Open Access

Allergen immunotherapy for insect venom allergy: protocol for a systematic review

  • Sangeeta Dhami1Email authorView ORCID ID profile,
  • Ulugbek Nurmatov2,
  • Eva-Maria Varga3,
  • Gunter Sturm4,
  • Antonella Muraro5,
  • Cezmi A. Akdis6, 7,
  • Darío Antolín-Amérigo8,
  • M. Beatrice Bilò9,
  • Danijela Bokanovic10,
  • Moises A. Calderon11, 12,
  • Ewa Cichocka-Jarosz13,
  • Joanna N. G. Oude Elberink14,
  • Radoslaw Gawlik15,
  • Thilo Jakob16,
  • Mitja Kosnik17,
  • Joanna Lange18,
  • Ervin Mingomataj19, 20,
  • Dimitris I. Mitsias21,
  • Holger Mosbech22,
  • Oliver Pfaar23,
  • Constantinos Pitsios24, 25,
  • Valerio Pravettoni26,
  • Graham Roberts27, 28,
  • Franziska Ruëff29,
  • Betül Ayşe Sin30 and
  • Aziz Sheikh31
Clinical and Translational Allergy20166:6

https://doi.org/10.1186/s13601-016-0095-x

Received: 25 November 2015

Accepted: 11 January 2016

Published: 16 February 2016

The Erratum to this article has been published in Clinical and Translational Allergy 2017 7:30

Abstract

Background

The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing the EAACI Guidelines for Allergen Immunotherapy (AIT) for the Management of Insect Venom Allergy. We seek to critically assess the effectiveness, cost-effectiveness and safety of AIT in the management of insect venom allergy.

Methods

We will undertake a systematic review, which will involve searching international biomedical databases for published, in progress and unpublished evidence. Studies will be independently screened against pre-defined eligibility criteria and critically appraised using established instruments. Data will be descriptively and, if possible and appropriate, quantitatively synthesised.

Discussion

The findings from this review will be used to inform the development of recomendations for EAACI’s Guidelines on AIT.

Keywords

AllergyInsect stingHymenoptera venom allergyInsect venom allergyAllergen immunotherapySystemic sting reaction

Background

Hymenoptera venom allergy is a potentially life-threatening allergic reaction following one or more stings to bees, wasps, polistes, hornets or fire ants. The risk of anaphylaxis to hymenoptera stings is greater in adults when compared to children due to increased sting exposure, co-morbidities and concomitant medications in this age group. Systemic reactions have been reported in up to 3 % of adults and 0.34 % of children [1, 2].

Symptoms range from large local reactions at the sting site to mild, moderate, and severe systemic reactions. Mild systemic reactions are usually generalized skin symptoms such as flush, urticaria and angioedema. Typically, dizziness, dyspnea, nausea are moderate symptoms while anaphylactic shock, asthma, loss of consciousness, or even cardiac or respiratory arrest all indicate a severe sting reaction. The fear of future reactions usually greatly impairs quality of life. Around a quarter of fatalities from anaphylaxis are triggered by venom allergy [35].

Patients are advised to carry an emergency kit containing H1-antihistamines, corticosteroids, and adrenaline (epinephrine) depending on their previous sting reaction. The only treatment that can potentially prevent further severe reactions is venom immunotherapy (VIT). This may be effective with long-term clinical benefit and improved quality of life [6, 7]. However, despite its life-saving potential, VIT is still being under-prescribed and under-used in Europe [8].

The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing the EAACI Guidelines for AIT. This systematic review is one of five inter-linked evidence syntheses that are being undertaken in order to provide a state-of-the-art synopsis of the current evidence base in relation to evaluating AIT for the treatment of insect venom allergy, allergic rhinoconjunctivitis, food allergy and allergic asthma, and allergy prevention. These will be used to inform the formulation of key clinical recommendations for subsequent clinical guidelines. The focus of this review is on assessing the effectiveness, safety and cost-effectiveness of VIT in the treatment of insect venom allergy.

Methods

Search strategy

A highly sensitive search strategy has been developed, and validated study design filters will be applied to retrieve all articles pertaining to the use of VIT for insect venom allergy from electronic bibliographic databases. We have conceptualized the search to incorporate the four elements below as shown in Fig. 1.
Fig. 1

Conceptualization of systematic review of allergen immunotherapy for insect venom allergy

To retrieve systematic reviews, we will use the systematic review filter developed at McMaster University Health Information Research Unit (HIRU) (http://hiru.mcmaster.ca/hiru/HIRU_Hedges_MEDLINE_Strategies.aspx#Reviews). To retrieve randomized controlled trials (RCTs), we will apply the Cochrane highly sensitive search strategy for identifying RCTs in MEDLINE [9]. To retrieve non-randomized studies, i.e. controlled clinical trials (CCTs), controlled before-and-after (CBA) and interrupted time-series (ITS) studies, we will use the Cochrane Effective Practice and Organisation of Care (EPOC) filter Version 2.4, available on request from the EPOC Group [10, 11]. To retrieve case series, we will use the filter developed by librarians at Clinical Evidence: http://clinicalevidence.bmj.com/x/set/static/ebm/learn/665076.html.

We will search the following databases:
  • Cochrane Library including:
    • Cochrane Database of Systematic Reviews (CDSR)

    • Database of Reviews of Effectiveness (DARE)

    • CENTRAL (Trials)

    • Methods Studies

    • Health Technology Assessments (HTA)

    • Economic Evaluations Database (EED)

  • MEDLINE (OVID)

  • Embase (OVID)

  • CINAHL (Ebscohost)

  • ISI Web of Science (Thomson Web of Knowledge)

  • TRIP Database (www.tripdatabase.com)

  • Clinicaltrials.gov (NIH web).

  • Clinicaltrialsregister.eu

  • Current controlled trials (www.controlled-trials.com)

  • Australian and New Zealand Clinical Trials Registry (http://www.anzctr.org.au).

The search strategy has been developed on OVID MEDLINE and then adapted for the other databases (see “Appendix”). In all cases, the databases will be searched from inception to October 31, 2015. Additional references will be located through searching the references cited by the identified studies, and unpublished work and research in progress will be identified through discussion with experts in the field. We will invite experts who are active in the field from a range of disciplines and regions to add to the list of included studies by identifying additional published and unpublished papers they are aware of and research in progress. There will be no language restrictions employed; where possible, all relevant literature will be translated into English.

Inclusion criteria

Patient characteristics

We are interested in identifying studies conducted on patients of any age with a physician confirmed diagnosis of systemic sting reaction to a venom sting from fire ants, bees and bumble bees, and paper wasps and wasps.

Interventions of interest

This review is focused on VIT using different products (purified and non-purified aqueous or depot) and different treatment protocols (conventional, cluster, rush and ultra-rush) adminsitered through the SCIT or SLIT routes.

Comparators

We are interested in studies comparing VIT with placebo or no treatment (i.e. a natural course of the disease).

Study designs

Systematic reviews of RCTs, and RCTs, will be used to investigate effectiveness; health economic analysis will be used to assess cost-effectiveness; and systematic reviews, and RCTs and case series with a minimum of 300 patients will be used to assess safety. We will appraise the evidence by looking at higher levels of evidence such as systematic reviews and/or meta-analyses of RCTs, together with individual RCTs. However, given the likelihood that we will find only a limited number of RCTs, we will also search for and include quasi-RCTs—[i.e. non-randomized CCTs, controlled before and after (CBA) studies and interrupted time series (ITS) analyses]. Given the high inherent risk of bias in making inferences from quasi-RCTs, clinical recommendations will be based on the findings from randomized controlled trials and the quasi-randomized controlled trials will only be used to guide suggestions on which areas need to be prioritized in future research [12].

Outcomes

Primary

  • Efficacy assessed by tolerated sting challenge or field sting both short-term and long-term, where long-term is defined as sustained clinical efficacy after discontinuation of treatment (VIT).

Secondary

  • Assessment of disease specific quality of life;

  • Safety as assessed by local and systemic reactions in accordance with the World Allergy Organization’s grading system of side-effects [13, 14];

  • Health economic analysis from the perspective of the health system/payer.

Exclusion criteria

  • Reviews, discussion papers, non-research letters and editorials;

  • Animal studies;

  • Quantitative studies not employing systematic review or RCT or quasi-RCT designs;

  • Qualitative studies;

  • Case series (<300 patients).

Study selection

All references will be uploaded into the systematic review software Distiller and undergo initial de-duplication. Study titles will be independently checked by two reviewers according to the above selection criteria and categorized as: included, not included or unsure. For those papers in the unsure category, we will retrieve the abstract and re-categorize as above. Any discrepancies will be resolved through discussion and, if necessary, a third reviewer will be consulted. Full text copies of potentially relevant studies will be obtained and their eligibility for inclusion independently assessed. Studies that do not fulfil all of the inclusion criteria will be excluded.

Quality assessment strategy

Quality assessments will independently be carried out on each study by two reviewers using the relevant version of the Critical Appraisal Skills Programme (CASP) quality assessment tool for systematic reviews and health economic evaluations [15]. We will assess the risk of bias of experimental studies using the criteria suggested by the Cochrane EPOC Group [16]. RCTs, CCTs and CBAs will be assessed for generation of allocation sequence, concealment of allocation, baseline outcome measurements, baseline characteristics, incomplete outcome data, blinding of outcome assessor, protection against contamination, selective outcome reporting and other risks of bias using the Cochrane risk of bias tool. For ITS designs, we will also assess the independence of the intervention from secular trends, the pre-specified shape of the intervention and if the intervention may have had an impact on data collection. These methodological assessments will draw on the principles incorporated into the Cochrane EPOC guidelines for assessing intervention studies [17]. Similarly, we will use the quality assessment form produced by the National Institute for Health and Clinical Excellence (NICE) to critically appraise case series [18]. Any discrepancies will be resolved by discussion or, if agreement could not be reached, by arbitration by a third reviewer.

Analysis, data synthesis and reporting

Data will be independently extracted onto a customized data extraction sheet in Distiller by two reviewers, and any discrepancies will be resolved by discussion or, if agreement cannot be reached, by arbitration by a third reviewer.

A descriptive summary with data tables will be produced to summarize the literature. If clinically and statistically appropriate, meta-analysis using either fixed-effect or random-effects modeling will be undertaken [9]. A narrative synthesis of the data will also be undertaken.

Sensitivity and subgroup analyses, and assessment for publication bias

Sensitivity analyses will be undertaken by comparing the summary estimates obtained by excluding studies judged to be at high risk of bias.

Subgroup analyses will be undertaken to compare:
  • Children (5–11 years) versus adolescents (12–17 years) versus adults (≥18 years);

  • Conventional versus cluster versus rush versus ultra-rush protocols in SCIT;

  • Conventional in SLIT versus SCIT;

  • 3 versus 5 years of treatment;

  • Different allergen doses (50 vs. 100 vs. 200 µg of maintenance VIT);

  • Bee versus wasp venom;

  • Comparing outcomes between those with and without co-existent mast cell disease [19].

Where possible, publication bias will be assessed through the creation of funnel plots, and tested by Egger’s regression test and Begg’s rank correlation test [20, 21].

Registration and reporting

This review will be registered with the International Prospective Register of Systematic Reviews (PROSPERO): http://www.crd.york.ac.uk/prospero/. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist will be used to guide the reporting of the systematic review: http://www.prisma-statement.org/.

Discussion

This review will involve systematically identifying, critiquing and synthesizing the evidence on the efficacy/effectiveness, cost-effectiveness and safety of VIT for the management of venom allergy. The findings from this review will be used to inform the development of recommendations for EAACI’s Guidelines on AIT. We anticipate that this review will be reported in 2016.

Notes

Declarations

Authors’ contributions

This protocol was drafted by S Dhami and the search strategy was developed by U. Nurmatov. It was revised following critical review initially by A. Sheikh, E.-V. Varga and G. Sturm and then by all the co-authors. All authors read and approved the final manuscript.

Funding

EAACI.

Competing interests

S. Dhami: support to undertake the systematic review; U. Nurmatov: support to undertake the review; E-M Varga: Steering Committee Member and National Study Co-ordinator of the GAP trial (ALK-Abello), Speakers honoraria recipient from Stallergenes, Meda,Nutricia, Alk-Abello, Bencard; G Sturm: Materials for research programme (ALK-Abello), research grant (ALK-Abello), advisory board (ALK-Abello, Meda), speaker (ALK-Abello, Stallergens, Bencard, Thermo Fisher); A Muraro: Acting in consulting capacity for ALK, Meda Pharma, Nestle, Nutricia, Novartis. Grants from: Nestlé: Co-investigator for research protocol, Nutricia: Co-investigator for research protocols; C Akdis: Materials for research programme (Allergopharma), research grant (Allergopharma, Swiss National Science Foundation, EU MeDall, EU Predicta, Swiss Polish Research Program), advisory board (Boehringer Ingelheim, Allergopharma, Novartis, Davos Diagnostics, Actellion, Alimentary Health Pharma Davos), speaker (none) D. Antolín-Amérigo: advisory board (Merck, Novartis, Sandoz), Medical expert of the ALK web for general public (ALK-Abelló), research grant (Merck-Serono-Fundación 2000), clinical trials (Diater Laboratorios, Stallergenes), educational grants (Merck, Pfizer), speaker (Allergy Therapeutics, GlaxoSmithKline, Merck, Stallergenes), honoraria for articles (Ferrer Laboratorios, Meda, Stallergenes); M. Beatrice Bilò: advisory board (ALK-Abello, Allergopharma, Novartis), speaker (ALK-Abello, Allergopharma, Stallergens, Thermo Fisher); D. Bokanovic: research grant (MEDA), speaker (ALK-Abello); Moises A. Calderon: lectures honorarium (ALK, Stallergens, Merck and Allergopharma), consultancy honorarium (ALK, Stallergenes and Hal); E. Cichocka-Jarosz: none; J.O. Elberink, speaker (Chiesi, Meda, Novartis); R. Gawlik: speaker (Stallergens, Hal); T. Jakob: Materials for research (Allergopharma GmbH, Thermo Fisher Scientific), research grant (Allergopharma GmbH, Thermo Fisher Scientific, Dr. Fooke Laboratories GmbH, Novartis, Birken AG, Cosmetics Europe), advisory board (ALK-Abello, Allergy Therapeutics, Novartis, Leti GmbH, Allergopharma), speaker (ALK-Abello, Allergy Therapeutics, Thermo Fisher Scientific); Mitja Kosnik: none; J Lange: none; E. Mingomataj: none; D. I. Mitsias: none; H. Mosbech: none; C. Pitsios: none; V. Pravettoni: consultant for an advisory board (ALK Abellò), speaker (Thermo Fisher); G. Roberts: Materials for research programme (ALK-Abello), research grant (ALK-Abello), advisory board (ALK-Abello), speaker (Allergy Therapeutics, ALK-Abelo); B. A. Sin: none; A. Sheikh: support to co-ordinate the undertaking of the systematic review and development of the guidelines.

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Authors’ Affiliations

(1)
Evidence-Based Health Care Ltd
(2)
Systematic Review at Decision Resources Group, Abacus International
(3)
Respiratory and Allergic Disease Division, Department of Pediatric and Adolescent Medicine, Medical University of Graz
(4)
Department of Dermatology and Venerology, Medical University of Graz and Outpatient Allergy Clinic Reumannplatz
(5)
Department of Women and Child Health, Food Allergy Referral Centre Veneto Region, Padua General University Hospital
(6)
Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich
(7)
Servicio de Enfermedades del Sistema Inmune-Alergia, Departamento de Medicina y Especialidades Médicas, Hospital Universitario Príncipe de Asturias
(8)
Universidad de Alcalá
(9)
Allergy Unit, Department of Internal Medicine, University Hospital of Ancona
(10)
Department of Dermatology and Venerology, Medical University of Graz
(11)
Section of Allergy and Clinical Immunology, Imperial College London
(12)
National Heart and Lung Institute, Royal Brompton Hospital
(13)
Department of Pediatrics, Jagiellonian University Medical College
(14)
Department of Allergology Internal Medicine, University Medical Hospital Groningen, University of Groningen
(15)
Department of Internal Medicine, Allergy and Clinical Immunology, Medical University of Silesia
(16)
Department of Dermatology and Allergology, University Medical Center Gießen and Marburg (UKGM), Justus Liebig University Gießen
(17)
Medical Faculty Ljubljana, University Clinic of Respiratory and Allergic Diseases Golnik
(18)
Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw
(19)
Department of Allergollogy and Clinical Immunology, Mother Theresa School of Medicine
(20)
Department of Paraclinical Disciplines, Faculty of Technical-Medical Sciences, Medicine University of Tirana
(21)
Department of Allergy and Clinical Immunology, 2nd Pediatric Clinic, University of Athens
(22)
Allergy Clinic, Copenhagen University Hospital Gentofte
(23)
Department of Otorhinolaryngology, Head and Neck Surgery, Center for Rhinology and Allergology, University Hospital, Mannheim
(24)
Department of Nutrition and Dietetics, Harokopio University
(25)
Allergy Outpatient Clinic, Apollonio Hospital
(26)
UOC Clinical Allergy and Immunology, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico
(27)
NIHR Respiratory Biomedical Research Unit, The David Hide Asthma and Allergy Research Centre, St Mary’s Hospital, Newport Isle of Wight, University Hospital Southampton NHS Foundation Trust
(28)
Faculty of Medicine, University of Southampton
(29)
Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universität
(30)
Division of Immunology and Allergy, Department of Pulmonary Diseases, Faculty of Medicine, Ankara University
(31)
Allergy and Respiratory Research Group, The University of Edinburgh

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Copyright

© Dhami et al. 2016

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