51
|
Beutgen VM, Schmelter C, Pfeiffer N, Grus FH. Contribution of the Commensal Microflora to the Immunological Homeostasis and the Importance of Immune-Related Drug Development for Clinical Applications. Int J Mol Sci 2021; 22:8896. [PMID: 34445599 PMCID: PMC8396286 DOI: 10.3390/ijms22168896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 11/16/2022] Open
Abstract
Not long ago, self-reactive immune activity was considered as pathological trait. A paradigm shift has now led to the recognition of autoimmune processes as part of natural maintenance of molecular homeostasis. The immune system is assigned further roles beneath the defense against pathogenic organisms. Regarding the humoral immune system, the investigation of natural autoantibodies that are frequently found in healthy individuals has led to further hypotheses involving natural autoimmunity in other processes as the clearing of cellular debris or decrease in inflammatory processes. However, their role and origin have not been entirely clarified, but accumulating evidence links their formation to immune reactions against the gut microbiome. Antibodies targeting highly conserved proteins of the commensal microflora are suggested to show self-reactive properties, following the paradigm of the molecular mimicry. Here, we discuss recent findings, which demonstrate potential links of the commensal microflora to the immunological homeostasis and highlight the possible implications for various diseases. Furthermore, specific components of the immune system, especially antibodies, have become a focus of attention for the medical management of various diseases and provide attractive treatment options in the future. Nevertheless, the development and optimization of such macromolecules still represents a very time-consuming task, shifting the need to more medical agents with simple structural properties and low manufacturing costs. Synthesizing only the biologically active sites of antibodies has become of great interest for the pharmaceutical industry and offers a wide range of therapeutic application areas as it will be discussed in the present review article.
Collapse
Affiliation(s)
| | | | | | - Franz H. Grus
- Experimental and Translational Ophthalmology, Department of Ophthalmology, University Medical Center, 55131 Mainz, Germany; (V.M.B.); (C.S.); (N.P.)
| |
Collapse
|
52
|
Treudler R, Simon JC. [What is the role of allergen immunotherapy in IgE-mediated food allergy?]. Hautarzt 2021; 72:770-775. [PMID: 34402920 DOI: 10.1007/s00105-021-04882-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 12/24/2022]
Abstract
In food allergy, allergen avoidance and emergency treatment are still therapeutic hallmarks but, recently, allergen immunotherapy (AIT), with different application routes, has gained more attention. In primary food allergy, oral immunotherapy has been frequently used in clinical trials. This year, an oral immunotherapy preparation for treatment of peanut allergy was licensed in Europe. In secondary food allergy, sublingual and subcutaneous extracts have been used in clinical trials, mostly with cross-reactive pollen allergens. As there is no AIT preparation licensed for this indication, therapy should only be started when there also is a need for treating associated respiratory symptoms.
Collapse
Affiliation(s)
- Regina Treudler
- Klinik für Dermatologie, Venerologie und Allergologie, Leipziger Interdisziplinäres Centrum für Allergologie - LICA-CAC, Universität Leipzig, Philipp-Rosenthal-Str. 23, 04103, Leipzig, Deutschland.
| | - Jan-Christoph Simon
- Klinik für Dermatologie, Venerologie und Allergologie, Leipziger Interdisziplinäres Centrum für Allergologie - LICA-CAC, Universität Leipzig, Philipp-Rosenthal-Str. 23, 04103, Leipzig, Deutschland
| |
Collapse
|
53
|
Nilsson C, Scurlock AM, Dellon ES, Brostoff JM, Pham T, Ryan R, Brown KR, Adelman DC, Aceves SS. Onset of eosinophilic esophagitis during a clinical trial program of oral immunotherapy for peanut allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:4496-4501. [PMID: 34389504 DOI: 10.1016/j.jaip.2021.07.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Caroline Nilsson
- Clinical Research and Education, Karolinska Institutet, Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Amy M Scurlock
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | | | - Robert Ryan
- Aimmune Therapeutics, London, United Kingdom
| | | | - Daniel C Adelman
- Aimmune Therapeutics, Brisbane, Calif; Department of Medicine, University of California San Francisco, San Francisco, Calif
| | - Seema S Aceves
- Department of Pediatrics, University of California, San Diego, San Diego, Calif
| |
Collapse
|
54
|
Patel N, Adelman DC, Anagnostou K, Baumert JL, Blom WM, Campbell DE, Chinthrajah RS, Mills ENC, Javed B, Purington N, Remington BC, Sampson HA, Smith AD, Yarham RAR, Turner PJ. Using data from food challenges to inform management of consumers with food allergy: A systematic review with individual participant data meta-analysis. J Allergy Clin Immunol 2021; 147:2249-2262.e7. [PMID: 33571537 PMCID: PMC8168954 DOI: 10.1016/j.jaci.2021.01.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/10/2021] [Accepted: 01/27/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Eliciting doses (EDs) (eg, ED01 or ED05 values, which are the amounts of allergen expected to cause objective symptoms in 1% and 5% of the population with an allergy, respectively) are increasingly being used to inform allergen labeling and clinical management. These values are generated from food challenge, but the frequency of anaphylaxis in response to these low levels of allergen exposure and their reproducibility are unknown. OBJECTIVE Our aim was to determine (1) the rate of anaphylaxis in response to low-level peanut exposure and (2) the reproducibility of reaction thresholds (and anaphylaxis) at food challenge. METHODS We conducted a systematic review and individual participant data meta-analysis of studies that reported at least 50 individuals with peanut allergy reacting to peanut at double-blind, placebo-controlled food challenge (DBPCFC) and were published between January 2010 and September 2020. Risk of bias was assessed by using National Institute for Clinical Excellence methodologic checklists. RESULTS A total of 19 studies were included (covering a total of 3151 participants, 534 of whom subsequently underwent further peanut challenge). At individual participant data meta-analysis, 4.5% (95% CI, 1.9% to 10.1%) of individuals reacted to 5 mg or less of peanut protein with anaphylaxis (moderate heterogeneity [I2 = 57%]). Intraindividual thresholds varied by up to 3 logs, although this variation was limited to a half-log change in 71.2% (95% CI, 56.2% to 82.6%) of individuals. In all, 2.4% (95% CI, 1.1% to 5.0%) of patients initially tolerated 5 mg of peanut protein but then reacted to this dose at subsequent challenge (low heterogeneity [I2 = 16%]); none developed anaphylaxis. CONCLUSION Around 5% of individuals reacting to an ED01 or ED05 level of exposure to peanut might develop anaphylaxis in response to that dose. This equates to 1 and 6 anaphylaxis events per 2500 patients exposed to an ED01 or ED05 dose, respectively, in the broader population of individuals with peanut allergy.
Collapse
Affiliation(s)
- Nandinee Patel
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Katherine Anagnostou
- Section of Allergy and Immunology, Baylor College of Medicine, Houston, Tex; Section of Allergy and Immunology, Department of Pediatrics, Texas Children's Hospital, Houston, Tex
| | - Joseph L Baumert
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, Neb
| | - W Marty Blom
- The Netherlands Organisation of Applied Scientific Research, Utrecht, The Netherlands
| | - Dianne E Campbell
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Sydney, Australia; DBV Technologies, Montrouge, France
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research, Stanford, Calif; Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, Stanford, Calif
| | - E N Clare Mills
- Division of Infection, Immunity and Respiratory Medicine, Manchester Institute of Biotechnology, University of Manchester, Manchester, United Kingdom
| | - Bushra Javed
- Division of Infection, Immunity and Respiratory Medicine, Manchester Institute of Biotechnology, University of Manchester, Manchester, United Kingdom
| | - Natasha Purington
- Department of Medicine, Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, Calif
| | - Benjamin C Remington
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, Neb
| | - Hugh A Sampson
- DBV Technologies, Montrouge, France; Division of Pediatric Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Paul J Turner
- National Heart and Lung Institute, Imperial College London, London, United Kingdom.
| |
Collapse
|
55
|
Francis O, Kim EH. Peanut Immunotherapy: Practical Applications. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00292-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
56
|
Smith HG, Kim EH. Increasing diversity in peanut oral immunotherapy research and accessibility. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2132-2133. [PMID: 33966874 DOI: 10.1016/j.jaip.2021.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 02/04/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Hunter G Smith
- University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Edwin H Kim
- University of North Carolina School of Medicine, Chapel Hill, NC
| |
Collapse
|
57
|
Duan S, Arlian BM, Nycholat CM, Wei Y, Tateno H, Smith SA, Macauley MS, Zhu Z, Bochner BS, Paulson JC. Nanoparticles Displaying Allergen and Siglec-8 Ligands Suppress IgE-FcεRI-Mediated Anaphylaxis and Desensitize Mast Cells to Subsequent Antigen Challenge. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2021; 206:2290-2300. [PMID: 33911007 PMCID: PMC8113104 DOI: 10.4049/jimmunol.1901212] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 03/15/2021] [Indexed: 01/01/2023]
Abstract
Siglec-8 is an inhibitory receptor expressed on eosinophils and mast cells. In this study, we took advantage of a novel Siglec-8 transgenic mouse model to assess the impact of modulating IgE-dependent mast cell degranulation and anaphylaxis using a liposomal platform to display an allergen with or without a synthetic glycan ligand for Siglec-8 (Sig8L). The hypothesis is that recruitment of Siglec-8 to the IgE-FcεRI receptor complex will inhibit allergen-induced mast cell degranulation. Codisplay of both allergen and Sig8L on liposomes profoundly suppresses IgE-mediated degranulation of mouse bone marrow-derived mast cells or rat basophilic leukemia cells expressing Siglec-8. In contrast, liposomes displaying only Sig8L have no significant suppression of antigenic liposome-induced degranulation, demonstrating that the inhibitory activity by Siglec-8 occurs only when Ag and Sig8L are on the same particle. In mouse models of anaphylaxis, display of Sig8L on antigenic liposomes completely suppresses IgE-mediated anaphylaxis in transgenic mice with mast cells expressing Siglec-8 but has no protection in mice that do not express Siglec-8. Furthermore, mice protected from anaphylaxis remain desensitized to subsequent allergen challenge because of loss of Ag-specific IgE from the cell surface and accelerated clearance of IgE from the blood. Thus, although expression of human Siglec-8 on murine mast cells does not by itself modulate IgE-FcεRI-mediated cell activation, the enforced recruitment of Siglec-8 to the FcεRI receptor by Sig8L-decorated antigenic liposomes results in inhibition of degranulation and desensitization to subsequent Ag exposure.
Collapse
MESH Headings
- Allergens/administration & dosage
- Anaphylaxis/drug therapy
- Anaphylaxis/genetics
- Anaphylaxis/immunology
- Animals
- Antigens, CD/genetics
- Antigens, CD/metabolism
- Antigens, Differentiation, B-Lymphocyte/genetics
- Antigens, Differentiation, B-Lymphocyte/metabolism
- Cell Degranulation/drug effects
- Cell Degranulation/genetics
- Cell Degranulation/immunology
- Cell Line, Tumor
- Desensitization, Immunologic/methods
- Disease Models, Animal
- Drug Delivery Systems/methods
- Humans
- Immunoglobulin E/metabolism
- Lectins/genetics
- Lectins/metabolism
- Ligands
- Liposomes
- Mast Cells/immunology
- Mice
- Mice, Inbred C57BL
- Mice, Transgenic
- Nanoparticles/chemistry
- Polysaccharides/administration & dosage
- Polysaccharides/metabolism
- Rats
- Receptors, IgE/genetics
- Receptors, IgE/metabolism
- Treatment Outcome
Collapse
Affiliation(s)
- Shiteng Duan
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
| | - Britni M Arlian
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
| | - Corwin M Nycholat
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
| | - Yadong Wei
- Department of Pharmacology and Molecular Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hiroaki Tateno
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
| | - Scott A Smith
- Department of Medicine, and Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN
| | - Matthew S Macauley
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
| | - Zhou Zhu
- Department of Pediatrics, Brown University Alpert Medical School, Providence, RI
| | - Bruce S Bochner
- Department of Medicine, Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - James C Paulson
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
| |
Collapse
|
58
|
Purington N, Andorf S, Bunning B, Chinthrajah S, Nadeau K, Desai M. Novel application of a discrete time-to-event model for randomized oral immunotherapy clinical trials with repeat food challenges. Stat Med 2021; 40:4136-4149. [PMID: 33959986 DOI: 10.1002/sim.9019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 01/11/2021] [Accepted: 04/18/2021] [Indexed: 12/28/2022]
Abstract
The evaluation of double-blind, placebo-controlled food challenges (DBPCFC) generally focuses on a participant passing a challenge at a predetermined dose, and does not consider the dose of reaction for those who fail or are censored due to study discontinuation. Further, a number of food allergy trials have incorporated multiple DBPCFCs throughout the duration of the study in order to evaluate changes in reaction over time including sustained unresponsiveness from treatment. Outcomes arising from these trials are commonly modeled using Chi-squared or Fisher's exact tests at each time point. We propose applying time-to-event methodology to food allergy trials in order to exploit the inherent granularity of challenge outcomes that additionally accommodates repeated DBPCFCs. Specifically, we consider dose-to-failure for each study challenge and extend the cumulative tolerated dose across challenges to result in a dose-time axis. A discrete time-to-event framework is applied to the dose-time outcome to assess the efficacy of treatment across the entire study period. We illustrate ideas with data from the Peanut Oral Immunotherapy Study: Safety, Efficacy and Discovery (POISED) trial, conducted at Stanford University, which evaluated the efficacy of oral immunotherapy on desensitization and sustained unresponsiveness in peanut allergic children and adults. We demonstrate the advantages of time-to-event approaches for assessing the efficacy of treatment over time and incorporating information for those who failed or were lost to follow up. Further, we introduce a dose-time outcome that is interpretable to clinicians and allows for examination of such outcomes over time.
Collapse
Affiliation(s)
- Natasha Purington
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Sandra Andorf
- Department of Medicine, Sean N. Parker Center for Allergy and Asthma Research, Stanford, California, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Divisions of Biomedical Informatics and Allergy & Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bryan Bunning
- Department of Medicine, Sean N. Parker Center for Allergy and Asthma Research, Stanford, California, USA
| | - Sharon Chinthrajah
- Department of Medicine, Sean N. Parker Center for Allergy and Asthma Research, Stanford, California, USA.,Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Kari Nadeau
- Department of Medicine, Sean N. Parker Center for Allergy and Asthma Research, Stanford, California, USA.,Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Manisha Desai
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Palo Alto, California, USA.,Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| |
Collapse
|
59
|
Bahna SL, Assa'ad AH. Food Allergy: Catering for the Needs of the Clinician. Immunol Allergy Clin North Am 2021; 41:331-345. [PMID: 33863487 DOI: 10.1016/j.iac.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The practice of food allergy (FA) for clinicians has boomed, with a dramatic rise in the number of patients and families seeking care and with many advances on several fronts. The practice itself sometimes is evidence-based science and sometimes an art of pattern and phenotype recognition. This article examines the tools for diagnosis and management and therapy options available to physicians providing care for patients with FA. The article touches on pressing needs of clinicians and highlights the rapid and important movements in national and international support and advances that will have a positive impact on the field of FA.
Collapse
Affiliation(s)
- Sami L Bahna
- Allergy and Immunology Section, Louisiana State University Health Sciences Center in Shreveport, 1501 Kings Highway Rm 5-323 Shreveport, Louisiana 71130-3832, USA
| | - Amal H Assa'ad
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229.
| |
Collapse
|
60
|
How to Incorporate Oral Immunotherapy into Your Clinical Practice. Curr Allergy Asthma Rep 2021; 21:30. [PMID: 33929616 DOI: 10.1007/s11882-021-01009-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss how to best incorporate oral immunotherapy into your clinical practice based on recent evidence and guidelines, and address controversies. RECENT FINDINGS Oral immunotherapy is the food immunotherapy treatment with the most literature supporting its use. Recent data from both randomized clinical trials and real-world studies show OIT is especially safe and effective in preschoolers, while avoidance may be less safe than previously thought. OIT guidelines support its use outside of research. Oral immunotherapy can be safely and effectively incorporated into your clinical practice, with careful planning and consideration of scenarios where benefits outweigh risks. Baseline oral food challenges are necessary in clinical trials, but in clinical practice, these are best done when the history is unclear due to resource limitations. There is a role for both regular food and FDA-approved products. Future research should focus on optimizing safety and adherence in the real-world setting.
Collapse
|
61
|
Guarnieri KM, Slack IF, Gadoury-Lévesque V, Eapen AA, Andorf S, Lierl MB. Peanut oral immunotherapy in a pediatric allergy clinic: Patient factors associated with clinical outcomes. Ann Allergy Asthma Immunol 2021; 127:214-222.e4. [PMID: 33839246 DOI: 10.1016/j.anai.2021.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/26/2021] [Accepted: 04/01/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Additional information is needed to inform optimal patient selection, expected outcomes, and treatment end points for clinical peanut oral immunotherapy (OIT). OBJECTIVE To provide insight into the optimal patient selection, expected outcomes, and treatment end points for clinical peanut oral immunotherapy by analyzing a real-world peanut OIT cohort. METHODS Records were reviewed for 174 children undergoing peanut OIT at a pediatric allergy clinic. Patient age, peanut skin prick test results, and peanut-specific immunoglobulin E (sIgE) results, with inclusion of additional foods in OIT, were analyzed for correlations with OIT outcomes. RESULTS To date, 144 patients have achieved maintenance dosing, 50 of whom transitioned to ad lib twice-weekly peanut ingestion. A total of 30 discontinued OIT. In addition, 47 patients who underwent multifood OIT had no significant difference in reactions (FDR-adjusted P = .48) or time-to-reach maintenance (FDR-adjusted P = .48) compared with those on peanut OIT alone. Age at initiation inversely correlated with achievement of maintenance: 92% of patients 0.5 to less than 5 years, 81% of those 5 to less than 11 years, and 70% of those 11 to less than 18 years reached and continued maintenance (P = .01). Baseline peanut-sIgE level positively correlated with number of reactions during updosing (P < .001) and maintenance (P = .005), though it was not significantly different in patients achieving successful maintenance vs those who discontinued OIT (P = .09). Furthermore, 66% of patients experienced greater than or equal to 1 adverse reaction during OIT. Of those on ad lib peanut ingestion, 2 reported mild reactions after lapses in peanut consumption. CONCLUSION Clinical peanut OIT has similar outcomes to research protocols. OIT can be successful in older children and those with high peanut-sIgE levels, though these factors affect outcomes. Clinical and laboratory criteria can guide successful transition to intermittent ad lib peanut consumption.
Collapse
Affiliation(s)
- Katharine M Guarnieri
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ian F Slack
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Vanessa Gadoury-Lévesque
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Amy A Eapen
- Division of Allergy and Clinical Immunology, Department of Medicine, Henry Ford Health System, Detroit, Michigan
| | - Sandra Andorf
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michelle B Lierl
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| |
Collapse
|
62
|
Aktuelle Entwicklungen zur Therapie der Erdnussallergie. ALLERGO JOURNAL 2021. [DOI: 10.1007/s15007-021-4774-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
63
|
Khan I, Daniell H. Oral delivery of therapeutic proteins bioencapsulated in plant cells: preclinical and clinical advances. Curr Opin Colloid Interface Sci 2021; 54. [PMID: 33967586 DOI: 10.1016/j.cocis.2021.101452] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Oral delivery of protein drugs (PDs) made in plant cells could revolutionize current approaches of their production and delivery. Expression of PDs reduces their production cost by elimination of prohibitively expensive fermentation, purification, cold transportation/storage, and sterile injections and increases their shelf life for several years. Ability of plant cell wall to protect PDs from digestive acids/enzymes, commensal bacteria to release PDs in gut lumen after lysis of plant cell wall and role of GALT in inducing tolerance facilitate prevention or treatment allergic, autoimmune diseases or anti-drug antibody responses. Delivery of functional proteins facilitate treatment of inherited or metabolic disorders. Recent advances in making PDs free of antibiotic resistance genes in edible plant cells, long-term storage at ambient temperature maintaining their efficacy, production in cGMP facilities, IND enabling studies for clinical advancement and FDA approval of orally delivered PDs augur well for advancing this novel drug delivery platform technology.
Collapse
Affiliation(s)
- Imran Khan
- Department of Basic and Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Henry Daniell
- Department of Basic and Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| |
Collapse
|
64
|
Wasserman RL, Factor J, Windom HH, Abrams EM, Begin P, Chan ES, Greenhawt M, Hare N, Mack DP, Mansfield L, Ben-Shoshan M, Stukus DR, Leek TV, Shaker M. An Approach to the Office-Based Practice of Food Oral Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1826-1838.e8. [PMID: 33684637 DOI: 10.1016/j.jaip.2021.02.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/30/2021] [Accepted: 02/25/2021] [Indexed: 12/13/2022]
Abstract
Oral immunotherapy (OIT) provides an active treatment option for patients with food allergies. OIT may improve quality of life and raise the threshold at which a patient with food allergy may react to an allergen, but it is a rigorous therapy that requires a high degree of commitment by the clinician, patients, and families. Recent guidelines from the Canadian Society for Allergy and Clinical Immunology have provided a framework for the ethical, evidence-based, and patient-oriented clinical practice of OIT, and the European Academy of Allergy, Asthma, and Immunology guidelines have also recommended that OIT can be used as a potential treatment. The recent Food and Drug Administration approval of an OIT pharmaceutical has accelerated the adoption of OIT. This review provides a summary of the recent Canadian Society for Allergy and Clinical Immunology guidelines and a consensus of practical experience of clinicians across the United States and Canada related to patient selection, office and staff preparation, the general OIT process, OIT-related reaction management, and treatment outcomes.
Collapse
Affiliation(s)
| | - Jeffrey Factor
- New England Food Allergy Treatment Center, West Hartford, Conn
| | - Hugh H Windom
- Windom Allergy, Asthma and Sinus Specialists, Sarasota, Fla
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Philippe Begin
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Université de Montréal, Montreal, QC, Canada
| | - Edmond S Chan
- Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | | | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | | | - Moshe Ben-Shoshan
- Division of Allergy Immunology and Dermatology, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | | | - Marcus Shaker
- Geisel School of Medicine at Dartmouth, Hanover, NH; Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| |
Collapse
|
65
|
Abstract
Food allergies are a common medical problem, with children being the most affected patient group. The standard of care of food allergy consists of the acute treatment in case of a reaction and food avoidance in the long term, which influences the quality of life of patients. In this article, current developments for the causal treatment of food allergy including specific immunotherapy and biologics will be discussed. Epicutaneous and oral immunotherapy are currently in clinical development for the treatment of food allergy, and the results demonstrate good tolerability and efficacy with an increase in the oral threshold level. Biologics and, in particular, anti-IgE are currently investigated for their therapeutic use in food allergies. The results are promising, suggesting efficacy and tolerability.
Collapse
|
66
|
Leonard SA, Laubach S, Wang J. Integrating oral immunotherapy into clinical practice. J Allergy Clin Immunol 2021; 147:1-13. [PMID: 33436161 DOI: 10.1016/j.jaci.2020.11.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/04/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
In 2020, the first food allergy treatment, an oral immunotherapy (OIT) product for peanut allergy, was approved by the Food and Drug Administration, and a peanut epicutaneous immunotherapy patch was under review. As food allergy therapies become available and widespread, allergy offices will need to adjust practices to be able to offer their patients these new treatments. OIT is an intensive therapy that requires commitment from patients and their families, and open communication with the practice is paramount. OIT may not be the right therapy for every patient, and although identifying good candidates is still an area rich for research opportunity, experience from cohorts and clinical trials provides some insight. It is important to understand the scope of practice for each member of the OIT team based on state regulations for a particular location. Staffing and space will likely dictate how many patients at an individual office could be on active OIT at one time. Emergency medications, supplies, and protocols must be in place. Screening, scheduling, visit procedures, monitoring, home dosing, dose modifications, safety precautions, adverse reactions, and maintenance will be addressed in this article. Finally, adjunct therapies under investigation will be reviewed.
Collapse
Affiliation(s)
- Stephanie A Leonard
- Division of Pediatric Allergy & Immunology, University of California San Diego, Rady Children's Hospital San Diego, San Diego, Calif.
| | - Susan Laubach
- Division of Pediatric Allergy & Immunology, University of California San Diego, Rady Children's Hospital San Diego, San Diego, Calif
| | - Julie Wang
- Jaffe Food Allergy Institute, Division of Pediatric Allergy, Mount Sinai School of Medicine, New York, NY
| |
Collapse
|
67
|
Eosinophilic Esophagitis as a Side Effect of Food Oral Immunotherapy. ACTA ACUST UNITED AC 2020; 56:medicina56110618. [PMID: 33207848 PMCID: PMC7697667 DOI: 10.3390/medicina56110618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 02/06/2023]
Abstract
Food allergies (FAs) include a spectrum of immune-mediated serious and potentially life-threatening medical conditions with an overall estimated prevalence ranging from 4% to 8% in the U.S. and Europe. Significant progress in food allergen-specific immunotherapy has been accomplished over the past 10 years. The most studied strategy has been oral immunotherapy (OIT), also known as food desensitization, a treatment in which a child is slowly and deliberately given a small amount of the food to ingest (that previously was a food allergy trigger) with the ultimate goal of the child eating that food without a reaction. OIT is now recommended in the European guidelines for the treatment of milk, egg, and peanut allergies and was the first American Food Drug Administration (FDA) approved product for the prevention of severe reaction to peanuts in 4–17 year olds to be released on the market. The side effects associated with OIT treatment trials are mild to moderate, predominantly oropharyngeal, and easily treated. More severe reactions, such as generalized urticaria/angioedema, wheezing/respiratory distress, laryngeal edema, and repetitive emesis, have been reported. However systemic reactions are very rare. Low-dose immunotherapy is associated with significantly fewer side effects. Currently, its most limiting allergic side effect is that approximately 10–15% of subjects treated with OIT experience gastrointestinal symptoms, preventing the continuation of therapy. Eosinophilic esophagitis (EoE) has also been reported as a cause of persistent abdominal symptoms in OIT.
Collapse
|
68
|
Bertolini TB, Biswas M, Terhorst C, Daniell H, Herzog RW, Piñeros AR. Role of orally induced regulatory T cells in immunotherapy and tolerance. Cell Immunol 2020; 359:104251. [PMID: 33248367 DOI: 10.1016/j.cellimm.2020.104251] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/30/2020] [Accepted: 11/01/2020] [Indexed: 12/24/2022]
Abstract
Oral antigen administration to induce regulatory T cells (Treg) takes advantage of regulatory mechanisms that the gastrointestinal tract utilizes to promote unresponsiveness against food antigens or commensal microorganisms. Recently, antigen-based oral immunotherapies (OITs) have shown efficacy as treatment for food allergy and autoimmune diseases. Similarly, OITs appear to prevent anti-drug antibody responses in replacement therapy for genetic diseases. Intestinal epithelial cells and microbiota possibly condition dendritic cells (DC) toward a tolerogenic phenotype that induces Treg via expression of several mediators, e.g. IL-10, transforming growth factor-β, retinoic acid. Several factors, such as metabolites derived from microbiota or diet, impact the stability and expansion of these induced Treg, which include, but are not limited to, FoxP3+ Treg, LAP+ Treg, and/or Tr1 cells. Here, we review various orally induced Treg, their plasticity and cooperation between the Treg subsets, as well as underlying mechanisms controlling their induction and role in oral tolerance.
Collapse
Affiliation(s)
- Thais B Bertolini
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Moanaro Biswas
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cox Terhorst
- Division of Immunology, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, MA, USA
| | - Henry Daniell
- Department of Basic and Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Roland W Herzog
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Annie R Piñeros
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
69
|
Food allergy: epidemiology, pathogenesis, diagnosis, prevention, and treatment. Curr Opin Immunol 2020; 66:57-64. [DOI: 10.1016/j.coi.2020.03.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/27/2020] [Indexed: 02/06/2023]
|
70
|
Ogura K, Yanagida N, Sato S, Imai T, Ito K, Kando N, Ikeda M, Shibata R, Murakami Y, Fujisawa T, Nagao M, Kawamoto N, Kondo N, Urisu A, Tsuge I, Kondo Y, Sugai K, Uchida O, Urashima M, Taniguchi M, Ebisawa M. Evaluation of oral immunotherapy efficacy and safety by maintenance dose dependency: A multicenter randomized study. World Allergy Organ J 2020; 13:100463. [PMID: 33024480 PMCID: PMC7527748 DOI: 10.1016/j.waojou.2020.100463] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 12/03/2022] Open
Abstract
Background Generally, oral immunotherapy (OIT) aims for daily administration. Recently, the efficacy of treatment with OIT at a low dose has been reported. However, the optimal dose and the evaluation of dose-dependent OIT outcome have not been described. Methods A multicenter, parallel, open-labeled, prospective, non-placebo controlled, randomized study enrolled 101 Japanese patients for treatment with OIT. We hypothesized that target dose OIT would induce short-term unresponsiveness (StU) earlier than reduced dose OIT. StU was defined as no response to 6200 mg whole egg, 3400 mg milk, and 2600 mg wheat protein, as evaluated by oral food challenge after 2-week ingestion cessation. To compare the two doses of OIT efficacy, the maximum ingestion doses during the maintenance phase of OIT were divided into 100%-dose or 25%-dose groups against their target StU dose, respectively. A total of 51 patients were assigned to the 100%-dose group [hen's egg (HE) = 26, cow's milk (CM) = 13, wheat = 12] and 50 to the 25%-dose group (HE = 25, CM = 13, wheat = 12). Primary outcome was established by comparing StU at 1 year. Secondary outcome was StU at 2 years and established by comparing allergic symptoms and immunological changes. Results The year 1 StU rates (%) for the 100%- and 25%-dose groups were 26.9 vs. 20.0 (HE), 7.7 vs. 15.4 (CM), and 50.0 vs. 16.7 (wheat), respectively. The year 2 StU rates were 30.8 vs. 36.0 (HE), 7.7 vs. 23.1 (CM), and 58.3 vs. 58.3 (wheat), respectively. There were no statistically significant differences in StU between years 1 and 2. The total allergic symptom rate in the 25%-dose group was lower than that in the 100%-dose group for egg, milk, and wheat. Antigen-specific IgE levels for egg-white, milk, and wheat decreased at 12 months. Conclusions Reduced maintenance dose of egg OIT showed similar therapeutic efficacy to the target dose. However, we were not able to clearly demonstrate the efficacy, particularly for milk and wheat. Reducing the maintenance dose for eggs, milk, and wheat may effectively lower the symptoms associated with their consumption compared to the target OIT dose. Furthermore, aggressive reduction of the maintenance dose might be important for milk and wheat, compared to the 25%-dose OIT. Trial registration UMIN000009373, Multicenter Oral Immunotherapy for Hen's Egg, Cow's Milk, and Wheat-Allergic Children at Outpatient Clinic.
Collapse
Key Words
- CM, cow’s milk
- Desensitization
- Dose-response relationship
- EPIT, epicutaneous immunotherapy
- FA, food allergy
- Food hypersensitivity
- HE, hens’ egg
- Immunotherapy
- OFC, oral food challenge
- OIT, oral immunotherapy
- SLIT, sublingual immunotherapy
- SU, sustained unresponsiveness
- StU, short-term unresponsiveness
- sIgE, specific immunoglobulin E
- sIgG, specific immunoglobulin G
- sIgG4, specific immunoglobulin G4
Collapse
Affiliation(s)
- Kiyotake Ogura
- Department of Pediatrics, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Noriyuki Yanagida
- Department of Pediatrics, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
| | - Sakura Sato
- Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Department of Allergy, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
| | - Takanori Imai
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Komei Ito
- Department of Allergy, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Naoyuki Kando
- Department of Allergy, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Masanori Ikeda
- Department of Pediatrics, National Hospital Organization, Fukuyama Medical Center, Hiroshima, Japan.,Department of Pediatric Acute Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Rumiko Shibata
- Department of Pediatrics, National Hospital Organization, Fukuoka National Hospital, Fukuoka, Japan
| | - Yoko Murakami
- Department of Pediatrics, National Hospital Organization, Fukuoka National Hospital, Fukuoka, Japan
| | - Takao Fujisawa
- Institute for Clinical Research, National Hospital Organization, Mie National Hospital, Mie, Japan
| | - Mizuho Nagao
- Institute for Clinical Research, National Hospital Organization, Mie National Hospital, Mie, Japan
| | - Norio Kawamoto
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Naomi Kondo
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Atsuo Urisu
- Department of Pediatrics, Fujita Health University, The Second Teaching Hospital, Aichi, Japan
| | - Ikuya Tsuge
- Department of Pediatrics, Fujita Health University, The Second Teaching Hospital, Aichi, Japan
| | - Yasuto Kondo
- Department of Pediatrics, Fujita Health University, The Second Teaching Hospital, Aichi, Japan
| | - Kazuko Sugai
- Department of Pediatrics, National Hospital Organization, Yokohama Medical Center, Kanagawa, Japan
| | - Osamu Uchida
- Department of Pediatrics, National Hospital Organization, Yokohama Medical Center, Kanagawa, Japan
| | - Mitsuyoshi Urashima
- Division of Molecular Epidemiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Masami Taniguchi
- Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Department of Allergy, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
| | - Motohiro Ebisawa
- Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Department of Allergy, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
| |
Collapse
|
71
|
Fiocchi A, Artesani MC, Fierro V, Riccardi C, Dahdah L, Mennini M. Oral immunotherapy for peanut allergy: The con argument. World Allergy Organ J 2020; 13:100445. [PMID: 33664931 PMCID: PMC7897709 DOI: 10.1016/j.waojou.2020.100445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/05/2020] [Accepted: 05/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background In some countries of the world, peanut allergy represents an important source of anaphylactic reactions. Traditionally treated with the avoidance of responsible allergens, this condition can also be targeted by oral peanut immunotherapy. Methods In this study, we review the beneficial and side effects of currently available forms of peanut oral immunotherapy (POIT). We report the discussions resulting from the publication of a meta-analysis that brought to light the downsides of oral immunotherapy for peanuts. Results In some clinical situations, the risk-benefit ratio can favor peanut oral immunotherapy over avoidance. In many other situations, this is not the case. The decision must be based on the values and preferences of clinicians and patients. Those not ready to accept serious adverse effects from POIT are likely to continue the elimination diet; those motivated to achieving desensitization, and prepared to accept serious adverse effects, may choose to undergo POIT. Conclusions Without being prejudiced against peanut oral immunotherapy, we indicate the possible evolution of treatment for this condition is in a rapidly evolving broader scenario. Among the future options, sublingual immunotherapy, parenteral immunotherapy with modified allergens, transcutaneous immunotherapy, and the use of biologics will become important options.
Collapse
Key Words
- EAACI, European academy of allergy asthma and immunology
- Efficacy
- ICER, Institute for clinical and economic review
- OFC, Oral food challenge
- OIT, Oral ImmunoTherapy
- OUtMATCH, Omalizumab as monotherapy and as adjunct therapy to multi-allergen OIT in Food allergic participants
- Oral immunotherapy
- PACE, Peanut allergen immunotherapy, clarifying the evidence meta-analysis
- POISED, Peanut oral immunotherapy Study:Safety, efficacy and discovery
- POIT, Peanut oral ImmunoTherapy
- Peanut allergy
- QoL, Quality of life
- Quality of life
- SCIT, Subcutaneous immunotherapy
- SLIT, Sublingual immunotherapy
- SPT, Skin prick test
- Safety
Collapse
Affiliation(s)
- Alessandro Fiocchi
- Corresponding author. Allergy Department, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Roma, Italy.
| | | | | | | | | | | |
Collapse
|
72
|
Oral immunotherapy for peanut allergy: The pro argument. World Allergy Organ J 2020; 13:100455. [PMID: 33005286 PMCID: PMC7519204 DOI: 10.1016/j.waojou.2020.100455] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/20/2020] [Accepted: 07/30/2020] [Indexed: 12/31/2022] Open
Abstract
Food allergy (FA) is a growing public health problem with personal, social, nutritional, and economic consequences. In the United States, it is estimated that 8% of children and 10.8% of adults have food allergies. Allergies to peanuts are particularly worrisome as unlike allergies to other allergenic foods, such as milk and egg, which are commonly outgrown by 5 or 10 years of age, 80% of peanut allergies persist into adulthood. The first drug for peanut allergy, Palforzia, was approved by the US Food and Drug Administration (FDA) in January 2020. For other food allergies, the current standard of care for the management of FA is suboptimal and is limited to dietary elimination of the offending allergen, vigilance against accidental ingestion, and treatment of allergic reactions with antihistamines and epinephrine. However, dietary avoidance can be challenging, and it is estimated that approximately 40% of patients with food allergies report at least one food allergy-related emergency department in their lifetime. Reactions, even from minimal exposures, can be life-threatening. Oral immunotherapy (OIT) has been the best researched therapeutic approach for treating FA over the last decade, with clinical trials investigating its efficacy, safety, and ability to improve participants' quality of life (QoL). A number of studies and meta-analyses have shown that OIT treatment is effective in raising the threshold of reactivity to peanuts and other foods in addition to producing a measurable serum immune response to such therapy. Although OIT-related adverse events (AEs) are common during treatment, serious reactions are rare. In fact, while the majority of patients experience AEs related to dosing, most continue daily dosing in hopes of achieving protection against the culprit food. Moreover, the majority of participants report improvement of QoL after OIT and are positive about undergoing OIT. These results show patients’ commitment to OIT and their optimism regarding the benefits of treatment. As a first step in therapeutic options to protect from reactions to unintentional ingestion of allergenic foods, and importantly, to address the many psychosocial aspects of living with FA, OIT shows promise. Future research will focus on identifying optimal OIT regimens that maintain protection after therapy and allow for regular food consumption without allergic symptoms. Education and informed shared decision making between patients and providers are essential in optimizing current therapy regimens.
Collapse
Key Words
- AEs, adverse events
- AF, Adult form
- BOT, Burden of treatment
- CF, Child form
- Efficacy
- FA, Food allergy
- FAIM, Food allergy independent measure
- FAQOL, Food allergy quality of life
- OIT, Oral immunotherapy
- Oral immunotherapy
- PB, Parental burden form
- PF, Parental form
- Peanut allergy
- PedsQL, Pediatric quality of life inventory
- QoL, Quality of life
- Quality of life
- SAE, Serious adverse events
- Safety
- TF, Teenage form
Collapse
|
73
|
Sood AK, Scurlock AM. Food allergy oral immunotherapy. JOURNAL OF FOOD ALLERGY 2020; 2:75-80. [PMID: 39022134 PMCID: PMC11250211 DOI: 10.2500/jfa.2020.2.200005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Food allergy oral immunotherapy (OIT) has demonstrated efficacy in promoting clinically relevant immunomodulation that leads to desensitization (reduced reactivity while on OIT) in the majority of treated individuals; however, sustained unresponsiveness after OIT cessation for a specified interval has only been observed in a subset. The potential therapeutic benefits of OIT must be balanced with the risk for adverse events. These adverse events may range from self-limited or easily treated oropharyngeal, respiratory, or gastrointestinal symptoms to persistent abdominal symptoms that lead to cessation of therapy and to anaphylaxis. To date, the majority of studies have evaluated single-allergen OIT approaches; however, multi-allergen OIT has demonstrated favorable safety and efficacy outcomes, and is the subject of ongoing investigation. Recent U.S. Food and Drug Administration approval of the first licensed OIT product for peanut allergy challenges the long-standing paradigm of dietary food avoidance as the sole option for individuals with food allergy. Yet, the limitations of this "first-generation" treatment support the need for continued research and development of next-generation therapies to improve efficacy, minimize risk, and allow for broad applicability to both individuals with single-food allergy and those with multifood allergies. Optimizing future therapies will require developing novel approaches that maximize both efficacy and safety and/or tolerability outcomes, potentially through the combination with biologic therapies or adjuvants. Shared decision-making among patients, physicians, and parents and/or caregivers is critical to select optimal candidates for treatment with OIT by balancing the potential therapeutic benefit and possible risk reduction with a realistic consideration of OIT treatment burden and the risk of treatment-related adverse events.
Collapse
Affiliation(s)
- Amika K. Sood
- From the Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, Arkansas
| | - Amy M. Scurlock
- From the Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, Arkansas
| |
Collapse
|
74
|
Abstract
Oral food challenge (OFC) is a procedure that is conducted most commonly by allergist/immunologists in their office or in food allergy centers to confirm a food allergy or to confirm tolerance to the food. The procedure as conducted in clinical practice is mostly open food challenge and, in research, a double-blind, placebo controlled food challenge. OFC has associated risks that can be minimized by having the challenges conducted by trained personnel who are prepared to treat allergic reactions and who have rescue medications available. However, OFCs have tremendous benefits to the patients and their families, including the potential to determine that a food is no longer an allergen and can be introduced into the diet. Even OFCs that result in clinical reactions have the benefit of confirming the food allergy and demonstrating the therapeutic effect of the rescue medications. The study of the outcomes of OFC has shed light on food allergy reactions and characteristics of the patients with food allergy as well as on the value of other diagnostic tests compared with OFC. OFCs have helped establish food allergy thresholds, confirm that subjects enrolled in research studies have the allergy, and demonstrate the response to the therapies tested in terms of ameliorating the allergic response or raising the reaction threshold. OFCs have also been used to promote the recent guidelines for the prevention of peanut allergy by identifying the infants at risk for peanut allergy but who are not allergic yet.
Collapse
Affiliation(s)
- Amal H Assa'ad
- From the Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| |
Collapse
|
75
|
Pharmacotherapy in allergy medicine: from 'ipse dixit' to the evidence-based medicine. Curr Opin Allergy Clin Immunol 2020; 20:407-413. [PMID: 32590509 DOI: 10.1097/aci.0000000000000659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of the article is to examine the contributions made in recent years by evidence-based medicine to the understanding, positioning, and use of drugs for the treatment of the main allergic conditions. RECENT FINDINGS Several antiasthmatic drugs have been reappraised for their efficacy characteristics and drug interactions in Cochrane reviews. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines have been reformulated in evidence-based medicine (EBM) terms in 2017; over these years, new point of care instruments contributed to the approximation of the guidelines to real life by drawing from the patients themselves information that allows to finely modeling the pharmacological suggestions. Last, at the time of the emergence of new drugs for the treatment of peanut allergy, new systematic reviews have helped to focus on the most suitable reference outcomes with the aim to respond promptly and adherently to patients' needs. SUMMARY EBM has contributed to changes in the GINA guidelines in the last two years. It has been instrumental in translating the ARIA guidelines in real life. It has also contributed to profiling the potential and limitations of oral peanut immunotherapy. In allergy medicine, EBM is a formidable aid for the advancement of knowledge.
Collapse
|
76
|
Turner-Bowker DM, Jalbert JJ, Krohe M, Yaworsky A, Kelly MT, Padilla B, Chaston E, Radin A, Mastey V, Nadeau KC. A novel patient-reported outcomes instrument assessing the side effects of peanut oral immunotherapy. Ann Allergy Asthma Immunol 2020; 126:61-68. [PMID: 32745610 DOI: 10.1016/j.anai.2020.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/16/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patients treated with peanut oral immunotherapy (OIT) may experience adverse reactions, particularly during up-dosing. OBJECTIVE To develop the Side Effects of Peanut Oral Immunotherapy Diary (SEPOD), an electronic questionnaire assessing the daily side effects of peanut OIT in clinical trials. METHODS Content and design of the SEPOD were informed by empirical literature review and meetings with 3 allergy-immunology experts. Interviews to confirm content and inform revisions were conducted in 24 pediatric patients with peanut allergy (14 treated with peanut OIT) aged 6 to 17 years; children aged 6 to 11 years were interviewed with their caregiver. RESULTS The SEPOD was drafted after literature review and expert interviews; the initial measurement approach comprised 2 SEPOD versions, a patient-reported outcome (PRO) version for children aged 12 to 17 years, and a caregiver-administered PRO version for children aged 6 to 11 years with instructions for caregiver questionnaire administration. Pediatric patients were expected to respond independently on both versions. Patient interviews indicated that some younger children (ie, aged 6-8 years) had difficulty understanding questions, even when reading aloud; therefore, a caregiver-administered outcome version, identical in content to the caregiver-administered PRO version, was developed for this age group. The final electronic SEPOD covered 23 peanut OIT side effects within the following 7 domains: gastrointestinal, dermatologic, itching, nasal, and respiratory, swelling (eyelid or periorbital, lip, tongue, and throat), pain (tongue, mouth, and throat), and dizziness. CONCLUSION This study yielded the SEPOD, a new clinical outcome assessment instrument with various methods of administration that can be used to assess the side effects of peanut OIT experienced by pediatric patients in a clinical trial setting.
Collapse
Affiliation(s)
| | - Jessica J Jalbert
- Health Economics and Outcomes Research, Regeneron Pharmaceuticals, Inc., Tarrytown, New York.
| | - Meaghan Krohe
- Patient-Centered Outcomes, Adelphi Values, Boston, Massachusetts
| | - Andrew Yaworsky
- Patient-Centered Outcomes, Adelphi Values, Boston, Massachusetts
| | - Masami T Kelly
- Patient-Centered Outcomes, Adelphi Values, Boston, Massachusetts
| | - Brad Padilla
- Patient-Centered Outcomes, Adelphi Values, Boston, Massachusetts
| | - Emily Chaston
- Patient-Centered Outcomes, Adelphi Values, Boston, Massachusetts
| | - Allen Radin
- Health Economics and Outcomes Research, Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Vera Mastey
- Health Economics and Outcomes Research, Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
77
|
Dougherty JA, Wagner JD, Stanton MC. Peanut Allergen Powder-dnfp: A Novel Oral Immunotherapy to Mitigate Peanut Allergy. Ann Pharmacother 2020; 55:344-353. [PMID: 32718178 DOI: 10.1177/1060028020944370] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To review data on efficacy and safety of peanut allergen powder-dnfp (PAP; Palforzia), a novel oral immunotherapy for peanut allergy, a common food allergy. DATA SOURCES A PubMed/CINAHL search in English was performed from inception to June 30, 2020, using the search words peanut allergy, desensitization, ARA101, and peanut oral immunotherapy. STUDY SELECTION AND DATA EXTRACTION QUANTIFICATION Published phase 2 and 3 clinical trials, documents presented to the Food and Drug Administration, and supplemental study documentation were reviewed. Articles evaluated PAP's pharmacology, pharmacokinetics, mechanism of action, efficacy, and safety. DATA SYNTHESIS PAP was efficacious and safe for treatment of peanut allergy in mostly Caucasian children, 4 to 17 years old. A key phase III clinical trial showed a statistically significant difference (primary end point) between PAP 600 mg and placebo groups (67.2% vs 4%; P < 0.001). During initial dose escalation and updosing phases, gastrointestinal and respiratory tract allergic reactions (ARs) were more common in the PAP group. More epinephrine rescue was used in the PAP group. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Oral immunotherapy for desensitization of peanut allergy was shown to reduce the severity of reactions if accidental allergen exposure occurs. Risk evaluation and mitigation strategy certification is required for pharmacies, health care providers, and clinics. More data in real-world populations will enhance its effectiveness. CONCLUSIONS In patients 4 to 17 years old, PAP mitigated ARs, including anaphylaxis, that may occur with accidental peanut exposure. Although there are risks, it was efficacious in more than two-thirds of participants in phase 2 and phase 3 efficacy trials.
Collapse
|
78
|
Abstract
The US Food and Drug Administration's approval of a peanut oral immunotherapy product in January 2020 is a landmark development in the field of food allergy therapy. While food allergy prevalence has been increasing, this product is the first approved therapy for food allergy. Oral immunotherapy has many similarities to subcutaneous immunotherapy and drug desensitization protocols, but does not lead to sustained unresponsiveness. The studies leading to approval of the Palforzia product demonstrated increase in the amount of peanut protein able to be consumed, with 67% of subjects randomized to the treatment arm able to consume 600 mg of peanut protein in double-blind placebo-controlled food challenge at study exit. However, side effects are an important consideration, and dropout rates in studies of Palforzia ranged from 11% to 21%. Postmarketing surveillance of this product will be critical in assessing its long-term risks and benefits.
Collapse
Affiliation(s)
- Joan H Dunlop
- Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
79
|
Larsen JM, Bang-Berthelsen CH, Qvortrup K, Sancho AI, Hansen AH, Andersen KIH, Thacker SSN, Eiwegger T, Upton J, Bøgh KL. Production of allergen-specific immunotherapeutic agents for the treatment of food allergy. Crit Rev Biotechnol 2020; 40:881-894. [PMID: 32515236 DOI: 10.1080/07388551.2020.1772194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Allergen-specific immunotherapy (IT) is emerging as a viable avenue for the treatment of food allergies. Clinical trials currently investigate raw or slightly processed foods as therapeutic agents, as trials using food-grade agents can be performed without the strict regulations to which conventional drugs are subjected. However, this limits the ability of standardization and may affect clinical trial outcomes and reproducibility. Herein, we provide an overview of methods used in the production of immunotherapeutic agents for the treatment of food allergies, including processed foods, allergen extracts, recombinant allergens, and synthetic peptides, as well as the physical and chemical processes for the reduction of protein allergenicity. Commercial interests currently favor producing standardized drug-grade allergen extracts for therapeutic use, and clinical trials are ongoing. In the near future, recombinant production could replace purification strategies since it allows the manufacturing of pure, native allergens or sequence-modified allergens with reduced allergenicity. A recurring issue within this field is the inadequate reporting of production procedures, quality control, product physicochemical characteristics, allergenicity, and immunological properties. This information is of vital importance in assessing therapeutic standardization and clinical safety profile, which are central parameters for the development of future therapeutic agents.
Collapse
Affiliation(s)
- Jeppe Madura Larsen
- National Food Institute, Technical University of Denmark, Kgs. Lyngby, Denmark
| | | | - Katrine Qvortrup
- Department of Chemistry, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Ana Isabel Sancho
- National Food Institute, Technical University of Denmark, Kgs. Lyngby, Denmark
| | | | | | | | - Thomas Eiwegger
- Division of Immunology and Allergy, Food Allergy and Anaphylaxis Program, The Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada.,Research Institute, The Hospital for Sick Children, Translational Medicine Program, Toronto, Canada.,Department of Immunology, The University of Toronto, Toronto, Canada
| | - Julia Upton
- Division of Immunology and Allergy, Food Allergy and Anaphylaxis Program, The Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | | |
Collapse
|
80
|
Kim EH, Burks AW. Food allergy immunotherapy: Oral immunotherapy and epicutaneous immunotherapy. Allergy 2020; 75:1337-1346. [PMID: 32034781 DOI: 10.1111/all.14220] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 01/07/2020] [Accepted: 01/23/2020] [Indexed: 01/14/2023]
Abstract
IgE-mediated food allergy remains a significant and growing problem across the globe. Of the various treatment modalities, oral immunotherapy (OIT) and epicutaneous immunotherapy (EPIT) have been the best studied. Across various studies of OIT for egg, milk, and peanut allergy, strong levels of desensitization have been shown. With egg and peanut OIT, a limited remission, or sustained unresponsiveness (SU), has further been demonstrated. These advances have been further validated by successful phase 2 and phase 3 studies of peanut OIT. EPIT, using daily administrations of a proprietary patch, demonstrated efficacy as well as safety and tolerability in parallel phase 2 studies; however, its phase 3 study did not meet its primary efficacy outcome. Despite its good track record of desensitization, the safety and tolerability of OIT has remained a question. EPIT, on the other hand, has proven safe and tolerable; however, the adequacy of its desensitization has remained to be determined. As OIT and EPIT continue their march toward regulatory review, optimizations for immunotherapy and novel therapies continue to be developed providing hope for food allergy patients everywhere.
Collapse
Affiliation(s)
- Edwin H. Kim
- University of North Carolina School of Medicine Chapel Hill North Carolina
| | - Arvil Wesley Burks
- University of North Carolina School of Medicine Chapel Hill North Carolina
| |
Collapse
|
81
|
Abrams EM, Chan ES, Sicherer S. Peanut Allergy: New Advances and Ongoing Controversies. Pediatrics 2020; 145:peds.2019-2102. [PMID: 32303583 DOI: 10.1542/peds.2019-2102] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2019] [Indexed: 11/24/2022] Open
Abstract
Peanut allergy is one of the most common food allergies in children, with increasing prevalence over time. The dual-allergen exposure hypothesis now supports transcutaneous sensitization to peanut as a likely pathophysiologic mechanism for peanut allergy development. As a result, there is emerging evidence that early peanut introduction has a role in peanut allergy prevention. Current first-line diagnostic tests for peanut allergy have limited specificity, which may be enhanced with emerging tools such as component-resolved diagnostics. Although management of peanut allergy includes avoidance and carrying an epinephrine autoinjector, risk of fatal anaphylaxis is extremely low, and there is minimal risk related to cutaneous or inhalational exposure. Quality of life in children with peanut allergy requires significant focus. Moving forward, oral and epicutaneous immunotherapy are emerging and exciting tools that may have a role to play in desensitization to peanut.
Collapse
Affiliation(s)
- Elissa M Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada;
| | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada; and
| | - Scott Sicherer
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| |
Collapse
|
82
|
Langlois A, Lavergne MH, Leroux H, Killer K, Azzano P, Paradis L, Samaan K, Lacombe-Barrios J, Mâsse B, Des Roches A, Bégin P. Protocol for a double-blind, randomized controlled trial on the dose-related efficacy of omalizumab in multi-food oral immunotherapy. Allergy Asthma Clin Immunol 2020; 16:25. [PMID: 32328115 PMCID: PMC7165401 DOI: 10.1186/s13223-020-00419-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 03/16/2020] [Indexed: 12/17/2022] Open
Abstract
Background Previous proof-of-concept studies have shown that a short course of omalizumab can safely accelerate the oral immunotherapy schedule for multiple allergens simultaneously. Considering the high cost of medication, the dose-related efficacy of omalizumab at decreasing the duration of oral immunotherapy up-dosing phase must be objectively quantified before cost–benefit analyses can be performed. The primary objective of this trial will be to compare the efficacy of 2 omalizumab dosages to placebo at decreasing time-to-maintenance dose during a symptom-driven multi-food OIT protocol. Methods A total of 90 participants aged 6 to 25 with multiple food allergies (3 or more) will be enrolled at four sites in Canada. Participants will be randomized to: (A) Omalizumab 8 mg/kg per month (n = 36); (B) Omalizumab 16 mg/kg per month (n = 36); or (C) Placebo (n = 18). Study drug will be administered at full dosage for 12 weeks, then progressively tapered at 50% dosage (8 mg/kg vs 4 mg/kg vs placebo) for 4 weeks and at 25% dosage (4 mg/kg vs 2 mg/kg vs placebo) for another 4 weeks. After a pre-treatment period of 8 weeks, participants will undergo an initial food escalation (IFE) to an OIT mix containing 3 allergens and start daily home dosing with biweekly increases until a target daily maintenance of 1500 mg protein is achieved. The amount escalated at each visit will vary based on treatment tolerance according to a standardized up-dosing algorithm. Participants will be followed for at least 12 months following the initial food escalation. The primary endpoint will be time from IFE to the target maintenance dose of 1500 mg protein. Time-to-event analytic methods, including the log-rank test, will be used to compare the 3 arms. Discussion This trial uses a novel pragmatic approach to compare OIT with omalizumab to OIT without omalizumab in a blinded manner, which allows to single out the effect of this anti-IgE medication on treatment effectiveness speed without the recourse to predetermined schedules. The innovative patient-centered up-dosing algorithm allows to maximise treatment effectiveness speed without compromising patient safety, regardless of whether the patient is on omalizumab or not. This study will also provide novel prospective data to inform on the optimal and most cost-effective dosage for this indication. Trial registration ClinicalTrials.gov, NCT04045301, Registered 5 August 2019, https://clinicaltrials.gov/ct2/show/NCT04045301
Collapse
Affiliation(s)
- Alexandra Langlois
- 1Department of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC Canada
| | | | - Hélène Leroux
- 3Centre Hospitalier Sainte-Justine Research Center, Montreal, QC Canada
| | - Kerstin Killer
- 3Centre Hospitalier Sainte-Justine Research Center, Montreal, QC Canada
| | - Pauline Azzano
- 1Department of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC Canada
| | - Louis Paradis
- 1Department of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC Canada.,2Department of Allergy and Immunology, Centre Hospitalier de l'Université de Montréal, 3175 Chemin de la Côte Sainte-Catherine, Montreal, QC H3T1C5 Canada
| | - Kathryn Samaan
- 1Department of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC Canada
| | - Jonathan Lacombe-Barrios
- 1Department of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC Canada
| | - Benoît Mâsse
- 3Centre Hospitalier Sainte-Justine Research Center, Montreal, QC Canada.,4School of Public Health, Université de Montréal, Montreal, QC Canada
| | - Anne Des Roches
- 1Department of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC Canada.,3Centre Hospitalier Sainte-Justine Research Center, Montreal, QC Canada
| | - Philippe Bégin
- 1Department of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC Canada.,2Department of Allergy and Immunology, Centre Hospitalier de l'Université de Montréal, 3175 Chemin de la Côte Sainte-Catherine, Montreal, QC H3T1C5 Canada.,3Centre Hospitalier Sainte-Justine Research Center, Montreal, QC Canada
| |
Collapse
|
83
|
O'Konek JJ, Landers JJ, Janczak KW, Lindsey HK, Mondrusov AM, Totten TD, Baker JR. Intranasal nanoemulsion vaccine confers long-lasting immunomodulation and sustained unresponsiveness in a murine model of milk allergy. Allergy 2020; 75:872-881. [PMID: 31557317 DOI: 10.1111/all.14064] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/05/2019] [Accepted: 08/27/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Immunotherapy for food allergy requires prolonged treatment protocols and, in most cases, does not lead to durable modulation of the allergic immune response. We have demonstrated an intranasal (IN) nanoemulsion adjuvant that redirects allergen-specific Th2 responses toward Th1 and Th17 immunity, and protects from allergen challenge after only 2-4 monthly administrations. Here, we investigate the ability of this technology to provide long-term modulation of allergy in a murine model of cow's milk allergy. METHODS Six weeks after sensitization to bovine casein, mice received four, monthly IN immunizations with nanoemulsion formulated with casein. Protection from casein challenge was assessed at 4 and 16 weeks after the final vaccine administration. RESULTS The NE vaccine significantly blunted the physiological responses to allergen challenge, and this effect persisted for at least 16 weeks. The protection from challenge was associated with the suppression of casein-specific Th2 immunity and induced Th1 and Th17 cytokines as well as induction of IL-10. Of interest, while immunized animals showed significantly decreased Th2 cytokine responses, cow's milk-specific IgE remained elevated in the serum at levels associated with reactivity in control sensitized animals. Protection was associated with suppressed mast cell activation and markedly reduced mast cell infiltration into the small intestine. CONCLUSION The sustained unresponsiveness of at least 16 weeks after vaccination suggests that the nanoemulsion vaccine alters the allergic phenotype in a persistent manner different from traditional desensitization, and this leads to long-term suppressive effects on allergic disease without eliminating serum IgE.
Collapse
Affiliation(s)
- Jessica J. O'Konek
- Mary H. Weiser Food Allergy Center University of Michigan Ann Arbor MI USA
| | - Jeffrey J. Landers
- Mary H. Weiser Food Allergy Center University of Michigan Ann Arbor MI USA
| | | | - Hayley K. Lindsey
- Mary H. Weiser Food Allergy Center University of Michigan Ann Arbor MI USA
| | - Anna M. Mondrusov
- Mary H. Weiser Food Allergy Center University of Michigan Ann Arbor MI USA
| | - Tiffanie D. Totten
- Mary H. Weiser Food Allergy Center University of Michigan Ann Arbor MI USA
| | - James R. Baker
- Mary H. Weiser Food Allergy Center University of Michigan Ann Arbor MI USA
| |
Collapse
|
84
|
Bégin P, Chan ES, Kim H, Wagner M, Cellier MS, Favron-Godbout C, Abrams EM, Ben-Shoshan M, Cameron SB, Carr S, Fischer D, Haynes A, Kapur S, Primeau MN, Upton J, Vander Leek TK, Goetghebeur MM. CSACI guidelines for the ethical, evidence-based and patient-oriented clinical practice of oral immunotherapy in IgE-mediated food allergy. Allergy Asthma Clin Immunol 2020; 16:20. [PMID: 32206067 PMCID: PMC7079444 DOI: 10.1186/s13223-020-0413-7] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/14/2020] [Indexed: 12/17/2022] Open
Abstract
Background Oral immunotherapy (OIT) is an emerging approach to the treatment of patients with IgE-mediated food allergy and is in the process of transitioning to clinical practice. Objective To develop patient-oriented clinical practice guidelines on oral immunotherapy based on evidence and ethical imperatives for the provision of safe and efficient food allergy management. Materials and methods Recommendations were developed using a reflective patient-centered multicriteria approach including 22 criteria organized in five dimensions (clinical, populational, economic, organizational and sociopolitical). Data was obtained from: (1) a review of scientific and ethic literature; (2) consultations of allergists, other healthcare professionals (pediatricians, family physicians, nurses, registered dieticians, psychologists, peer supporters), patients and caregivers; and patient associations through structured consultative panels, interviews and on-line questionnaire; and (3) organizational and economic data from the milieu of care. All data was synthesized by criteria in a multicriteria deliberative guide that served as a platform for structured discussion and development of recommendations for each dimension, based on evidence, ethical imperatives and other considerations. Results The deliberative grid included 162 articles from the literature and media reviews and data from consultations involving 85 individuals. Thirty-eight (38) recommendations were made for the practice of oral immunotherapy for the treatment of IgE mediated food allergy, based on evidence and a diversity of ethical imperatives. All recommendations were aimed at fostering a context conducive to achieving objectives identified by patients and caregivers with food allergy. Notably, specific recommendations were developed to promote a culture of shared responsibility between patients and healthcare system, equity in access, patient empowerment, shared decision making and personalization of OIT protocols to reflect patients' needs. It also provides recommendations to optimize organization of care to generate capacity to meet demand according to patient choice, e.g. OIT or avoidance. These recommendations were made acknowledging the necessity of ensuring sustainability of the clinical offer in light of various economic considerations. Conclusions This innovative CPG methodology was guided by patients' perspectives, clinical evidence as well as ethical and other rationales. This allowed for the creation of a broad set of recommendations that chart optimal clinical practice and define the conditions required to bring about changes to food allergy care that will be sustainable, equitable and conducive to the well-being of all patients in need.
Collapse
Affiliation(s)
- P Bégin
- 1Division of Clinical Immunology, Rheumatology and Allergy, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC Canada.,2Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC Canada.,3Research Center of the Sainte-Justine University Hospital Center, Montreal, QC Canada
| | - E S Chan
- 4Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC Canada
| | - H Kim
- 5Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON Canada.,6Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON Canada
| | - M Wagner
- 7Unit Methods, Ethics and Participation, INESSS, National Institute for Excellence in Health and Social Services, Montreal, QC Canada
| | - M S Cellier
- 3Research Center of the Sainte-Justine University Hospital Center, Montreal, QC Canada
| | - C Favron-Godbout
- 8Department of Bioethics, School of Public Health of the University of Montreal, Montreal, Canada
| | - E M Abrams
- 9Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, MB Canada
| | - M Ben-Shoshan
- 10Division of Allergy Immunology and Dermatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, QC Canada
| | - S B Cameron
- 4Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC Canada.,Community Allergy Clinic, Victoria, BC Canada
| | - S Carr
- 12Department of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - D Fischer
- 5Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON Canada
| | - A Haynes
- 13Discipline of Pediatrics, Memorial University of Newfoundland, St. John's, NL Canada
| | - S Kapur
- 14Department of Pediatrics, Dalhousie University, Halifax, NS Canada
| | - M N Primeau
- 15Division of Allergy and Clinical Immunology, Department of Medicine, CISSS Laval, Laval, QC Canada
| | - J Upton
- 16Division of Immunology and Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - T K Vander Leek
- 12Department of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - M M Goetghebeur
- 7Unit Methods, Ethics and Participation, INESSS, National Institute for Excellence in Health and Social Services, Montreal, QC Canada
| |
Collapse
|
85
|
Tsai M, Mukai K, Chinthrajah RS, Nadeau KC, Galli SJ. Sustained successful peanut oral immunotherapy associated with low basophil activation and peanut-specific IgE. J Allergy Clin Immunol 2020; 145:885-896.e6. [PMID: 31805311 PMCID: PMC6957313 DOI: 10.1016/j.jaci.2019.10.038] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/27/2019] [Accepted: 10/31/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Oral immunotherapy (OIT) can successfully desensitize many peanut-allergic subjects, but clinical tolerance diminishes over time on discontinuation, or low-dose maintenance, of peanut. Therefore, to improve the efficacy and sustainability of such therapy, we sought to identify biomarkers and clinical tools that can predict therapeutic outcomes and monitor treatment responses. OBJECTIVE We evaluated whether basophil activation in whole blood, and plasma levels of peanut-specific immunoglobulins, are useful biomarkers for peanut OIT. METHODS We longitudinally measured, before, during, and after OIT, basophil activation in whole blood ex vivo in response to peanut stimulation, and peanut-specific IgE (sIgE) and peanut-specific IgG4 (sIgG4), in a large, single-site, double-blind, randomized, placebo-controlled, phase 2 peanut OIT study. We compared basophil responsiveness and peanut-specific immunoglobulins between those who were clinically reactive and those who were tolerant to peanut oral challenges. RESULTS Peanut OIT significantly decreased basophil activation, peanut sIgE, Ara h 1, Ara h 2, and Ara h 3 IgE levels, and sIgE/total IgE, but increased sIgG4/sIgE. Participants who became reactive to 4 g of peanut 13 weeks off active OIT exhibited higher peanut-induced basophil activation ex vivo and higher peanut sIgE levels and sIgE/total IgE, but lower sIgG4/sIgE. Notably, participants entering the study with low basophil responsiveness were more likely to achieve treatment success. Substantial suppression of basophil activation was required to maintain long-term clinical tolerance after peanut OIT. CONCLUSIONS Assessments of peanut-induced basophil activation and peanut-specific immunoglobulins can help to predict treatment outcomes, and to differentiate transient desensitization versus sustained unresponsiveness after OIT.
Collapse
Affiliation(s)
- Mindy Tsai
- Department of Pathology, Stanford University School of Medicine, Stanford, Calif; Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, Calif
| | - Kaori Mukai
- Department of Pathology, Stanford University School of Medicine, Stanford, Calif; Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, Calif
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, Calif; Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, Calif; Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Stephen J Galli
- Department of Pathology, Stanford University School of Medicine, Stanford, Calif; Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, Calif; Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, Calif.
| |
Collapse
|
86
|
Abstract
Food allergies are a growing public health concern affecting approximately 8% of children and 10% of adults in the United States. Several immunotherapy approaches are under active investigation, including oral immunotherapy, epicutaneous immunotherapy, and sublingual immunotherapy. Each of these approaches uses a similar strategy of administering small, increasing amounts of allergen to the allergic subject. Immunologic studies have described changes in the T-cell compartment, serum and salivary immunoglobulin profile, and mast cell and basophil degranulation status in response to allergens. This review highlights the immunologic changes induced by food allergen-specific immunotherapy and discusses future directions in this field.
Collapse
Affiliation(s)
- Johanna M Smeekens
- UNC Department of Pediatrics, UNC Food Allergy Initiative, UNC Chapel Hill, 116 Manning Drive, Mary Ellen Jones Building, Room 3004, Chapel Hill, NC 27599, USA.
| | - Michael D Kulis
- UNC Department of Pediatrics, UNC Food Allergy Initiative, UNC Chapel Hill, 116 Manning Drive, Mary Ellen Jones Building, Room 3004, Chapel Hill, NC 27599, USA
| |
Collapse
|
87
|
|
88
|
Capucilli P, Wang KY, Spergel JM. Food reactions during avoidance: Focus on peanut. Ann Allergy Asthma Immunol 2020; 124:459-465. [PMID: 32001367 DOI: 10.1016/j.anai.2020.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/20/2019] [Accepted: 01/13/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Peanut allergy has historically been difficult to manage, with most cases persisting into adulthood. Novel therapies for peanut allergy treatment are on the horizon, yet allergists must maintain a robust understanding of the risks and benefits of the current standard of therapy, avoidance diet. DATA SOURCES A comprehensive literature search using PubMed of reviews and clinical articles was performed. STUDY SELECTIONS Articles discussing peanut or other food-related allergic reactions, accidental exposures or anaphylaxis pertinent to avoidance diet or comparative to oral immunotherapy trials were selected. RESULTS Peanut remains a leading allergen associated with accidental ingestions responsible for food-related reactions, both mild and severe. Fatal reactions, however, are rare and measures such as anaphylaxis plans can significantly decrease the risk of accidental anaphylaxis. Patients may over estimate situations thought to increase risk for reactions to peanut, such as inhalation or contact through skin. In oral immunotherapy trials, the rate of anaphylaxis secondary to treatment was significantly higher than avoidance practices. CONCLUSION Clinicians should continue to discuss avoidance as a viable option for long-term peanut allergy management and empower patients to differentiate relevant situations in which accidental reactions might occur.
Collapse
Affiliation(s)
- Peter Capucilli
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Kathleen Y Wang
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jonathan M Spergel
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
89
|
Adverse events associated with peanut oral immunotherapy in children - a systematic review and meta-analysis. Sci Rep 2020; 10:659. [PMID: 31959857 PMCID: PMC6971009 DOI: 10.1038/s41598-019-56961-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/17/2019] [Indexed: 12/21/2022] Open
Abstract
While peanut oral immunotherapy (POIT) represents a promising treatment for peanut allergies in children, safety concerns remain a common barrier to widespread adoption. We aimed to systematically assess available evidence to determine the risk and frequency of adverse events occurring during POIT, and examine study-level characteristics associated with their occurrence and severity. A systematic search of MEDLINE, EMBASE, and Web of Science was conducted through April 2019. Controlled and non-controlled studies evaluating POIT were eligible. Twenty-seven studies, involving 1488 subjects, were included. Adverse events to POIT were common and led to treatment discontinuation in 6.6% of children (95% CI 4.4–9.0; 27 studies, I2 = 48.7%). Adverse events requiring treatment with epinephrine occurred among 7.6% (4.5–11.4; 26 studies, I2 = 75.5%) of participants, at a rate of 2.0 per 10,000 doses (0.8–3.7; 15 studies, I2 = 64.4). Use of a rush treatment phase and targeting a higher maintenance dose were associated with a higher risk and frequency of epinephrine use, while using co-treatments in addition to POIT was associated with a lower risk of treatment discontinuation due to adverse events. While adverse events to POIT are common, this study provides promising explorative evidence that certain modifications to existing treatment protocols could significantly improve treatment outcomes.
Collapse
|
90
|
Affiliation(s)
- Edwin H. Kim
- Medicine and Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Chirag Patel
- Fellow-in-training, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - A. Wesley Burks
- UNC School of Medicine; CEO UNC Healthcare University of North Carolina School of Medicine, Chapel Hill, NC, USA
| |
Collapse
|
91
|
Rachid R. Peanut Oral Immunotherapy: Is It Safer in Preschoolers than in Older Age Groups? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2768-2769. [PMID: 31706493 DOI: 10.1016/j.jaip.2019.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Rima Rachid
- Division of Immunology, Boston Children's Hospital, Department of Pediatrics Harvard Medical School, Boston, Mass.
| |
Collapse
|
92
|
Vázquez-Cortés S, Jaqueti P, Arasi S, Machinena A, Alvaro-Lozano M, Fernández-Rivas M. Safety of Food Oral Immunotherapy: What We Know, and What We Need to Learn. Immunol Allergy Clin North Am 2019; 40:111-133. [PMID: 31761113 DOI: 10.1016/j.iac.2019.09.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Oral immunotherapy (OIT) for food allergy entails a risk of adverse reactions, including anaphylaxis. This safety concern is the major barrier for OIT to become a therapeutic option in clinical practice. The high heterogeneity in safety reporting of OIT studies prevents setting the safety profile accurately. An international consensus is needed to facilitate the analysis of large pooled clinical data with homogeneous safety reporting, that together with integrated omics, and patients/families' opinions, may help stratify the patients' risk and needs, and help developing safe(r) individualized care pathways. This will give OIT the right place in the food allergy therapy.
Collapse
Affiliation(s)
- Sonia Vázquez-Cortés
- Allergy Department, Hospital Clinico San Carlos, IdISSC, ARADyAL, Prof. Martin Lagos s/n, Madrid 28040, Spain
| | - Paloma Jaqueti
- Allergy Department, Hospital Clinico San Carlos, IdISSC, Prof. Martin Lagos s/n, Madrid 28040, Spain
| | - Stefania Arasi
- Pediatric Allergology Unit, Department of Pediatric Medicine, Bambino Gesù Children's Research Hospital (IRCCS), Piazza S. Onofrio, Rome 00161, Italy
| | - Adrianna Machinena
- Allergy and Clinical Immunology Department, Hospital Sant Joan de Deu, Secció d'Al-lergia i Immunologia Clínica, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, Barcelona 08590, Spain
| | - Montserrat Alvaro-Lozano
- Allergy and Clinical Immunology Department, Hospital Sant Joan de Deu, Secció d'Al-lergia i Immunologia Clínica, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, Barcelona 08590, Spain
| | - Montserrat Fernández-Rivas
- Allergy Department, Hospital Clinico San Carlos, Medicine UCM, IdISSC, ARADyAL, Prof. Martin Lagos s/n, Madrid 28040, Spain.
| |
Collapse
|
93
|
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.
Collapse
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.
| |
Collapse
|
94
|
Oral Immunotherapy (OIT): A Personalized Medicine. ACTA ACUST UNITED AC 2019; 55:medicina55100684. [PMID: 31614929 PMCID: PMC6843277 DOI: 10.3390/medicina55100684] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/04/2019] [Accepted: 10/09/2019] [Indexed: 01/05/2023]
Abstract
Oral Immunotherapy (OIT), a promising allergen-specific approach in the management of Food Allergies (FA), is based on the administration of increasing doses of the culprit food until reaching a maintenance dose. Each step should be adapted to the patient, and OIT should be considered an individualized treatment. Recent studies focused on the standardization and identification of novel biomarkers in order to correlate endotypes with phenotypes in the field of FA.
Collapse
|
95
|
Samstein M, Ponda P. The Clinical Utility of Epicutaneous Immunotherapy for Peanut Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:2503-2504. [PMID: 36443999 DOI: 10.1016/j.jaip.2019.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/10/2019] [Accepted: 05/18/2019] [Indexed: 06/16/2023]
Affiliation(s)
- Miriam Samstein
- Division of Allergy Immunology, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
| | - Punita Ponda
- Division of Allergy Immunology, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| |
Collapse
|
96
|
Blackman AC, Anagnostou A. Identification of goals and barriers to treatment from 92 consecutive consultations with families considering peanut oral immunotherapy. Ther Adv Vaccines Immunother 2019; 7:2515135519869763. [PMID: 31489399 PMCID: PMC6712748 DOI: 10.1177/2515135519869763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/19/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Peanut allergy has become an important public health issue. It can be the cause of severe reactions and also the trigger of significant anxiety for the allergic individual, especially with regards to the risk of unintentional accidental exposures. Peanut oral immunotherapy (POIT) is a newly developed treatment approach that has been shown to be highly effective in multiple research studies and has been associated with an acceptable safety profile. This treatment modality is likely to become more mainstream in the next few years with new commercial entities pursuing United States Food and Drug Administration approval for relevant products and multiple providers offering various forms of immunotherapy in their practices. METHODS The aim of our study was to obtain an accurate assessment of goals of treatment as well as concerns and barriers from families considering POIT in either the research or clinical setting. A single clinician allergist met with all the families and conducted semi-structured interviews on POIT. Families were provided with standardized written information on POIT prior to the consultation, which was used as a formalized instrument to communicate treatment protocols. Conversations were not recorded, but collected information was scribed by a second clinician who did not actively participate in the consultation. Scribed information was coded by the investigators. Thematic analysis identified common topics emerging from the discussions. RESULTS We report on the results of 92 consecutive family consultations on POIT conducted over a period of 1 year. Approximately 50% of the families had already researched POIT online, with 25% of families reported being part of Facebook parent groups. Groups identified the following areas as the most important considerations: efficacy, practical information, safety, benefits and goals, eligibility criteria and support in making the right decision. For all families pursuing POIT for their child, the initial goal was achieving protection from accidental exposure and cross-contamination and for approximately one-quarter, consumption of high peanut doses was the ultimate goal. CONCLUSION Our research adds to the limited available data in this area and provides information that may be used as an initial platform for clinical consultations and shared decision-making in POIT. Obtaining a better understanding of patients' expectations and concerns will hopefully facilitate this process, enabling more fruitful and engaging interactions between families and healthcare providers in the field of food allergy.
Collapse
Affiliation(s)
- Andrea C. Blackman
- Texas Children’s Hospital, Department of Pediatrics, Section of Immunology, Allergy and Retrovirology, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Aikaterini Anagnostou
- Texas Children’s Hospital, Department of Pediatrics, Section of Immunology, Allergy and Retrovirology, 1102 Bates Avenue Ste 330, Houston, TX 77030, USA
| |
Collapse
|
97
|
Brandström J, Vetander M, Sundqvist A, Lilja G, Johansson SGO, Melén E, Sverremark‐Ekström E, Nopp A, Nilsson C. Individually dosed omalizumab facilitates peanut oral immunotherapy in peanut allergic adolescents. Clin Exp Allergy 2019; 49:1328-1341. [DOI: 10.1111/cea.13469] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/15/2019] [Accepted: 07/01/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Josef Brandström
- Sachs' Children and Youth Hospital Södersjukhuset Stockholm Sweden
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Mirja Vetander
- Sachs' Children and Youth Hospital Södersjukhuset Stockholm Sweden
- Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
- Center for Allergy Research Karolinska Institutet Stockholm Sweden
| | | | - Gunnar Lilja
- Sachs' Children and Youth Hospital Södersjukhuset Stockholm Sweden
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - S. G. O. Johansson
- Sachs' Children and Youth Hospital Södersjukhuset Stockholm Sweden
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Erik Melén
- Sachs' Children and Youth Hospital Södersjukhuset Stockholm Sweden
- Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - Eva Sverremark‐Ekström
- Department of Molecular Biosciences, TheWenner‐Gren Institute Stockholm University Stockholm Sweden
| | - Anna Nopp
- Sachs' Children and Youth Hospital Södersjukhuset Stockholm Sweden
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Caroline Nilsson
- Sachs' Children and Youth Hospital Södersjukhuset Stockholm Sweden
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
| |
Collapse
|
98
|
Daniell H, Kulis M, Herzog RW. Plant cell-made protein antigens for induction of Oral tolerance. Biotechnol Adv 2019; 37:107413. [PMID: 31251968 PMCID: PMC6842683 DOI: 10.1016/j.biotechadv.2019.06.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 05/21/2019] [Accepted: 06/24/2019] [Indexed: 12/15/2022]
Abstract
The gut associated lymphoid tissue has effective mechanisms in place to maintain tolerance to food antigens. These can be exploited to induce antigen-specific tolerance for the prevention and treatment of autoimmune diseases and severe allergies and to prevent serious immune responses in protein replacement therapies for genetic diseases. An oral tolerance approach for the prevention of peanut allergy in infants proved highly efficacious and advances in treatment of peanut allergy have brought forth an oral immunotherapy drug that is currently awaiting FDA approval. Several other protein antigens made in plant cells are in clinical development. Plant cell-made proteins are protected in the stomach from acids and enzymes after their oral delivery because of bioencapsulation within plant cell wall, but are released to the immune system upon digestion by gut microbes. Utilization of fusion protein technologies facilitates their delivery to the immune system, oral tolerance induction at low antigen doses, resulting in efficient induction of FoxP3+ and latency-associated peptide (LAP)+ regulatory T cells that express immune suppressive cytokines such as IL-10. LAP and IL-10 expression represent potential biomarkers for plant-based oral tolerance. Efficacy studies in hemophilia dogs support clinical development of oral delivery of bioencapsulated antigens to prevent anti-drug antibody formation. Production of clinical grade materials in cGMP facilities, stability of antigens in lyophilized plant cells for several years when stored at ambient temperature, efficacy of oral delivery of human doses in large animal models and lack of toxicity augur well for clinical advancement of this novel drug delivery concept.
Collapse
Affiliation(s)
- Henry Daniell
- Department of Biochemistry, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Michael Kulis
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Roland W Herzog
- Department of Pediatrics, Indiana University, Indianapolis, IN 46202, USA.
| |
Collapse
|
99
|
Shah F, Shi A, Ashley J, Kronfel C, Wang Q, Maleki SJ, Adhikari B, Zhang J. Peanut Allergy: Characteristics and Approaches for Mitigation. Compr Rev Food Sci Food Saf 2019; 18:1361-1387. [DOI: 10.1111/1541-4337.12472] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 05/19/2019] [Accepted: 05/22/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Faisal Shah
- Inst. of Food Science and Technology, Chinese Academy of Agricultural Sciences/Key research Laboratory of Agro‐Products ProcessingMinistry of Agriculture Beijing 100193 P. R. China
| | - Aimin Shi
- Inst. of Food Science and Technology, Chinese Academy of Agricultural Sciences/Key research Laboratory of Agro‐Products ProcessingMinistry of Agriculture Beijing 100193 P. R. China
| | - Jon Ashley
- International Iberian Nanotechnology LaboratoryFood Quality and Safety Research group Berga 4715‐330 Portugal
| | - Christina Kronfel
- Food Processing and Sensory Quality ResearchUnited States Dept. of Agriculture New Orleans LA 70124 USA
| | - Qiang Wang
- Inst. of Food Science and Technology, Chinese Academy of Agricultural Sciences/Key research Laboratory of Agro‐Products ProcessingMinistry of Agriculture Beijing 100193 P. R. China
| | - Soheila J. Maleki
- Food Processing and Sensory Quality ResearchUnited States Dept. of Agriculture New Orleans LA 70124 USA
| | - Benu Adhikari
- School of ScienceRMIT Univ. Melbourne VIC 3083 Australia
| | - Jinchuang Zhang
- Inst. of Food Science and Technology, Chinese Academy of Agricultural Sciences/Key research Laboratory of Agro‐Products ProcessingMinistry of Agriculture Beijing 100193 P. R. China
| |
Collapse
|
100
|
Chu DK, Wood RA, French S, Fiocchi A, Jordana M, Waserman S, Brożek JL, Schünemann HJ. Oral immunotherapy for peanut allergy (PACE): a systematic review and meta-analysis of efficacy and safety. Lancet 2019; 393:2222-2232. [PMID: 31030987 DOI: 10.1016/s0140-6736(19)30420-9] [Citation(s) in RCA: 267] [Impact Index Per Article: 53.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Oral immunotherapy is an emerging experimental treatment for peanut allergy, but its benefits and harms are unclear. We systematically reviewed the efficacy and safety of oral immunotherapy versus allergen avoidance or placebo (no oral immunotherapy) for peanut allergy. METHODS In the Peanut Allergen immunotherapy, Clarifying the Evidence (PACE) systematic review and meta-analysis, we searched MEDLINE, EMBASE, Cochrane Controlled Register of Trials, Latin American & Caribbean Health Sciences Literature, China National Knowledge Infrastructure, WHO's Clinical Trials Registry Platform, US Food and Drug Administration, and European Medicines Agency databases from inception to Dec 6, 2018, for randomised controlled trials comparing oral immunotherapy versus no oral immunotherapy for peanut allergy, without language restrictions. We screened studies, extracted data, and assessed risk of bias independently in duplicate. Main outcomes included anaphylaxis, allergic or adverse reactions, epinephrine use, and quality of life, meta-analysed by random effects. We assessed certainty (quality) of evidence by the GRADE approach. This study is registered with PROSPERO, number CRD42019117930. RESULTS 12 trials (n=1041; median age across trials 8·7 years [IQR 5·9-11·2]) showed that oral immunotherapy versus no oral immunotherapy increased anaphylaxis risk (risk ratio [RR] 3·12 [95% CI 1·76-5·55], I2=0%, risk difference [RD] 15·1%, high-certainty), anaphylaxis frequency (incidence rate ratio [IRR] 2·72 [1·57-4·72], I2=0%, RD 12·2%, high-certainty), and epinephrine use (RR 2·21 [1·27-3·83], I2=0%, RD 4·5%, high-certainty) similarly during build-up and maintenance (pinteraction=0·92). Oral immunotherapy increased serious adverse events (RR 1·92 [1·00-3·66], I2=0%, RD 5·7%, moderate-certainty), and non-anaphylactic reactions (vomiting: RR 1·79 [95%CI 1·35-2·38], I2=0%, high-certainty; angioedema: 2·25 [1·13-4·47], I2=0%, high-certainty; upper tract respiratory reactions: 1·36 [1·02-1·81], I2=0%, moderate-certainty; lower tract respiratory reactions: 1·55 [0·96-2·50], I2=28%, moderate-certainty). Passing a supervised challenge, a surrogate for preventing out-of-clinic reactions, was more likely with oral immunotherapy (RR 12·42 [95% CI 6·82-22·61], I2=0%, RD 36·5%, high-certainty). Quality of life was not different between groups (combined parents and self report RR 1·21 [0·87-1·69], I2=0%, RD 0·03%, low-certainty). Findings were robust to IRR, trial sequential, subgroup, and sensitivity analyses. INTERPRETATION In patients with peanut allergy, high-certainty evidence shows that available peanut oral immunotherapy regimens considerably increase allergic and anaphylactic reactions over avoidance or placebo, despite effectively inducing desensitisation. Safer peanut allergy treatment approaches and rigorous randomised controlled trials that evaluate patient-important outcomes are needed. FUNDING None.
Collapse
Affiliation(s)
- Derek K Chu
- Department of Medicine, McMaster University, Hamilton, Ontario, ON, Canada; St Joseph's Healthcare Hamilton, Hamilton, Ontario, ON, Canada.
| | - Robert A Wood
- Division of Allergy & Immunology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon French
- Department of Medicine, McMaster University, Hamilton, Ontario, ON, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, ON, Canada; St Joseph's Healthcare Hamilton, Hamilton, Ontario, ON, Canada
| | - Alessandro Fiocchi
- Allergy Division, Bambino Gesù Children's Hospital, Istituti di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Manel Jordana
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, ON, Canada
| | - Susan Waserman
- Department of Medicine, McMaster University, Hamilton, Ontario, ON, Canada; St Joseph's Healthcare Hamilton, Hamilton, Ontario, ON, Canada
| | - Jan L Brożek
- Department of Medicine, McMaster University, Hamilton, Ontario, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, ON, Canada; Michael G DeGroote Cochrane Canada Centre, Hamilton, ON, Canada
| | - Holger J Schünemann
- Department of Medicine, McMaster University, Hamilton, Ontario, ON, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, ON, Canada; St Joseph's Healthcare Hamilton, Hamilton, Ontario, ON, Canada; Michael G DeGroote Cochrane Canada Centre, Hamilton, ON, Canada
| |
Collapse
|