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Multiple studies have revealed the large socio-economic effect of allergic diseases, as they may impair people’s performance at school and work. Allergic rhinitis is one of the most expensive diseases for national economies and healthcare systems due to its high prevalence.1 Allergies often lead to absenteeism from work. A German study revealed that every 10th sick day in Germany is attributed to allergies.2 Similar results were reported from other European countries3 and the U.S.4
The number of people suffering from allergies (more than 128 million people in Europe)5 often leads to a reduced quality of life. The provision of the best possible treatment and prevention of exacerbation or progression of the disease is one of the top health priorities in the EU.
The standard treatment algorithm and prevention of allergic reactions begins with allergen avoidance, or at least reduction of the triggering allergens, if the type of allergen is known. However, this option is often possible only insufficiently, especially for environmental allergens such as pollen or dust mites. Avoiding allergens in the workplace is also a particular challenge, e.g., paints, latex or dust.
If contact with allergens cannot be avoided, symptomatic treatment with different types of medication can help to relieve symptoms. Unlike allergen avoidance and specific immunotherapy, drug therapy does not target the causes of the disease, but only eliminates or relieves symptoms.
Symptomatic medication includes:
A specific treatment option is hyposensitisation, also called allergen-specific immunotherapy (AIT). It is an allergen-specific treatment which aims to stop, or at least reduce, symptoms in the long term after re‑exposure. It is the only causal therapy currently available apart from allergy abstinence. Studies have proved that successful AIT reduces the risk of developing allergic asthma or new allergies.
The treatment principle of AIT consists of slow administration of the culprit allergen at high doses to allergic patients with the aim of inducing tolerance to the allergen. The allergens in this specific immunotherapy can be administered as a subcutaneous injection (SCIT), sublingually (SLIT) and recently orally (OIT).6
Although AIT is a successful and cost-effective way to treat allergies, it has a limited outcome. AIT protocols typically last several years to complete and, as a result, are characterised by low treatment adherence and a high rate of drop-out patients.7 On the other hand, effectiveness has been evaluated only for some allergens, e.g., pollen from grasses, cereals and herbs, tree pollen, house dust mites and wasp and bee venom.
Current research is focusing on mechanisms of improvement and are working on identifying biomarkers with predictive value for the success of AIT. Biomarkers might allow a personalised assessment on a per-patient basis of the likelihood that AIT will result in amelioration of the disease.
Newer approaches to allergy treatment are passive immunotherapies. It is a form of targeted treatment using monoclonal antibodies against antigens and intervening at different sites of the immune system’s response.
Understanding the interplay of immunoglobulins and other substances in the allergic immune response is the key to this type of treatment. Currently available targeted interventions work in different ways: (i) by an effective reduction of IgE levels; (ii) by administration of blocking IgG that binds and inhibits allergens; or (iii) by blockage of inflammatory substances released by the immune system, such as cytokines or interleukins to inhibit initiation and maintenance of the allergic response.8
One substance is omalizumab: the first humanised monoclonal antibody specific for IgE-mediated allergies was approved in 2003 for the treatment of allergic asthma and subsequently for the treatment of other allergens. Early trials demonstrated that omalizumab could significantly reduce nasal and ocular symptoms of seasonal allergic rhinitis and asthma symptoms in cat allergen-sensitised subjects. More recent studies found that using omalizumab in combination with AIT showed reduced symptoms severity, reduced need for rescue medication and fewer days with allergic symptoms, irrespective of allergen.9
More immunotherapies have emerged since and substances such as dupilomab, mepolizumab or reslizumab have shown effectiveness in symptom reduction and increase of life quality due to less exacerbation in different studies. Other recently approved immunotherapies need confirmation through more clinical studies in their use in allergy treatment.
Targeted intervention already holds the potential to effectively provide therapeutic benefit to patients and offers more promise for the future.
Although the number of people with allergies is steadily increasing and although more treatment options are approved for antiallergic treatment, health care for patients with allergic diseases is still inadequate. An example from Germany: according to experts, only 30% of patients with hay fever are treated sufficiently, and only 10% of them are treated according to current guidelines.10 Allergen specific immunotherapy is rarely used: one German study found that only 7% of patients with allergic rhinitis receive this type of therapy, although it is more effective and cost-effective than symptomatic pharmacotherapy in the long term.11
This may be explained by the fact that allergies are a rather “new” medical field. Despite it’s being a major global public health issue, the public and the health establishment have generally not recognised the importance of allergic diseases.12 This frequently results in a lack of correct diagnosis and sub-optimal disease management and has negative effects on quality of life, increased morbidity and considerable additional direct and indirect costs.13
Due to given health policy and reimbursement developments and increasing numbers of people with allergies, there is risk of a worsening care situation in the future. On the other hand, acceptance and implementation of new therapeutic options such as immunotherapy offer the chance to treat severe and performance-limiting allergies and to achieve a satisfactory cessation of allergy symptoms in the future.
Whether new therapeutic interventions can have an impact on disability claims due to occupational allergens or on severe environmental allergens with limitation of performance is currently not quite clear. The central points of medical claims assessment are to check whether avoiding contact with allergens in the workplace is technically feasible, and whether all therapeutically possible and, most importantly, accessible measures have been exhausted.
Allergies play an important role not only in the national economy, but also in the context of insurance medicine. Europe has seen a steady increase in the number of people with allergies. Dr. Sandra Mitic describes different types of allergies and the relevance for medical underwriting in the first part of this blog series.
