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Keywords:

  • adherence;
  • allergist;
  • sublingual immunotherapy

Sublingual immunotherapy (SLIT) is accepted as a viable alternative to injection immunotherapy, and largely used in clinical practice in many European countries. The clinical efficacy of SLIT for the most relevant allergens has been ascertained in numerous clinical trials and meta-analyses (1), and the safety profile has been reported to be satisfactory in several post marketing surveys, including both adults and children. Since SLIT is self managed by the patients, the adherence to treatment still represents a concern, as adherence is essential for the success of the treatment. Looking at the literature, the adherence to SLIT in clinical trials and postmarketing surveys, would result to be overall satisfactory (2, 3). Nonetheless, additional important information about the factors which influence adherence could be provided by the physicians who prescribe SLIT in their everyday clinical practice, but the allergists’ viewpoint has not yet been investigated. For this reason we performed a questionnaire-based survey among Italian allergists, in order to know their opinions on the problem.

A dedicated questionnaire was posted to 325 allergy specialists, over the entire Italian territory, randomly selected from a national list. The questionnaire was made by 10 questions concerning different factors, which can favourably influence the adherence to SLIT. The factors were: perceived efficacy, tolerability, reimbursement, administration regimen (precoseasonal/continuous), ease of use, regular contact with the patient, approval from the GP, patients’ education, follow-up visits. Each question had to be answered by a score from 1 to 10 (‘extremely important’ to ‘of no relevance’). In an additional question, the physician was asked to chose the most relevant factor that, in their opinion, impairs the adherence.

Out of the 325 contacted allergists, 296 returned a valid questionnaire (i.e. with all the questions answered). Their mean age was 51, 40.5% were female and the occupation was distributed as follows: 5% private practice, 60% hospital, 35% territorial healthcare setting. The most apparent result was that the perception of clinical efficacy was considered as the most important factor (ranked 1 by 54% of respondents) positively influencing the adherence, immediately followed by the possibility of reimbursement (rank 1 = 34%) and by the absence of side effects (rank 1 = 21.3%). The remaining factors ranked 1 in less than 20% of the answers, as shown in Fig. 1. Of note, patients’ education, acceptance by the GP and regular follow-up were not judged as particularly relevant. Also, the ease of use of SLIT received a marginal consideration. The cost of SLIT was reported as the main reason for discontinuation by 95% of the physicians, followed by the absence of the perception of clinical efficacy (48%) and by the presence of side effects (42%).

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Figure 1.  Percentage of respondents who ranked 1 (extremely important) the aspects listed in the x-axis.

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Adherence to the therapeutic regimen is crucial in all fields of medicine (4–6), especially in chronic diseases such as rhinitis or asthma, and is particularly true with SLIT, which is self-managed by the patient at home and involves several months of treatment. In the present work, we aimed at investigating how specialists perceive the adherence problems in the case of SLIT, with questions on the factors that are commonly believed to affect the compliance itself. As expected, the patient’s perceived clinical efficacy is considered the most important factor, even more important than tolerability. On the other hand, surprisingly, the patient’s education was not judged as a relevant issue, as well as the ease of use of the treatment. These results suggest that there is room for improving adherence also by acting on specialists’ attitudes, and that a regular evaluation of the efficacy as perceived by the patient would probably improve the adherence.

References

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  2. References
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    Passalacqua G, Musarra A, Pecora S, Amoroso S, Antonicelli L, Senna GE et al. Quantitative assessment of the compliance with a once-daily sublingual immunotherapy regimen in real life (EASY Project: Evaluation of A novel SLIT formulation during a Year). J Allergy Clin Immunol 2006;117:946948.
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