LETTER TO THE EDITOR Subcutaneous immunotherapy in hemophilic patients
The review of subcutaneous immunotherapy (SCIT) by Roche and Wise1 showed that SCIT is a safe and effective treatment for allergic rhinitis, and its adverse effects are usually mild. However, the clinical benefits are accompanied by complex immunological changes that could be dangerous in some patients. Recently, we published a case report about late recurrence of inhibitor antibodies against factor VIII (FVIII) in a hemophilic patient when he started desensitizing therapy using allergenic vaccines against grass pollen.2 The reappearance of the inhibitor coincided with the simultaneous administration of FVIII recombinant concentrates and SCIT, suggesting the existence of a causal relationship between SCIT and development of the inhibitor.3 We speculated that parenteral administration of a peptide antigen, as exogenous FVIII, coinciding with increased T helper 1 (Th1) lymphocytes favored by SCIT, could lead
to an immunological “danger signal,” culminating in the alloantibody development.4 This explanation supports the hypothesis that SCIT administration coincident with the infusion of FVIII should be avoided, as it could be perceived by the immune system as a danger signal, and its coincidence with increased Th1 lymphocytes favored by SCIT could facilitate the development of inhibitors in hemophilic patients. Currently, the development of inhibitor antibodies against FVIII is the most serious treatment-related complication for hemophilia A patients; therefore, it is very important to avoid any situation that could relate to its appearance. Nuria Bermejo, MD, PhD, Department of Hematology, ´ ´ Hospital San Pedro de Alcantara, Caceres, Spain
References 1. Roche AM, Wise SK. Subcutaneous immunotherapy. Int Forum Allergy Rhinol. 2014;4(S2):S51–S54. 2. Bermejo N, Mart´ın Aguilera C, Carnicero F, Bergua J. Allergenic vaccines administration and inhibitor devel-
opment in haemophilia. Haemophilia. 2012;18:e392– e393. 3. Gouw SC, van der Bom JG, Marijke van den Berg H. Treatment-related risk factors of inhibitor development
Potential conflict of interest: None provided. DOI: 10.1002/alr.21510 View this article online at wileyonlinelibrary.com.
271
International Forum of Allergy & Rhinology, Vol. 5, No. 3, March 2015
in previously untreated patients with hemophilia A: the CANAL cohort study. Blood. 2007;109:4648–4654. 4. Kurnik K. New early prophylaxis regimen that avoids immunological danger signals can reduce FVIII inhibitor development. Haemophilia. 2010;16:256–262.
The review of subcutaneous immunotherapy (SCIT) by Roche and Wise1 showed that SCIT is a safe and effective treatment for allergic rhinitis, and its adverse effects are usually mild. However, the clinical benefits are accompanied by complex immunological changes that could be dangerous in some patients. Recently, we published a case report about late recurrence of inhibitor antibodies against factor VIII (FVIII) in a hemophilic patient when he started desensitizing therapy using allergenic vaccines against grass pollen.2 The reappearance of the inhibitor coincided with the simultaneous administration of FVIII recombinant concentrates and SCIT, suggesting the existence of a causal relationship between SCIT and development of the inhibitor.3 We speculated that parenteral administration of a peptide antigen, as exogenous FVIII, coinciding with increased T helper 1 (Th1) lymphocytes favored by SCIT, could lead
to an immunological “danger signal,” culminating in the alloantibody development.4 This explanation supports the hypothesis that SCIT administration coincident with the infusion of FVIII should be avoided, as it could be perceived by the immune system as a danger signal, and its coincidence with increased Th1 lymphocytes favored by SCIT could facilitate the development of inhibitors in hemophilic patients. Currently, the development of inhibitor antibodies against FVIII is the most serious treatment-related complication for hemophilia A patients; therefore, it is very important to avoid any situation that could relate to its appearance. Nuria Bermejo, MD, PhD, Department of Hematology, ´ ´ Hospital San Pedro de Alcantara, Caceres, Spain
References 1. Roche AM, Wise SK. Subcutaneous immunotherapy. Int Forum Allergy Rhinol. 2014;4(S2):S51–S54. 2. Bermejo N, Mart´ın Aguilera C, Carnicero F, Bergua J. Allergenic vaccines administration and inhibitor devel-
opment in haemophilia. Haemophilia. 2012;18:e392– e393. 3. Gouw SC, van der Bom JG, Marijke van den Berg H. Treatment-related risk factors of inhibitor development
Potential conflict of interest: None provided. DOI: 10.1002/alr.21510 View this article online at wileyonlinelibrary.com.
271
International Forum of Allergy & Rhinology, Vol. 5, No. 3, March 2015
in previously untreated patients with hemophilia A: the CANAL cohort study. Blood. 2007;109:4648–4654. 4. Kurnik K. New early prophylaxis regimen that avoids immunological danger signals can reduce FVIII inhibitor development. Haemophilia. 2010;16:256–262.
