 14-year Study  Parents did not know they were in a study, those evaluating the patients were unaware of which group the child was in.  230 enrolled,173 still in study after 4 years and 130 competed the study on reaching age 16 years.  Similar numbers dropped out of each treatment group. DE Johnstone, A Dutton Pediatrics 1968l42:793-802

5. The Value of Hyposensitization Therapy for Bronchial Asthma in Children - A 14-year Study  “Free of Asthma” After 4 years - placebo and lowest dose 18% - 1/5,000 w/v 58% - 1/250 w/v 81%  “Free of Asthma” at end of study (age 16 yr) - placebo and lowest dose 22% - 1/5,000 w/v 66% - 1/250 w/v 78% DE Johnstone, A Dutton Pediatrics 1968l42:793-802

6. A Double-blind Study of the Effectiveness and Specificity of Injection Therapy in Ragweed Hay Fever  Patients were matched for symptom scores during the ragweed pollen season of 1962.  Patients were receiving injections with ragweed plus other allergens.  In March 1963 caramelized sugar was substituted for ragweed extract in one of each pair.  Symptoms & medication scored during 1963 ragweed season. FC Lowell & W Franklin. N. Engl J Med1965;273:675-9

7. Effectiveness and Specificity of Ragweed Immunotherapy 1200 800 400 0 1926291623307142128 ******* Aug.Sept.Oct. treateduntreatedmedianmean 1963 Total Score Lowell & Franklin NEJM 1965

8. Comparison of Two Dosages of Ragweed Extract in the Treatment of Pollenosis  Same study design.  Ragweed content was reduced 95% in the extract of one of each matched pair of subjects. W Franklin & FC Lowell. JAMA 1967;201:915-7

9. 1964 Aug.Sept.Oct. Symptom and Severity Score 300 200 100 0 low dose high dose meanmedian * * ** * 6 20 12 273 ? 10 17 24 3 Comparison of Two Doses of Ragweed Extract W Franklin, FC Lowell JAMA 1967;201;915

10. Seasonal Asthma in Northern California: Allergic Causes and Efficacy of Immunotherapy  18 grass-allergic subjects received pre- and co- seasonal injections of allergen extracts, 9 with placebo and 9 with grass pollen extract.  2-10 other allergens were included in each patients treatment extract.  Projected maintenance dose of grass contained 9.3 mcg of Gp 1 allergen. MJ Reid, et al. J Allergy Clin Immunol 1986;78:590-600

11. 8 6 4 2 0 1985 ASTHMA MEAN SMS Grass treated Non-grass treated 25 20 15 10 0 RHINITIS MEAN SMS Grass treated Non-grass treated 300 200 100 0 COUNTS/cm 2 Grass pollen count APRILMAYJUNE MONTHS 5 Response to Grass Subcutaneous I.T. P < 0.05 P = 0.11 MJ Reid, et al. J Allergy Clin Immunol 1986;78:590-600 N = 9

12. Evidence for Effectiveness of Immunotherapy Employing Multiple Allergens  Johnstone included all allergens to which the child was skin test positive. He demonstrated a dose dependent improvement in asthma.  Lowell & Franklin removed or reduced only ragweed in patients’ multi-allergen mixture and demonstrated increased symptoms during the ragweed pollen season.  Reid added only grass or placebo to multiple allergen mixes and showed significant reduction in asthma symptoms during the grass pollen season.

13. Sheila M. Amar, MD, Ronald J. Harbeck, PhD, Michael Sills, BS, Lori J. Silveira, MS, Holly O’Brien, RN, Harold S. Nelson, MD National Jewish Health, J Allergy Clin Immunol 2009;121:

14.  Single-center, randomized, double-blind, placebo-controlled  SLIT for 10 months, 56 subjects randomized to 3 arms - SLIT with timothy pollen extract alone (17 mcg Phl p 5 daily) - SLIT with same dose of timothy extract + 9 additional pollen extracts - SLIT placebo

15. TM Group, Allergen Extract Amount Timothy1.0 mL Diluent9.0 mL Caramelized Sugar Placebo GroupAmount Diluent10 mL Caramelized Sugar *Amount added to 10 ml vial for 1 month of treatment *CMD : Timothy approximately 30x SCIT dose (17 mcg Phl p 5 qday), other allergens 15-20x SCIT dose MAT Group, Allergen ExtractAmount Timothy1.0 mL Maple, Box-Elder1.0 mL Ash, White1.0 mL Juniper, Western1.0 mL Elm, American1.0 mL Cottonwood, Common1.0 mL Firebush (Kochia)1.0 mL Ragweed, Western1.0 mL Sagebrush, Common1.0 mL Russian Thistle1.0 mL

16. Multi-allergen Sublingual Immunotherapy: Results  Only 3 “ of rain fell in Denver the first 6 months of 2008  Accordingly there was little grass pollen, few symptoms and no difference in symptom scores or medication use among the three treatment groups.  There were, however, significant differences in several clinically relevant outcomes.

17. p=0.03

18. p=0.001 p=0.04

19. p=0.005

20. Evidence for Effectiveness of Immunotherapy Employing Multiple Allergens: Conclusions  Four studies support the effectiveness of subcutaneous immunotherapy employing multiple allergens.  The only study of multiple allergen sublingual immunotherapy raises questions regarding its effectiveness.