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Nicolaides RE, Parrish CP, Bird JA. Food Allergy Immunotherapy with Adjuvants. Immunol Allergy Clin North Am 2020; 40:149-173. [DOI: 10.1016/j.iac.2019.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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52
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Ciaccio CE, Bauer ME, Nowak-Wegrzyn A. Food OIT: What do we know, what don't we know, and what do we need to know? Ann Allergy Asthma Immunol 2020; 123:118-119. [PMID: 31376842 DOI: 10.1016/j.anai.2019.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 12/13/2022]
Affiliation(s)
| | - Maureen Egan Bauer
- Department of Pediatrics, Children's Hospital Colorado, The University of Colorado, Aurora, Colorado
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York
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53
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a brief discussion on the differential diagnosis for peripheral eosinophilia. We will then focus on targeted immunotherapies for atopic disease, their effects on absolute peripheral eosinophil counts, and use of peripheral eosinophils as a predictor of treatment response. RECENT FINDINGS In atopic disease, lower absolute peripheral eosinophil counts are typically associated with improved outcomes. Much of the current evidence on eosinophils as a biomarker comes from post hoc analyses in therapeutic immunotherapy. While changes in eosinophilia were not the primary outcome of interest in many studies, some patterns did emerge. Cytolytic monoclonal antibodies AK002 and benralizumab completely reduce peripheral and tissue eosinophil numbers. Dupilumab may have paradoxical transient eosinophilia despite observed clinical efficacy. Atopic inflammation is complex largely due to the various cytokines which affect eosinophil activation, proliferation, differentiation, and survival. This demonstrates the challenges of using peripheral eosinophilia alone as a biomarker for atopic disease activity. More attention should spotlight how different immunotherapy modalities affect eosinophil-driven responses.
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54
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Oral immunotherapy vs food avoidance: The answer is maybe. Ann Allergy Asthma Immunol 2020; 122:552-553. [PMID: 31171236 DOI: 10.1016/j.anai.2019.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 02/24/2019] [Indexed: 01/06/2023]
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Abstract
Food allergies, defined as an immune response to food proteins, affect as many as 8% of young children and 2% of adults in western countries, and their prevalence appears to be rising like all allergic diseases. In addition to well-recognized urticaria and anaphylaxis triggered by IgE antibody- mediated immune responses, there is an increasing recognition of cell-mediated disorders, such as eosinophilic esophagitis and food protein-induced enterocolitis. Non-IgE-Mediated gastrointestinal food allergies are a heterogeneous group of food allergies in which there is an immune reaction against food but the primary pathogenesis is not a production of IgE and activation of mast cells and basophils. Those diseases tend to affect mainly the gastrointestinal tract and can present as acute (FPIES) or chronic reaction, such as Eosinophilic Esophagitis (EoE), Food Protein-Induced Allergic Proctocolitis (FPIAP). The role of food allergy in Non-EoE gastrointestinal Eosinophilic disorders (Non- EoE EGID) is poorly understood. In some diseases like EoE, T cell seems to play a major role in initiating the immunological reaction against food, however, in FPIES and FPIAP, the mechanism of sensitization is not clear. Diagnosis requires food challenges and/or endoscopies in most of the patients, as there are no validated biomarkers that can be used for monitoring or diagnosis of Non-IgE mediated food allergies. The treatment of Non-IgE food allergy is dependent on diet (FPIES, and EoE) and/or use of drugs (i.e. steroids, PPI) in EoE and Non-EoE EGID. Non-IgE mediated food allergies are being being investigated.
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Affiliation(s)
- Antonella Cianferoni
- Division of Allergy and Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States
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56
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Chinthrajah RS, Purington N, Andorf S, Long A, O'Laughlin KL, Lyu SC, Manohar M, Boyd SD, Tibshirani R, Maecker H, Plaut M, Mukai K, Tsai M, Desai M, Galli SJ, Nadeau KC. Sustained outcomes in oral immunotherapy for peanut allergy (POISED study): a large, randomised, double-blind, placebo-controlled, phase 2 study. Lancet 2019; 394:1437-1449. [PMID: 31522849 PMCID: PMC6903389 DOI: 10.1016/s0140-6736(19)31793-3] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/08/2019] [Accepted: 06/14/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Dietary avoidance is recommended for peanut allergies. We evaluated the sustained effects of peanut allergy oral immunotherapy (OIT) in a randomised long-term study in adults and children. METHODS In this randomised, double-blind, placebo-controlled, phase 2 study, we enrolled participants at the Sean N Parker Center for Allergy and Asthma Research at Stanford University (Stanford, CA, USA) with peanut allergy aged 7-55 years with a positive result from a double-blind, placebo-controlled, food challenge (DBPCFC; ≤500 mg of peanut protein), a positive skin-prick test (SPT) result (≥5 mm wheal diameter above the negative control), and peanut-specific immunoglobulin (Ig)E concentration of more than 4 kU/L. Participants were randomly assigned (2·4:1·4:1) in a two-by-two block design via a computerised system to be built up and maintained on 4000 mg peanut protein through to week 104 then discontinued on peanut (peanut-0 group), to be built up and maintained on 4000 mg peanut protein through to week 104 then to ingest 300 mg peanut protein daily (peanut-300 group) for 52 weeks, or to receive oat flour (placebo group). DBPCFCs to 4000 mg peanut protein were done at baseline and weeks 104, 117, 130, 143, and 156. The pharmacist assigned treatment on the basis of a randomised computer list. Peanut or placebo (oat) flour was administered orally and participants and the study team were masked throughout by use of oat flour that was similar in look and feel to the peanut flour and nose clips, as tolerated, to mask taste. The statistician was also masked. The primary endpoint was the proportion of participants who passed DBPCFCs to a cumulative dose of 4000 mg at both 104 and 117 weeks. The primary efficacy analysis was done in the intention-to-treat population. Safety was assessed in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT02103270. FINDINGS Between April 15, 2014, and March 2, 2016, of 152 individuals assessed, we enrolled 120 participants, who were randomly assigned to the peanut-0 (n=60), peanut-300 (n=35), and placebo groups (n=25). 21 (35%) of peanut-0 group participants and one (4%) placebo group participant passed the 4000 mg challenge at both 104 and 117 weeks (odds ratio [OR] 12·7, 95% CI 1·8-554·8; p=0·0024). Over the entire study, the most common adverse events were mild gastrointestinal symptoms, which were seen in 90 of 120 patients (50/60 in the peanut-0 group, 29/35 in the peanut-300 group, and 11/25 in the placebo group) and skin disorders, which were seen in 50/120 patients (26/60 in the peanut-0 group, 15/35 in the peanut-300 group, and 9/25 in the placebo group). Adverse events decreased over time in all groups. Two participants in the peanut groups had serious adverse events during the 3-year study. In the peanut-0 group, in which eight (13%) of 60 participants passed DBPCFCs at week 156, higher baseline peanut-specific IgG4 to IgE ratio and lower Ara h 2 IgE and basophil activation responses were associated with sustained unresponsiveness. No treatment-related deaths occurred. INTERPRETATION Our study suggests that peanut OIT could desensitise individuals with peanut allergy to 4000 mg peanut protein but discontinuation, or even reduction to 300 mg daily, could increase the likelihood of regaining clinical reactivity to peanut. Since baseline blood tests correlated with week 117 treatment outcomes, this study might aid in optimal patient selection for this therapy. FUNDING National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- R Sharon Chinthrajah
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Natasha Purington
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA; Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - Sandra Andorf
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Andrew Long
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Katherine L O'Laughlin
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Shu Chen Lyu
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Monali Manohar
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Scott D Boyd
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Pathology, Stanford University, Stanford, CA, USA
| | - Robert Tibshirani
- Department of Biomedical Data Sciences, Stanford University, Stanford, CA, USA; Department of Statistics, Stanford University, Stanford, CA, USA
| | - Holden Maecker
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Microbiology and Immunology, Stanford University, Stanford, CA, USA
| | - Marshall Plaut
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Kaori Mukai
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Pathology, Stanford University, Stanford, CA, USA
| | - Mindy Tsai
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Pathology, Stanford University, Stanford, CA, USA
| | - Manisha Desai
- Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - Stephen J Galli
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Pathology, Stanford University, Stanford, CA, USA; Department of Microbiology and Immunology, Stanford University, Stanford, CA, USA
| | - Kari C Nadeau
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA.
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57
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Muir AB, Brown-Whitehorn T, Godwin B, Cianferoni A. Eosinophilic esophagitis: early diagnosis is the key. Clin Exp Gastroenterol 2019; 12:391-399. [PMID: 31616174 PMCID: PMC6699505 DOI: 10.2147/ceg.s175061] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/09/2019] [Indexed: 12/16/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is a disorder which affects all ages, from infancy through adulthood. It typically affects atopic individuals (Table 1) and is a chronic allergic disorder, with foods ubiquitous in the diet being the most described trigger of this isolated eosinophilic inflammation of the esophagus in both adults and children. This inflammatory process leads to esophageal symptoms such as dysphagia and feeding intolerance. In this review, we provide a brief overview of the current state of EoE therapy and symptomatology and then try to make the case for early diagnosis and treatment to prevent some of the long-term consequences of esophageal inflammation.
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Affiliation(s)
- Amanda B Muir
- Gastroenterology Division, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Bridget Godwin
- Gastroenterology Division, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Antonella Cianferoni
- Gastroenterology Division, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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58
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Risk Factors and Treatment Outcomes for Oral Immunotherapy-Induced Gastrointestinal Symptoms and Eosinophilic Responses (OITIGER). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:125-131. [PMID: 31382040 DOI: 10.1016/j.jaip.2019.07.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 07/24/2019] [Accepted: 07/24/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND We recently described that oral immunotherapy (OIT)-induced gastrointestinal symptoms were associated with peripheral eosinophilic responses (termed OITIGER). OBJECTIVE To identify treatment outcomes after dose modification and risk factors for developing OITIGER. METHODS Treatment modifications in patients with OITIGER (n = 65) including cumulative dose reductions or treatment suspension were individualized and based on the severity of symptoms and an associated absolute eosinophil count (AEC, eosinophils/μL) of more than 900. Multivariate analysis for risk factors associated with OITIGER was performed in milk-OIT subjects. RESULTS Treatment modifications reduced the cumulative daily dosage load by a median of 50% (interquartile range, 50%-67%) in 43 of 65 (66.1%) patients, deferred dose increases in 2 of 65 (3.1%) patients, or temporarily suspended treatment in 18 of 65 (27.7%) patients. Two patients (3.1%) had no treatment intervention. Symptoms and eosinophilia abated on dosage modification, allowing for resumption of dose increases (n = 34) or reinitiation of treatment (n = 9) after a median of 29 (interquartile range, 20-56) and 19 (interquartile range, 17-44) days, respectively. OITIGER reoccurred during treatment in 10 of 54 (18.5%) patients, which resolved after further dose modification. In long-term follow-up (>3-26 months), 31 of 32 patients were asymptomatic with stable AECs. Patients with OITIGER had a higher OIT failure rate (P = .004) and were less likely to reach full desensitization (P < .001), as compared with asymptomatic patients (n = 684). Multivariate analysis identified several risk factors for OITIGER: starting dose more than 120 mg (P < .001; odds ratio, 7.14), second-month dose more than 4-fold over the starting dose (P = .037; odds ratio, 2.18), and baseline AEC more than 600/μL (P = .002; odds ratio, 3.2). CONCLUSIONS OITIGER is transient or reversible in most subjects, and its occurrence is related to OIT starting dose, its rate of increase, and baseline AECs.
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59
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Kauppila TK, Paassilta M, Kukkonen AK, Kuitunen M, Pelkonen AS, Makela MJ. Outcome of oral immunotherapy for persistent cow's milk allergy from 11 years of experience in Finland. Pediatr Allergy Immunol 2019; 30:356-362. [PMID: 30685892 DOI: 10.1111/pai.13025] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 12/20/2018] [Accepted: 01/15/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND The safety and efficacy of long-term milk oral immunotherapy (OIT) in Finnish children with persistent cow's milk allergy (CMA) were evaluated in an open-label, non-randomized study. METHODS During the 11-year study, 296 children aged 5 years or older with immunoglobulin E (IgE)-mediated CMA started milk OIT. Follow-up data were collected at three time points: the post-buildup phase, 1 year thereafter, and at the cross-sectional long-term follow-up between January 2016 and December 2017. Patients were divided according to baseline milk-specific IgE (sIgE) level and by the amount of milk consumption at the long-term follow-up. The high-dose group consumed ≥2 dL of milk daily, while the failure group consumed <2 dL of milk or were on a milk-avoidance diet. RESULTS Out of the initial study group, 244/296 (83%) patients participated in the long-term follow-up. Among these patients, 136/244 (56%) consumed ≥2 dL of milk daily. The median follow-up time was 6.5 years. Of the recorded markers and clinical factors, the baseline milk sIgE level was most associated with maintaining milk OIT (P < 0.001). Respiratory symptoms in the post-buildup phase increased the risk of treatment failure (OR 3.5, 95% CI: 1.5-8.1, P = 0.003) and anaphylaxis (OR 14.3, 95% CI: 1.8-114, P = 0.01). CONCLUSION More than half of the patients were able to maintain the targeted milk dose in their daily diet. Baseline milk sIgE level and reactivity during the early treatment stage strongly predicted the long-term outcome and safety of milk OIT.
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Affiliation(s)
- Tiina Kaisa Kauppila
- University of Helsinki, Helsinki, Finland.,Helsinki University Hospital, Skin and Allergy Hospital, Helsinki, Finland
| | | | | | - Mikael Kuitunen
- Children's Hospital, University of Helsinki, Helsinki, Finland
| | - Anna S Pelkonen
- Helsinki University Hospital, Skin and Allergy Hospital, Helsinki, Finland
| | - Mika J Makela
- Helsinki University Hospital, Skin and Allergy Hospital, Helsinki, Finland
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60
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Ruffner MA, Capucilli P, Hill DA, Spergel JM. Screening children for eosinophilic esophagitis: allergic and other risk factors. Expert Rev Clin Immunol 2019; 15:315-318. [PMID: 30722709 PMCID: PMC6687298 DOI: 10.1080/1744666x.2019.1579643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/04/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Melanie A Ruffner
- a Division of Allergy & Immunology , Children's Hospital of Philadelphia , Philadelphia , PA , USA
- b Department of Pediatrics , University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
| | - Peter Capucilli
- a Division of Allergy & Immunology , Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - David A Hill
- a Division of Allergy & Immunology , Children's Hospital of Philadelphia , Philadelphia , PA , USA
- b Department of Pediatrics , University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
| | - Jonathan M Spergel
- a Division of Allergy & Immunology , Children's Hospital of Philadelphia , Philadelphia , PA , USA
- b Department of Pediatrics , University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
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61
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Braun C, Caubet JC. Food oral immunotherapy is superior to food avoidance-CON. Ann Allergy Asthma Immunol 2019; 122:569-571. [PMID: 30772390 DOI: 10.1016/j.anai.2019.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/01/2019] [Accepted: 02/07/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Camille Braun
- University Lyon 1 Claude Bernard, Villeurbanne, France
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.
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62
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Sackesen C, Altintas DU, Bingol A, Bingol G, Buyuktiryaki B, Demir E, Kansu A, Kuloglu Z, Tamay Z, Sekerel BE. Current Trends in Tolerance Induction in Cow's Milk Allergy: From Passive to Proactive Strategies. Front Pediatr 2019; 7:372. [PMID: 31620408 PMCID: PMC6760011 DOI: 10.3389/fped.2019.00372] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 08/30/2019] [Indexed: 12/15/2022] Open
Abstract
This review addresses the current strategies of inducing tolerance development in infant and childhood cow's milk protein allergy (CMPA). The change in prevention strategies for CMPA has been emphasized based on the lack of evidence to support the efficacy of food allergen avoidance in infancy and the concept of the dual-allergen-exposure hypothesis, which suggests that allergen exposure through the skin leads to sensitization, whereas early oral consumption of allergenic food protein induces oral tolerance. The new approach is based on the likelihood of early introduction of allergenic foods to the infant's diet to reduce the development of food allergies through oral tolerance induction. The latest treatment guidelines recommend the continuation of breast feeding and the elimination of cow's milk and products from the maternal diet in exclusively breast-fed infants with CMPA, the use of an extensively hydrolyzed infant formula (eHF) with proven efficacy in CMPA as the first elimination diet in formula-fed infants with CMPA and the use of amino acid-based formula (AAF) in severe cases, such as anaphylaxis, enteropathy, eosinophilic esophagitis, and food protein-induced enterocolitis syndrome (FPIES), as well as cases of multiple system involvement, multiple food allergies, and intolerance to extensively hydrolyzed formula (eHF). In conclusion, this paper presents the current knowledge on tolerance development in infants and children with CMPA to increase the awareness of the clinicians concerning the new approaches in CMPA treatment Tolerance development is considered a relatively new concept in CMPA, inducing a shift in interventions in CMPA from a passive (avoidance of responsible allergen) toward a proactive (tolerance induction) strategy.
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Affiliation(s)
- Cansin Sackesen
- Division of Pediatric Allergy, Department of Pediatrics, Koc University School of Medicine, Istanbul, Turkey
| | - Derya Ufuk Altintas
- Division of Pediatric Allergy, Department of Pediatrics, Cukurova University School of Medicine, Adana, Turkey
| | - Aysen Bingol
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Gulbin Bingol
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Acibadem University School of Medicine, Istanbul, Turkey
| | - Betul Buyuktiryaki
- Division of Pediatric Allergy and Asthma, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Esen Demir
- Division of Pediatric Allergy, Department of Pediatrics, Ege University School of Medicine, Izmir, Turkey
| | - Aydan Kansu
- Division of Pediatric Gastroenterology, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Zarife Kuloglu
- Division of Pediatric Gastroenterology, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
| | - Zeynep Tamay
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul University Istanbul School of Medicine, Istanbul, Turkey
| | - Bulent Enis Sekerel
- Division of Pediatric Allergy and Asthma, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
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63
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Wright BL, Fernandez-Becker NQ, Kambham N, Purington N, Tupa D, Zhang W, Rank MA, Kita H, Shim KP, Bunning BJ, Doyle AD, Jacobsen EA, Boyd SD, Tsai M, Maecker H, Manohar M, Galli SJ, Nadeau KC, Chinthrajah RS. Baseline Gastrointestinal Eosinophilia Is Common in Oral Immunotherapy Subjects With IgE-Mediated Peanut Allergy. Front Immunol 2018; 9:2624. [PMID: 30524424 PMCID: PMC6261984 DOI: 10.3389/fimmu.2018.02624] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/25/2018] [Indexed: 12/14/2022] Open
Abstract
Rationale: Oral immunotherapy (OIT) is an emerging treatment for food allergy. While desensitization is achieved in most subjects, many experience gastrointestinal symptoms and few develop eosinophilic gastrointestinal disease. It is unclear whether these subjects have subclinical gastrointestinal eosinophilia (GE) at baseline. We aimed to evaluate the presence of GE in subjects with food allergy before peanut OIT. Methods: We performed baseline esophagogastroduodenoscopies on 21 adults before undergoing peanut OIT. Subjects completed a detailed gastrointestinal symptom questionnaire. Endoscopic findings were assessed using the Eosinophilic Esophagitis (EoE) Endoscopic Reference Score (EREFS) and biopsies were obtained from the esophagus, gastric antrum, and duodenum. Esophageal biopsies were evaluated using the EoE Histologic Scoring System. Immunohistochemical staining for eosinophil peroxidase (EPX) was also performed. Hematoxylin and eosin and EPX stains of each biopsy were assessed for eosinophil density and EPX/mm2 was quantified using automated image analysis. Results: All subjects were asymptomatic. Pre-existing esophageal eosinophilia (>5 eosinophils per high-power field [eos/hpf]) was present in five participants (24%), three (14%) of whom had >15 eos/hpf associated with mild endoscopic findings (edema, linear furrowing, or rings; median EREFS = 0, IQR 0–0.25). Some subjects also demonstrated basal cell hyperplasia, dilated intercellular spaces, and lamina propria fibrosis. Increased eosinophils were noted in the gastric antrum (>12 eos/hpf) or duodenum (>26 eos/hpf) in 9 subjects (43%). EPX/mm2 correlated strongly with eosinophil counts (r = 0.71, p < 0.0001). Conclusions: Pre-existing GE is common in adults with IgE-mediated peanut allergy. Eosinophilic inflammation (EI) in these subjects may be accompanied by mild endoscopic and histologic findings. Longitudinal data collection during OIT is ongoing.
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Affiliation(s)
- Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Nielsen Q Fernandez-Becker
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Neeraja Kambham
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States.,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Natasha Purington
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Dana Tupa
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Wenming Zhang
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Hirohito Kita
- Division of Allergic Diseases, Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kelly P Shim
- Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Bryan J Bunning
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Alfred D Doyle
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Elizabeth A Jacobsen
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Scott D Boyd
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States.,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Mindy Tsai
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Holden Maecker
- Institute for Immunity, Transplantation, and Infection, Stanford University School of Medicine, Stanford, CA, United States
| | - Monali Manohar
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Stephen J Galli
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States.,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States.,Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, United States
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
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64
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Salmivesi S, Korppi M. The time has come to stop placebo-controlled trials of milk oral immunotherapy and focus on real-life studies. Acta Paediatr 2018; 107:1855-1856. [PMID: 29992616 DOI: 10.1111/apa.14493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/24/2018] [Accepted: 07/09/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Susanna Salmivesi
- Allergy Center; Tampere University Hospital; Tampere Finland
- Tampere Center for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Matti Korppi
- Tampere Center for Child Health Research; Tampere University and University Hospital; Tampere Finland
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Steinbach EC, Hernandez M, Dellon ES. Eosinophilic Esophagitis and the Eosinophilic Gastrointestinal Diseases: Approach to Diagnosis and Management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:1483-1495. [PMID: 30201096 PMCID: PMC6134874 DOI: 10.1016/j.jaip.2018.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/06/2018] [Accepted: 06/21/2018] [Indexed: 12/12/2022]
Abstract
The eosinophilic gastrointestinal diseases (EGIDs) represent disorders of the gastrointestinal (GI) tract that result from the local infiltration and aberrant activity of eosinophils and other immune cells. Eosinophilic esophagitis (EoE) is the most well-characterized EGID and is defined by the presence of intraepithelial eosinophils in the esophagus (≥15 eosinophils per high-powered field) and clinical symptoms associated with esophageal dysfunction. The other EGIDs are rare and lack strong data regarding pathogenesis and management. The incidence and prevalence of EoE are increasing, and EoE is now a major cause of upper GI morbidity. Management is multidisciplinary, with collaboration between gastroenterologists, allergists, pathologists, and dieticians, and is aimed at amelioration of symptoms and prevention of long-term complications such as esophageal stricture. Treatment options for EoE include proton pump inhibitors, swallowed topical corticosteroids, and elimination diets. Esophageal dilation is used when esophageal strictures or fibrostenotic changes are present. Additional therapies targeting eosinophils and other mediators of Th2 inflammation are under development and are promising. Treatment options for other EGIDs typically involve corticosteroids or dietary elimination.
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Affiliation(s)
- Erin C Steinbach
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Michelle Hernandez
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC.
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Spergel JM, Aceves SS, Kliewer K, Gonsalves N, Chehade M, Wechsler JB, Groetch M, Friedlander J, Dellon ES, Book W, Hirano I, Muir AB, Cianferoni A, Spencer L, Liacouras CA, Cheng E, Kottyan L, Wen T, Platts-Mills T, Rothenberg ME. New developments in patients with eosinophilic gastrointestinal diseases presented at the CEGIR/TIGERS Symposium at the 2018 American Academy of Allergy, Asthma & Immunology Meeting. J Allergy Clin Immunol 2018; 142:48-53. [PMID: 29803797 PMCID: PMC6129859 DOI: 10.1016/j.jaci.2018.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/17/2018] [Accepted: 05/18/2018] [Indexed: 12/28/2022]
Abstract
The Consortium of Eosinophilic Gastrointestinal Diseases and the International Gastrointestinal Eosinophil Researchers organized a day-long symposium at the recent 2018 Annual Meeting of the American Academy of Allergy, Asthma & Immunology, which was coupled for the first time with the World Allergy Organization meeting to create an international platform. The symposium featured experts in many facets of eosinophilic gastrointestinal diseases, including allergy, immunology, gastroenterology, pathology, and nutrition, and was a well-attended event. The basic science, genetics, cellular immunology, and clinical features of the diseases, with a focus on epithelial, eosinophil, and mast cell responses, as well as current and emerging treatment options, were reviewed. Here we briefly review some of the highlights of the material presented at the meeting.
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Affiliation(s)
- Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Seema S Aceves
- Division of Allergy, Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, Rady Children's Hospital, San Diego, La Jolla, Calif
| | - Kara Kliewer
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, Ill
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joshua B Wechsler
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Marion Groetch
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joshua Friedlander
- Digestive Health Institute, Children's Hospital Colorado, and the Aerodigestive Program, University of Colorado School of Medicine, Aurora, Colo
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Wendy Book
- American Partnership for Eosinophilic Disorders, Atlanta, Ga
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, Ill
| | - Amanda B Muir
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Antonella Cianferoni
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | | | - Chris A Liacouras
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Edaire Cheng
- Departments of Pediatrics and Internal Medicine, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Leah Kottyan
- Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Ting Wen
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Thomas Platts-Mills
- Division of Asthma, Allergy, and Immunology, University of Virginia, Charlottesville, Va
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio.
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Ferguson AE, Fulkerson PC. Eosinophilic esophagitis: Time to classify into endotypes? J Allergy Clin Immunol 2018; 142:71-72. [PMID: 29751005 DOI: 10.1016/j.jaci.2018.04.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/20/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Anna E Ferguson
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Patricia C Fulkerson
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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