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The effects of house dust mite sublingual immunotherapy tablet on immunologic biomarkers and nasal allergen challenge symptoms

2017; Elsevier BV; Volume: 141; Issue: 2 Linguagem: Inglês

10.1016/j.jaci.2017.08.016

1097-6825

Natasha C. Gunawardana, Qing Zhao, Leonidas N. Carayannopoulos, Kuenhi Tsai, Vladislav A. Malkov, Diana Selverian, Graham W. Clarke, Tim Mant, Brent D. Butts, Kaare Lund, Trevor T. Hansel, Hendrik Nolte,

Dermatology and Skin Diseases

House dust mite (HDM) is the most common cause of allergic sensitization in many countries worldwide1Bousquet P.J. Chinn S. Janson C. Kogevinas M. Burney P. Jarvis D. Geographical variation in the prevalence of positive skin tests to environmental aeroallergens in the European Community Respiratory Health Survey I.Allergy. 2007; 62: 301-309Crossref PubMed Scopus (286) Google Scholar and allergic asthma is strongly associated with HDM sensitization.2Sporik R. Holgate S.T. Platts-Mills T.A. Cogswell J.J. Exposure to house-dust mite allergen (Der p I) and the development of asthma in childhood: a prospective study.N Engl J Med. 1990; 323: 502-507Crossref PubMed Scopus (1449) Google Scholar Treatment with the SQ HDM sublingual immunotherapy (SLIT) tablet (12 SQ-HDM) significantly improves allergic rhinoconjunctivitis symptoms, reduces the risk of moderate or severe asthma exacerbations, and decreases inhaled corticosteroid use in subjects with HDM allergic asthma.3Virchow J.C. Backer V. Kuna P. Prieto L. Nolte H. Villesen H.H. et al.Efficacy of a house dust mite sublingual allergen immunotherapy tablet in adults with allergic asthma: a randomized clinical trial.JAMA. 2016; 315: 1715-1725Crossref PubMed Scopus (277) Google Scholar, 4Demoly P. Emminger W. Rehm D. Backer V. Tommerup L. Kleine-Tebbe J. Effective treatment of house dust mite-induced allergic rhinitis with 2 doses of the SQ HDM SLIT-tablet: results from a randomized double-blind, placebo-controlled phase III trial.J Allergy Clin Immunol. 2016; 137: 444-451Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar, 5Nolte H. Bernstein D.I. Nelson H.S. Kleine-Tebbe J. Sussman G.L. Seitzberg D. et al.Efficacy of house dust mite SLIT-tablet in North American adolescents and adults in a randomized, placebo-controlled trial.J Allergy Clin Immunol. 2016; 138: 1631-1638Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 6Nolte H. Maloney J. Nelson H.S. Bernstein D.I. Lu S. Li Z. et al.Onset and dose-related efficacy of house dust mite sublingual immunotherapy tablets in an environmental exposure chamber.J Allergy Clin Immunol. 2015; 135: 1494-1501.e6Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar, 7Mosbech H. Deckelmann R. de Blay F. Pastorello E.A. Trebas-Pietras E. Andres L.P. et al.Standardized quality (SQ) house dust mite sublingual immunotherapy tablet (ALK) reduces inhaled corticosteroid use while maintaining asthma control: a randomized, double-blind, placebo-controlled trial.J Allergy Clin Immunol. 2014; 134: 568-575.e7Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar SLIT is likely to modify T- and B-lymphocyte populations, resulting in an increase in local regulatory pathways, including the production of cytokines that inhibit allergic inflammation.8Jutel M. Akdis C.A. Immunological mechanisms of allergen-specific immunotherapy.Allergy. 2011; 66: 725-732Crossref PubMed Scopus (195) Google Scholar SLIT increases non-IgE antibodies with the capacity to block the actions of allergen-specific IgE (IgE-blocking factor [IgE-BF] effect), including IgG4, which inversely correlates with symptoms in grass pollen immunotherapy.9Shamji M.H. Ljorring C. Francis J.N. Calderon M.A. Larche M. Kimber I. et al.Functional rather than immunoreactive levels of IgG4 correlate closely with clinical response to grass pollen immunotherapy.Allergy. 2012; 67: 217-226Crossref PubMed Scopus (218) Google Scholar There have been difficulties in establishing accurate, reliable biomarkers to assess immunotherapy treatment response, and there has been little work surrounding the pharmacodynamics and identification of biomarkers for HDM allergy immunotherapy. In this exploratory double-blind, randomized, parallel group trial (NCT01852825), adults with HDM allergic rhinitis received 12 SQ-HDM (MK-8237, Merck & Co, Inc, Kenilworth, NJ, and Hørsholm, Denmark; n = 16) or placebo (n = 7) daily for 12 weeks. Nasal allergen challenges (NACs) were conducted at 2 weeks pretreatment (baseline) and weeks 8 and 12 (see Fig E1 in this article's Online Repository at www.jacionline.org). The coprimary end points were change in HDM-specific serum IgG4 (against Dermatophagoides pteronyssinus and Dermatophagoides farinae) and IgE-BF at week 12. Nasosorption and nasal curettage were used to assess nasal mucosal molecular and cellular events that occur following NACs. Nasal congestion, rhinorrhea, itching, and sneezing were measured as a total nasal symptom score (TNSS), and peak nasal inspiratory flow (PNIF) rates were recorded at intervals up to 6 hours after NACs. TNSS and PNIF were measured as average time-weighted scores for early phase (1 hour pre-NAC through 1 hour post-NAC) and late phase (2 hours post-NAC through 6 hours). Nasosorption for IL-5, IL-13, and thymus and activation regulated chemokine (TARC) levels and nasal curettage for mucosal mRNA expression were performed before and after NACs. Further details of the study design, subject selection criteria, assessments, and statistical methods are described in this article's Online Repository at www.jacionline.org. A total of 23 subjects were randomized (n = 16, 12 SQ-HDM; n = 7, placebo) and 21 subjects completed the study. Demographic and baseline characteristics are presented in Table E1 in this article's Online Repository at www.jacionline.org. This is the first study to explore early (week 2) changes in immunologic parameters after HDM SLIT-tablet treatment. Changes in serum IgG4 against D farinae and D pteronyssinus were not apparent at week 2, but IgG4 was significantly increased from baseline with 12 SQ-HDM versus placebo at week 8 and increased further by week 12 (Fig 1, A; see Table E2 in this article's Online Repository at www.jacionline.org). Similar results were observed for IgE-BF. Thus, the primary hypotheses were confirmed on the basis of statistical significance at 1-side α value of 0.05 after the multiplicity adjustment. The demonstrated induction of immunologic parameters with 12 SQ-HDM treatment is consistent with results found in large clinical trials, where immunologic changes were detected as early as week 4.3Virchow J.C. Backer V. Kuna P. Prieto L. Nolte H. Villesen H.H. et al.Efficacy of a house dust mite sublingual allergen immunotherapy tablet in adults with allergic asthma: a randomized clinical trial.JAMA. 2016; 315: 1715-1725Crossref PubMed Scopus (277) Google Scholar, 5Nolte H. Bernstein D.I. Nelson H.S. Kleine-Tebbe J. Sussman G.L. Seitzberg D. et al.Efficacy of house dust mite SLIT-tablet in North American adolescents and adults in a randomized, placebo-controlled trial.J Allergy Clin Immunol. 2016; 138: 1631-1638Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar NACs induced a rise in early phase TNSS, peaking at 15 minutes post-NAC. Symptoms abated within the first hour and no late-phase symptoms were observed in either treatment group (Fig 1, B). Treatment with 12 SQ-HDM reduced early phase NAC-induced symptoms by 43% at week 8 and 57% at week 12 (see Fig E2 in this article's Online Repository at www.jacionline.org). The difference between the 12 SQ-HDM group and placebo (90% CI) was −40.0 (−81.4, 1.5) at week 8 (P = .11) and −61.1 (−100.2, −22.0) at week 12 (P = .01). Similar results were observed for peak symptoms (15 minutes post-NAC), with 12 SQ-HDM reducing symptoms by 36% at week 8 and 52% at week 12 (Fig 1, B). The difference between the 12 SQ-HDM group and placebo (90% CI) for peak symptoms was −72.4 (−149.2, 4.5) at week 8 (P = .12) and −114.4 (−189.1, −39.6) at week 12 (P = .02). The reduction in early phase symptoms suggests an effect on mucosal mast cell activity, which could be caused by IgE-blocking antibodies. There was no significant difference between the 12 SQ-HDM group and placebo in change from baseline for PNIF during any NAC. The difference in change from baseline (90% CI) for time-weighted PNIF during the NAC early phase was −7.3 (−32.1, 17.5) at week 8 (P = .62) and −0.6 (−20.5, 19.3) at week 12 (P = .96). Cytokines such as IL-5 and IL-13 are markers of type 2 inflammation during late-phase allergic inflammation. NACs increased levels of IL-5, IL-13, and TARC in the nasal mucosa from baseline to 6.5 hours postchallenge in most subjects (see Fig E3 in this article's Online Repository at www.jacionline.org). No significant differences in fold changes from −1 hour pre-NAC to 6.5 hours post-NAC between 12 SQ-HDM and placebo were observed for IL-5 at any time point (Fig 2, A). No significant differences from baseline NAC in nasal mucosal lining fluid IL-5, IL-13, or TARC concentrations were observed between 12 SQ-HDM and placebo at weeks 8 or 12. Thus, this study failed to demonstrate a reduction with 12 SQ-HDM in type 2 inflammation induced in response to NACs. There was a good correlation between absolute values for known mRNA markers of mast cells, IL-5 and IL-13, and eosinophils (see Fig E4 in this article's Online Repository at www.jacionline.org). A trend toward reduction in eosinophil, mast cell, and TH2 inflammation markers from baseline in the 12-SQ HDM–treated group versus placebo was observed, but this did not reach statistical significance (Fig 2, B). Further mRNA analysis was restricted because of incomplete sample sets after processing. There were no consistent correlations found between the eosinophil, mast cell, and TH2 inflammation markers and visual analogue scale symptoms across all the NAC time points, either with placebo or with 12 SQ-HDM. The present results are within the context of NAC conditions (as opposed to a natural setting) and are limited by the sample size. It is possible that treatment with 12 SQ-HDM for longer than 12 weeks is necessary to reduce TH2 mediators and mucosal eosinophil infiltration. HDM NACs and treatment with 12 SQ-HDM were well tolerated. No serious adverse events, systemic allergic events, or epinephrine administrations were reported. The adverse event profile was consistent with that reported in large clinical trials of 12 SQ-HDM.3Virchow J.C. Backer V. Kuna P. Prieto L. Nolte H. Villesen H.H. et al.Efficacy of a house dust mite sublingual allergen immunotherapy tablet in adults with allergic asthma: a randomized clinical trial.JAMA. 2016; 315: 1715-1725Crossref PubMed Scopus (277) Google Scholar, 4Demoly P. Emminger W. Rehm D. Backer V. Tommerup L. Kleine-Tebbe J. Effective treatment of house dust mite-induced allergic rhinitis with 2 doses of the SQ HDM SLIT-tablet: results from a randomized double-blind, placebo-controlled phase III trial.J Allergy Clin Immunol. 2016; 137: 444-451Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar, 5Nolte H. Bernstein D.I. Nelson H.S. Kleine-Tebbe J. Sussman G.L. Seitzberg D. et al.Efficacy of house dust mite SLIT-tablet in North American adolescents and adults in a randomized, placebo-controlled trial.J Allergy Clin Immunol. 2016; 138: 1631-1638Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 6Nolte H. Maloney J. Nelson H.S. Bernstein D.I. Lu S. Li Z. et al.Onset and dose-related efficacy of house dust mite sublingual immunotherapy tablets in an environmental exposure chamber.J Allergy Clin Immunol. 2015; 135: 1494-1501.e6Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar Two events of hypersensitivity (mild local reactions) occurred. Induction of HDM-specific IgG4 and IgE-BF by 12 SQ-HDM, along with significant improvement in early phase NAC-induced nasal symptoms, suggests that IgE-BF generation may contribute to the mechanism of action of 12 SQ-HDM during the first 12 weeks of treatment. There was no significant effect on mucosal IL-5 and IL-13, or eosinophil-associated gene expression, indicating that the early mechanism of action of 12 SQ-HDM is likely to be based on inhibition of mast cell activity and is unrelated to inhibition of eosinophil activity. We thank Ashish Jain and Laura George for their contributions to the study. Medical writing and editorial assistance was provided by Erin P. Scott, PhD, of Scott Medical Communications, LLC. This assistance was funded by Merck & Co, Inc, Kenilworth, NJ. Randomization was conducted by a computer-generated allocation schedule provided by the sponsor. Each site was given a range of randomization numbers from the allocation schedule and subjects were assigned a number sequentially. Blinding of investigators and subjects was maintained through the use of a placebo identical in appearance to active treatment. The protocol was approved and the study overseen by the Research Ethics Committee of NRES Committee South Central-Oxford A (Bristol, UK). All subjects provided written informed consent. Subjects aged 18 to 55 years with a clinical history of allergic rhinitis with or without conjunctivitis to HDM and who used medications for its symptomatic relief within the last year were recruited. Intermittent mild asthma was allowed if it was controlled without regular use of corticosteroids (including inhaled corticosteroids) over the last 12 months. Subjects had a positive skin prick test response (average wheal diameter of duplicate tests ≥3 mm larger than with the saline control) to D pteronyssinus (with or without a concomitant reaction to D farinae), and a serum-specific IgE to D pteronyssinus of 0.7 kU/L or more (with or without specific IgE to D farinae). Subjects experiencing symptoms from a respiratory tract infection or an allergic rhinoconjunctivitis exacerbation within 4 weeks before the screening NAC were excluded from the study. The TNSS was assessed by visual analogue scale (VAS) on a scale of 0 (absent) to 100 (severe) for each of the symptoms of nasal congestion, rhinorrhea, itching, and sneezing with a total maximum score of 400.E1Oldenbeuving N.B. KleinJan A. Mulder P.G. Lumley P. de Groot E.J. van Drunen C.M. et al.Evaluation of an intranasal house dust mite provocation model as a tool in clinical research.Allergy. 2005; 60: 751-759Crossref PubMed Scopus (27) Google Scholar At screening (before baseline NAC), the VAS score was required to be less than 150/400 and participants had to demonstrate VAS score increases of 25 or more for at least 2 symptoms within 2 hours of the nasal challenge. Serum for measurement of IgE-BF and IgG4 was collected at randomization, and weeks 2, 8, and 12. IgE-BF was measured using a validated immunoassay (ADVIA Centaur Specific IgE 2-step assay with ADVIA Centaur Specific IgE, Siemens Healthcare Diagnostics, Deerfield, Ill)E2Wurtzen P.A. Lund G. Lund K. Arvidsson M. Rak S. Ipsen H. A double-blind placebo-controlled birch allergy vaccination study II: correlation between inhibition of IgE binding, histamine release and facilitated allergen presentation.Clin Exp Allergy. 2008; 38: 1290-1301Crossref PubMed Scopus (88) Google Scholar in a recently adapted version that used a 1:1 mixture of D pteronyssinus and D farinae extracts.E3Johansen N. Gronager P.M. Ipsen H. Stranzl T. Lund K. Characterisation of a new method for quantitative determination of house dust mite allergen specific IgE-blocking factor for monitoring allergy immunotherapy with SQ HDM SLIT-tablet.Allergy. 2016; 71 (ab321): 118-272Crossref Google Scholar HDM species-specific IgG4 was measured by ImmunoCap (Phadia AB, Portage, Mich) as previously described.E4Bufe A. Eberle P. Franke-Beckmann E. Funck J. Kimmig M. Klimek L. et al.Safety and efficacy in children of an SQ-standardized grass allergen tablet for sublingual immunotherapy.J Allergy Clin Immunol. 2009; 123: 167-173.e7Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar Antihistamines and decongestants had to be discontinued for more than 3 days and nasal or ocular corticosteroids for 21 days before NACs. Nasal lavage was performed as previously described using 5 mL of sterile normal saline flushed into the nasal cavity 20 times over approximately 1 minute before any sampling.E5Greiff L. Pipkorn U. Alkner U. Persson C.G. The “nasal pool” device applies controlled concentrations of solutes on human nasal airway mucosa and samples its surface exudations/secretions.Clin Exp Allergy. 1990; 20: 253-259Crossref PubMed Scopus (150) Google Scholar HDM allergen extract (Aquagen, D pteronyssinus, 100,000 SQ-U/mL; ALK, Hørsholm, Denmark) was diluted in normal saline to 9,000 SQ-U/mL according to the manufacturer's instructions and administered using a nasal Pfeiffer Bidose applicator (Aptar Pharma, Milton Keynes, UK). A single nasal spray (100 μL) was given to each nostril in each challenge (total bilateral challenge of ∼1800 SQ-U). NAC was performed at week −2 (baseline), and weeks 8 and 12 of the study (Fig E1). Nasosorption was undertaken 1 hour pre-NAC (baseline) and 15 minutes and 6.5 hours post-NAC (Fig E1). Nasal curettage was performed at 1 hour pre-NAC (baseline) and 6.5 hours post-NAC. The TNSS using VAS out of a total score of 400 was recorded before NAC, every 15 minutes in the first hour after NAC, at 90 minutes, and hourly for 6 hours. The PNIF was measured using an inspiratory flow meter connected to a facemask according to published guidelines.E6Malm L. Gerth van Wijk R. Bachert C. Guidelines for nasal provocations with aspects on nasal patency, airflow, and airflow resistance. International Committee on Objective Assessment of the Nasal Airways, International Rhinologic Society.Rhinology. 2000; 38: 1-6PubMed Google Scholar Subjects were coached on the method and allowed to become familiar with the equipment. At each time point in the NAC (same time points as symptom scores), 3 measurements were taken of which the highest was recorded. Synthetic absorptive membranes in 7 mm × 30 mm strips with rounded ends (Hunt Developments, Midhurst, West Sussex) were inserted into both nostrils using forceps under direct vision with a head-mounted lamp. This process was timed for 2 minutes with application of nasal clips to ensure good apposition on the mucosal surface of the inferior turbinate. After withdrawal, synthetic absorptive membrane strips were processed as previously described and the collected eluate immediately stored at −80°C for subsequent immunoassay.E7Leaker B.R. Malkov V.A. Mogg R. Ruddy M.K. Nicholson G.C. Tan A.J. et al.The nasal mucosal late allergic reaction to grass pollen involves type 2 inflammation (IL-5 and IL-13), the inflammasome (IL-1β), and complement.Mucosal Immunol. 2017; 10: 408-420Crossref PubMed Scopus (43) Google Scholar Mucosal lining fluid (MLF) spun through cellulose acetate centrifuge filters was stored frozen at −80°C at the sites. Concentrations of IL-5, IL-13, and TARC were determined using Mesoscale V-plex singleplex immunoassays (Mesoscale Diagnostics, Rockland, Md). Fit-for-purpose validations were performed internally where interassay and intraassay variability ( 80%), linearity, sensitivity, and freeze/thaw stability (<20% change) were assessed and passed internal prespecified cutoffs in each category. Nasal scrapes were collected using Rhino-Probe plastic nasal curettes (Arlington Scientific, Springville, Utah) from the inferior side of the inferior turbinate under direct vision. The nasal mRNA was assessed using NanoString's nCounter Analysis System (NanoString Technologies, Inc, Seattle, Wash). Libraries for RNA sequencing were prepared by Beijing Genomics Institute (Philadelphia, Pa, or Hong Kong, China) using 100 ng of purified total RNA and the Truseq stranded total RNA RiboZero library preparation kit (Illumina Catalog #: RS-122-2201) strictly following the Illumina guide (15031048 E). Briefly, rRNA was depleted with rRNA Removal Mix and then the remaining RNA fragmented into approximately 160-bp fragments. These fragments served as templates for first-strand cDNA synthesis using random hexamer-primers, followed by second stand synthesis with the addition of buffer, dNTPs, RNase H, and DNA polymerase I. Double-stranded cDNA was purified using the QiaQuick PCR extraction kit (Qiagen) followed by end repair, base A addition, and ligation of sequencing adapters. Ligated fragments were purified by magnetic beads and amplified via PCR. The resulting library products were quantified with the Agilent2100 bioanalyzer and were sequenced using an Illumina HiSeqTM 4000 for a total of 3 GB of 50-bp paired-end read data per sample. The coprimary end points were the change induced by 12 SQ-HDM from baseline in HDM-specific (against D farinae and D pteronyssinus) IgG4 and IgE-BF antibodies (against both species together) at week 12. Secondary end points were changes in nasal MLF IL-5 concentration after treatment and in response to NACs, and changes in time-weighted average TNSS during NACs for early (baseline to 1 hour post-NAC) and peak (15 minutes post-NAC) responses. Changes in the TNSS during NACs for late (2 hours to 6 hours post-NAC) responses were also evaluated. Safety was assessed through adverse event reporting. Exploratory end points included nasal MLF IL-13 and TARC concentrations, PNIF, and nasal mRNA signature. End-point analysis was performed for the per-protocol population, which in this study was also all subjects as the treated population. Descriptive statistics were calculated for the coprimary end points of IgG4 and IgE-BF. Within-group change from baseline and between-group differences in serum HDM-specific IgG4 antibody were evaluated on the basis of a constrained longitudinal data analysis (cLDA) method with log-transformed data.E8Liang K.Y. Zeger S.L. Longitudinal data analysis using generalized linear models.Biometrika. 1986; 73: 13-22Crossref Scopus (13566) Google Scholar The model included time (categorical variable), treatment, and time by treatment interaction as fixed effects and subjects as random effect. The 90% 2-sided CI (corresponding to a 95% 1-sided CI) for the geometric mean ratio of the end points in 12 SQ-HDM–treated patients to those in placebo-treated patients at week 12 was reported. Change from baseline in IgE-BF was analyzed in a similar manner to IgG4, but on the original scale (not log-scale). To preserve the overall type I error at a 1-sided α level of 0.05, analysis of the coprimary end points was tested in a step-down procedure. Specifically, the evaluation of the HDM-specific IgE-BF response was tested only if the HDM-specific IgG4 response was statistically significant. Furthermore, as the IgG4 response was evaluated for the 2 HDM species (D farinae and D pteronyssinus), a Hochberg step-up procedure was used and the hypothesis was considered successful if statistical significance was found for at least 1 of the 2 HDM species. Gene expression alignment and transcript quantitation was performed in Omicsoft Array Studio version 7.2.2.29. Briefly, cleaned reads were aligned to the human B37.3 genome reference using the Omicsoft Aligner with a maximum of 4 allowed mismatches. Gene-level counts were determined by the RSEM algorithm as implemented in Omicsoft Array Studio and using RefGene transcript annotation prepared March 21, 2014. The TNSS and the PNIF were measured as average time-weighted scores from baseline (1 hour pre-NAC) through 1 hour post-NAC (early phase NAC). Least square means and 95% 2-sided CIs were calculated for each treatment group at each NAC. Between-group differences in change from pretreatment NAC and 90% 2-sided CIs were calculated for TNSS, PNIF, and cytokine levels using the same cLDA model used for the coprimary end points.Fig E2The TNSS during early and late phases of NACs at weeks −2, 8, and 12. Percentages indicate change from baseline. *P ≤ .05 for change from baseline versus placebo.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig E3Subject-level protein concentrations in nasal mucosal lining fluid at 1 hour pre-NAC, 15 minutes post-NAC (except TARC), and 6.5 hours post-NAC at weeks −2, 8, and 12 for IL-5 (A), IL-13 (B), and TARC (C). BLOQ, Below limit of quantitation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig E3Subject-level protein concentrations in nasal mucosal lining fluid at 1 hour pre-NAC, 15 minutes post-NAC (except TARC), and 6.5 hours post-NAC at weeks −2, 8, and 12 for IL-5 (A), IL-13 (B), and TARC (C). BLOQ, Below limit of quantitation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig E4Correlations between mRNA markers.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table E1Subjects' demographic and baseline characteristicsCharacteristic12 SQ-HDM(n = 16)Placebo(n = 7)Sex: female, n (%)8 (50)3 (43)Age (y), mean (range)31 (19-52)36 (23-53)White, n (%)14 (88)6 (86)Blood eosinophil levels (min, max)0.2 (0.1, 0.7)0.2 (0.1, 0.4)D farinae SPT wheal size (mm), mean (min, max)11.3 (6.6, 16.0)12.4 (4.3, 18.5)D farinae serum-specific IgE (kU/L), mean (min, max)19.9 (1.6, 58.8)16.8 (1.6, 36.0)D pteronyssinus SPT wheal size (mm), mean (min, max)12.5 (5.9, 19.0)10.6 (6.0, 14.8)D pteronyssinus serum-specific IgE (kU/L), mean (min, max)33.4 (1.6, 98.2)27.7 (3.7, 60.0)SPT, Skin prick test. Open table in a new tab Table E2Fold change from baseline for IgG4 and change from baseline for IgE-BFTreatmentWeekMinMedianMaxLeast square GM/mean (95% CI)∗GM for IgG4 and mean for IgE-BF.GMR/CFB vs placebo (90% CI)†GMR for IgG4 and CFB for IgE-BF.P valueIgG4 D farinae 12 SQ-HDM00.010.181.000.18 (0.12 to 0.26)——80.040.321.680.32 (0.21 to 0.49)1.83 (1.20 to 2.81).024120.040.462.360.39 (0.25 to 0.62)2.36 (1.52 to 3.66).003 Placebo00.130.170.470.18 (0.12 to 0.26)——80.110.160.430.18 (0.11 to 0.29)——120.110.150.450.17 (0.10 to 0.29)——IgG4 D pteronyssinus 12 SQ-HDM00.030.291.520.28 (0.20 to 0.39)——80.080.602.600.52 (0.35 to 0.78)1.86 (1.24 to 2.78).015120.070.632.940.62 (0.40 to 0.97)2.18 (1.36 to 3.49).010 Placebo00.170.270.750.28 (0.20 to 0.39)——80.140.300.780.28 (0.17 to 0.46)——120.170.260.790.28 (0.16 to 0.49)——IgE-BF 12 SQ-HDM0−0.42−0.170.14−0.15 (−0.20 to −0.09)——8−0.280.060.570.07 (−0.05 to 0.18)0.22 (0.05 to 0.38).03812−0.250.070.620.10 (−0.03 to 0.23)0.24 (0.07 to 0.41).027 Placebo0−0.27−0.150.00−0.15 (−0.20 to −0.09)——8−0.38−0.130.03−0.15 (−0.32 to 0.02)——12−0.41−0.100.03−0.14 (−0.32 to 0.04)——CFB, Change from baseline; GM, geometric mean; GMR, ratio of geometric mean.∗ GM for IgG4 and mean for IgE-BF.† GMR for IgG4 and CFB for IgE-BF. Open table in a new tab SPT, Skin prick test. CFB, Change from baseline; GM, geometric mean; GMR, ratio of geometric mean.