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Immunotherapy
CORRESPONDENCE
Immunotherapy To the Editor: A recent issue of Iwternational Congress News distributed as a service of Schering Corporation, summarizes the paper delivered by Dr. Lichtenstein and co-authors in Tokyo. To quote a pertinent paragraph: “The clinical relief following immunotherapy is essentially no greater than that which can be obtained with the use of intranasal dexamethasone. . . . Moreover, despite attempting a number of different regimens of immunotherapy we have been unable to [further] increase the level of clinical relief signifteantly. It is our present concept that because of the extensive time and expense involved in this therapy, and because of the possible risk involved, immunotherapy is of dubious value in light of the modest clinical relief obtained.” If this is an excerpt taken out of context, it would be wise for Dr. Lichtenstein to correct it before this becomes widespread gospel. If it is indeed a correct and complete quote, then there is certainly need for much concern in reconciling conclusions from short periods of clinical observations with the experiences of many competent clinicians treating many millions of hay fever sufferers for more than half a century. The report on 21 patients relying on such nebulous immunological findings as rise in blocking antibody titers does not merit a challenge nor can the merits or demerits of immunotherapy be satisfactorily resolved through public pronouncements or counter challenges. The widespread employment of specific immunotherapy deserves mature and more careful study and reporting to avoid adding to the confusion in the minds of clinicians, federal agencies and the trusting allergic patients. But what should be a cause of greater concern from this report is equating the clinical effectiveness of specific immunotherapy with intranasal dexamethasone. The harmful effect on the normal ciliated columnar nasal epithelium from continual local use of steroids is clear and needs no elaboration. Implied recommendation for its repeated and long-term use would inevitably produce irreparable harm. Such conclusions and recommendation by a highly regarded group of investigators in the field of immunology can only encourage drug companies manufacturing corticosteroids to promote the use of this drug intranasally and for drug salesmen to tout them to unthinking clinicians in plaee of timehonored, effective measures. Those clinicians with a clear understanding of the physiology and the pathology of the nose must speak up promptly to head off a possible therapeutic catastrophe. Frank Perlman, Y.D. Portland, Ore. Reply
To th.e Editor: Prom time to time it becomes useful to review and evaluate years of work and express an opinion as to the value of and indications for a mode of treatment. Such was the rationale behind a paper from our group at the International Association of Allergology last fall, sections of which are discussed by Dr. Perlman in his letter. Such also was the rationale behind a review recently published by one of our number.* In that review we note that, “So long as only subjective evaluations were available, discussions of specific immunization tended to become polemics exposing mainly the prejudices of the participants. Objective evaluations, however, now allow one to examine some hard won facts arising out of scientific investigation *Norman, P. 8.: 58: 111, 1974.
Specific
therapy
in allergy.
Pro
(with
reservations),
Med. Clin. North
Am.
Vol. 64, No. 2, pp. 119-129
Immunotherapy To the Editor: A recent issue of Iwternational Congress News distributed as a service of Schering Corporation, summarizes the paper delivered by Dr. Lichtenstein and co-authors in Tokyo. To quote a pertinent paragraph: “The clinical relief following immunotherapy is essentially no greater than that which can be obtained with the use of intranasal dexamethasone. . . . Moreover, despite attempting a number of different regimens of immunotherapy we have been unable to [further] increase the level of clinical relief signifteantly. It is our present concept that because of the extensive time and expense involved in this therapy, and because of the possible risk involved, immunotherapy is of dubious value in light of the modest clinical relief obtained.” If this is an excerpt taken out of context, it would be wise for Dr. Lichtenstein to correct it before this becomes widespread gospel. If it is indeed a correct and complete quote, then there is certainly need for much concern in reconciling conclusions from short periods of clinical observations with the experiences of many competent clinicians treating many millions of hay fever sufferers for more than half a century. The report on 21 patients relying on such nebulous immunological findings as rise in blocking antibody titers does not merit a challenge nor can the merits or demerits of immunotherapy be satisfactorily resolved through public pronouncements or counter challenges. The widespread employment of specific immunotherapy deserves mature and more careful study and reporting to avoid adding to the confusion in the minds of clinicians, federal agencies and the trusting allergic patients. But what should be a cause of greater concern from this report is equating the clinical effectiveness of specific immunotherapy with intranasal dexamethasone. The harmful effect on the normal ciliated columnar nasal epithelium from continual local use of steroids is clear and needs no elaboration. Implied recommendation for its repeated and long-term use would inevitably produce irreparable harm. Such conclusions and recommendation by a highly regarded group of investigators in the field of immunology can only encourage drug companies manufacturing corticosteroids to promote the use of this drug intranasally and for drug salesmen to tout them to unthinking clinicians in plaee of timehonored, effective measures. Those clinicians with a clear understanding of the physiology and the pathology of the nose must speak up promptly to head off a possible therapeutic catastrophe. Frank Perlman, Y.D. Portland, Ore. Reply
To th.e Editor: Prom time to time it becomes useful to review and evaluate years of work and express an opinion as to the value of and indications for a mode of treatment. Such was the rationale behind a paper from our group at the International Association of Allergology last fall, sections of which are discussed by Dr. Perlman in his letter. Such also was the rationale behind a review recently published by one of our number.* In that review we note that, “So long as only subjective evaluations were available, discussions of specific immunization tended to become polemics exposing mainly the prejudices of the participants. Objective evaluations, however, now allow one to examine some hard won facts arising out of scientific investigation *Norman, P. 8.: 58: 111, 1974.
Specific
therapy
in allergy.
Pro
(with
reservations),
Med. Clin. North
Am.
Vol. 64, No. 2, pp. 119-129