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Langlois A, Graham F, Bégin P. Epicutaneous peanut patch device for the treatment of peanut allergy. Expert Rev Clin Immunol 2019; 15:449-460. [DOI: 10.1080/1744666x.2019.1593138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Alexandra Langlois
- Department of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - François Graham
- Department of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
- Department of Allergy and Immunology, Centre Hospitalier de l’Université de Montréal, Hôpital Notre-Dame, Montreal, QC, Canada
| | - Philippe Bégin
- Department of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
- Department of Allergy and Immunology, Centre Hospitalier de l’Université de Montréal, Hôpital Notre-Dame, Montreal, QC, Canada
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202
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Soller L, Abrams EM, Chan ES. An update on the controversy around offering oral immunotherapy to peanut-allergic children outside of research. Ann Allergy Asthma Immunol 2019; 122:559-562. [PMID: 30794857 DOI: 10.1016/j.anai.2019.02.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 02/08/2019] [Accepted: 02/10/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Lianne Soller
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.
| | - Elissa M Abrams
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada; Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
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203
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Fiocchi A, Artesani MC, Riccardi C, Mennini M, Pecora V, Fierro V, Calandrelli V, Dahdah L, Valluzzi RL. Impact of Omalizumab on Food Allergy in Patients Treated for Asthma: A Real-Life Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1901-1909.e5. [PMID: 30797778 DOI: 10.1016/j.jaip.2019.01.023] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 12/03/2018] [Accepted: 01/04/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The effects of omalizumab on food allergy thresholds have been little studied. OBJECTIVE To assess the real-life effects of omalizumab on food threshold tolerability in children treated for severe asthma. METHODS In this observational, real-life, efficacy study, we reviewed the food allergen thresholds of patients with severe asthma, as well as their immediate reactions to 2+ foods before and after a 4-month treatment with omalizumab. We also evaluated their control of asthma and their quality of life, as measured by Pediatric Quality of Life Inventory (PedsQL). RESULTS Fifteen children, allergic to 37 foods, were evaluated. Omalizumab induced an increase in the allergen threshold for milk, egg, wheat, and hazelnut from a mean 1012.6 ± 1464.5 mg protein to 8727 ± 6463.3 eliciting dose (P < .001). A total of 70.4% of subjects tolerated the complete challenge dose after 4 months of treatment with omalizumab. These foods were reintroduced in the patients' diet without the need for any oral immunotherapy procedures. The remaining foods were partially tolerated. The number of reactions to the unintended ingestion of allergenic foods over 4 months dropped from 47 to 2. The PedsQL increased from 61 ± 5.32 to 87 ± 7.33 (parental judgment; P < .001) and from 65 ± 7.39 to 90 ± 4.54 (patients' judgment; P < .001). The mean cost of omalizumab was €1311.63 per month. CONCLUSIONS During treatment with omalizumab for severe uncontrolled asthma, the food allergen threshold increases to 8.6 times its original value. The quality of life of patients also increased, due to a better asthma control and a reduction in dietary restrictions. The cost/benefit ratio of such treatment for selected cases of food allergy remains to be evaluated.
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Affiliation(s)
- Alessandro Fiocchi
- Division of Allergy, University Department of Pediatrics, Pediatric Hospital Bambino Gesù, Rome, Italy.
| | - Maria Cristina Artesani
- Division of Allergy, University Department of Pediatrics, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Carla Riccardi
- Division of Allergy, University Department of Pediatrics, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Maurizio Mennini
- Division of Allergy, University Department of Pediatrics, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Valentina Pecora
- Division of Allergy, University Department of Pediatrics, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Vincenzo Fierro
- Division of Allergy, University Department of Pediatrics, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Veronica Calandrelli
- Division of Allergy, University Department of Pediatrics, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Lamia Dahdah
- Division of Allergy, University Department of Pediatrics, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Rocco Luigi Valluzzi
- Division of Allergy, University Department of Pediatrics, Pediatric Hospital Bambino Gesù, Rome, Italy
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204
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Reier-Nilsen T, Michelsen MM, Lødrup Carlsen KC, Carlsen KH, Mowinckel P, Nygaard UC, Namork E, Borres MP, Håland G. Feasibility of desensitizing children highly allergic to peanut by high-dose oral immunotherapy. Allergy 2019; 74:337-348. [PMID: 30225844 DOI: 10.1111/all.13604] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 07/30/2018] [Accepted: 08/12/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND There are limited data on the feasibility, efficacy and safety of high-dose oral immunotherapy (OIT) in children highly allergic to peanuts. OBJECTIVE In children highly allergic to peanut, we primarily aimed to determine the feasibility of reaching the maximum maintenance dose (MMD) of 5000 mg peanut protein or, alternatively, a lower individual maintenance dose (IMD), by OIT up-dosing. Secondarily, we aimed to identify adverse events (AEs) and determine factors associated with reaching a maintenance dose. METHODS The TAKE-AWAY peanut OIT trial enrolled 77 children 5-15 years old, with a positive oral peanut challenge. Fifty-seven were randomized to OIT with biweekly dose step-up until reaching MMD or IMD and 20 to observation only. Demographic and biological characteristics, AEs, medication and protocol deviations were explored for associations with reaching maintenance dose. RESULTS All children had anaphylaxis defined by objective symptoms in minimum two organ systems during baseline challenge. The MMD was reached by 21.1%, while 54.4% reached an IMD of median (minimum, maximum) 2700 (250, 4000) mg peanut protein, whereas 24.5% discontinued OIT. During up-dosing, 19.4% experienced anaphylaxis. Not reaching the MMD was caused by distaste for peanuts (66.7%), unacceptable AEs (26.7%) and social reasons (6.7%). Increased peanut s-IgG4 /s-IgE ratio (OR [95% CI]: 1.02 [1.00, 1.04]) was associated with reaching MMD. CONCLUSION Although 75.5% of children with peanut anaphylaxis reached a maintenance dose of 0.25-5 g, only 21.1% reached the MMD. Distaste for peanuts and AEs, including high risk of anaphylaxis, limited the feasibility of reaching MMD.
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Affiliation(s)
- Tonje Reier-Nilsen
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Merethe Melbye Michelsen
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Karin C. Lødrup Carlsen
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Kai-Håkon Carlsen
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Petter Mowinckel
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
| | - Unni C. Nygaard
- Norwegian Institute of Public Health; Division for Infection Control and Environmental Health; Oslo Norway
| | - Ellen Namork
- Norwegian Institute of Public Health; Division for Infection Control and Environmental Health; Oslo Norway
| | - Magnus P. Borres
- Thermo Fisher Scientific; Uppsala Sweden
- Institute of Maternal & Child Health; Uppsala University; Uppsala Sweden
| | - Geir Håland
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
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205
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Vickery BP, Ebisawa M, Shreffler WG, Wood RA. Current and Future Treatment of Peanut Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:357-365. [DOI: 10.1016/j.jaip.2018.11.049] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 12/14/2022]
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206
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Rodríguez del Río P, Escudero C, Sánchez-García S, Ibáñez MD, Vickery BP. Evaluating primary end points in peanut immunotherapy clinical trials. J Allergy Clin Immunol 2019; 143:494-506. [DOI: 10.1016/j.jaci.2018.09.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/17/2018] [Accepted: 09/28/2018] [Indexed: 12/20/2022]
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207
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Dantzer JA, Wood RA. Next-Generation Approaches for the Treatment of Food Allergy. Curr Allergy Asthma Rep 2019; 19:5. [PMID: 30689123 DOI: 10.1007/s11882-019-0839-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW IgE-mediated food allergies are an increasing health concern, and current management includes food avoidance and use of emergency medications. Effective treatment of food allergy is highly desirable. Next generation approaches for the treatment of food allergy aim to improve both safety and efficacy, potentially including long-term tolerance. RECENT FINDINGS Oral immunotherapy (OIT) and epicutaneous immunotherapy (EPIT) will likely be integrated into clinical practice as part of food allergy management in the near future. Newer approaches, such as sublingual immunotherapy (SLIT), modified proteins, lysosomal-associated membrane protein DNA (LAMP DNA) vaccines, and the use of immunomodulatory agents, are early in development and depending on results, could also become important treatment options. This is a review of novel approaches to the treatment of food allergy that are currently under investigation, including the use of SLIT, modified proteins, probiotics, Chinese herbal supplements, biologic therapies, and DNA vaccines, as well as a summary of the current status of OIT and EPIT.
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Affiliation(s)
- Jennifer A Dantzer
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, John Hopkins University School of Medicine, 600 N. Wolfe St., CMSC 1102, Baltimore, MD, 21287, USA
| | - Robert A Wood
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, John Hopkins University School of Medicine, 600 N. Wolfe St., CMSC 1102, Baltimore, MD, 21287, USA.
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208
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Casale TB, Haselkorn T, Ciaccio CE, Sriaroon P, Chipps BE. Harmonization of Terminology for Tolerated and Reactive Dose in Food Allergy Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:389-392. [PMID: 30557719 DOI: 10.1016/j.jaip.2018.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/05/2018] [Accepted: 12/07/2018] [Indexed: 11/17/2022]
Abstract
Currently, there is no Food and Drug Administration-approved therapy for food allergy. Several new potential treatments are under investigation, including food allergen immunotherapy via various routes of administration, such as oral immunotherapy, epicutaneous immunotherapy, subcutaneous immunotherapy, and sublingual immunotherapy. The double-blind, placebo-controlled food challenge (DBPCFC) has traditionally been used for diagnostic purposes, but extrapolation of the specific terminology used in food allergy diagnosis to interpretation of efficacy in clinical trials is incongruent and difficult to apply. There is a need for standardization of the terminology used in food allergy clinical trials, because inconsistencies can lead to potential misinterpretation of end points. The reactive dose, previously referred to as the eliciting dose, is defined as the dose given that induces the onset of unequivocal allergic symptoms, or the dose that stops the challenge based on physician discretion. Conversely, the single highest tolerated dose is defined as the highest dose given during a food challenge that elicits either no symptoms or symptoms that do not meet stopping criteria per the study protocol. The evolving field of food allergy provides a novel opportunity to define those end points that are most meaningful for patients, which is fundamental for successful implementation, education, and safety.
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Affiliation(s)
- Thomas B Casale
- Division of Allergy and Immunology, University of South Florida, Tampa, Fla.
| | | | | | - Panida Sriaroon
- Division of Allergy and Immunology, University of South Florida, Tampa, Fla
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209
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Oral and Sublingual Immunotherapy for Treatment of IgE-Mediated Food Allergy. Clin Rev Allergy Immunol 2018; 55:139-152. [PMID: 29656306 DOI: 10.1007/s12016-018-8677-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Development of active therapies for IgE-mediated food allergy is a critical action step toward alleviating the adverse medical, psychosocial, and economic burdens on affected patients and families. Significant progress has been observed specifically in the application of single-allergen oral and sublingual immunotherapy for treatment of IgE-mediated food allergy, with emphasis on milk, egg, and peanut as the primary allergens. Oral immunotherapy (OIT) has demonstrated efficacy in promoting immunomodulatory effects that lead to the clinical outcome of desensitization, defined as reduced reactivity while on active OIT, in the majority of treated individuals; however, achievement of sustained unresponsiveness following cessation of therapy has been observed in a smaller subset of treated subjects. The potential therapeutic benefits of OIT must be carefully considered in light of the significant potential for adverse events ranging from self-limited or easily treated oropharyngeal, respiratory or gastrointestinal symptoms, to persistent abdominal complaints that lead to cessation of therapy in an estimated 10-15% of treated individuals. To date, the majority of studies have focused on single-allergen OIT approaches; however, multi-allergen OIT has shown promise in initial trials and is the subject of ongoing investigation to address the complex needs of multi-food allergic individuals. Sublingual immunotherapy (SLIT) has been utilized for the treatment of food allergy and pollen-food allergy syndrome, demonstrating moderate efficacy, a favorable safety profile and variable tolerability, with oropharyngeal symptoms most commonly observed. Although studies directly comparing OIT and SLIT are limited, in general, the favorable safety profile associated with SLIT comes at the expense of reduced efficacy, while the more robust clinical effects observed with OIT come at the risk of potentially intolerable, treatment-limiting side effects. Future investigation to address specific knowledge gaps including optimal dose, duration, age of initiation, maintenance schedule, mechanisms, predictors of risk and therapeutic response will be important to maximize efficacy, minimize risk and develop personalized, effective approaches to targeting food allergy.
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210
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Pfaar O, Lou H, Zhang Y, Klimek L, Zhang L. Recent developments and highlights in allergen immunotherapy. Allergy 2018; 73:2274-2289. [PMID: 30372537 DOI: 10.1111/all.13652] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 10/22/2018] [Accepted: 10/22/2018] [Indexed: 12/30/2022]
Abstract
Allergen immunotherapy (AIT) is the only disease-modifying treatment option for patients with IgE-mediated inhalant allergies. Though used in clinical practice for more than 100 years, most innovations in AIT efficacy and safety have been developed in the last two decades. This expert review aimed to highlight the recent progress in AIT for both application routes, the sublingual (SLIT) and subcutaneous (SCIT) forms. As such, it covers recent aspects regarding efficacy and safety in clinical trials and real-life data and outlines new concepts in consensus and position papers as well as in guidelines for AIT. Potential clinical and nonclinical biomarkers are discussed. This review also focuses on potential future perspectives in AIT, such as alternative application routes, immune-modulating adjuvants, and recombinant vaccines. In conclusion, this state of the art review provides a comprehensive overview of AIT and highlights unmet needs for the future.
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Affiliation(s)
- Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery; Section of Rhinology and Allergy; University Hospital Marburg; Philipps-Universität Marburg; Marburg Germany
| | - Hongfei Lou
- Department of Otolaryngology; Head and Neck Surgery; Beijing TongRen Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Nasal Diseases; Beijing Institute of Otolaryngology; Beijing China
- Department of Allergy; Beijing TongRen Hospital; Capital Medical University; Beijing China
| | - Yuan Zhang
- Department of Otolaryngology; Head and Neck Surgery; Beijing TongRen Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Nasal Diseases; Beijing Institute of Otolaryngology; Beijing China
- Department of Allergy; Beijing TongRen Hospital; Capital Medical University; Beijing China
| | - Ludger Klimek
- Center for Rhinology and Allergology; Wiesbaden Germany
| | - Luo Zhang
- Department of Otolaryngology; Head and Neck Surgery; Beijing TongRen Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Nasal Diseases; Beijing Institute of Otolaryngology; Beijing China
- Department of Allergy; Beijing TongRen Hospital; Capital Medical University; Beijing China
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211
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Efron A, Zeldin Y, Gotesdyner L, Stauber T, Maoz Segal R, Binson I, Dinkin M, Dinkowitz L, Shahar D, Deutch M, Yaron M, Nevet A, Reshef A, Agmon-Levin N, Kenett RS, Kidon MI. A Structured Gradual Exposure Protocol to Baked and Heated Milk in the Treatment of Milk Allergy. J Pediatr 2018; 203:204-209.e2. [PMID: 30270168 DOI: 10.1016/j.jpeds.2018.07.091] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/17/2018] [Accepted: 07/26/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of a structured gradual exposure protocol (SGEP) with extensively heated and baked milk in promoting allergy resolution in children with cow milk allergy (CMA). STUDY DESIGN In a case control study, children with CMA aged 1-4 years who were treated with SGEP including extensively heated and baked milk, were compared with children treated with strict avoidance. Data were collected from medical records and from validated telephone questionnaires. Data analysis was performed using a nonparametric Kaplan-Meier and proportional hazard Cox regression model, after evaluation of the adequacy of the case control matching. RESULTS There were 43 children with milk allergy-26 (62%) males with a mean age at intervention of 21 months (range, 12-47 months)-who were treated with SGEP and followed to a mean age of 40 months (range, 20-82 months). The median age at resolution of CMA was compared with a matched group of 67 children treated with strict avoidance at least until 4 years of age or followed until earlier resolution, with a mean age at follow-up of 71 months (range, 11-176 months). The median estimated age at CMA resolution in the SGEP group was 36 months (95% CI, 34.5-49.7) compared with 98 months (95% CI, 82.4-114.1) in controls (P < .001). At last follow-up, 86% of treated children were tolerant to unheated milk proteins vs 52% of controls (P = .003). CONCLUSION A structured protocol with extensively heated and baked milk seems to promote faster resolution of CMA.
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Affiliation(s)
- Adi Efron
- Clinical Allergy and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yuri Zeldin
- Clinical Allergy and Immunology, "Goldman" School of Medicine, Ben Gurion University, Beer Sheva, Israel; Clalit Health Services, Tel Aviv, Israel
| | - Leora Gotesdyner
- Clinical Allergy and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tali Stauber
- Clinical Allergy and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel; Allergy and Clinical Immunology Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Ramit Maoz Segal
- Allergy and Clinical Immunology Unit, Sheba Medical Center, Tel Hashomer, Israel
| | | | | | | | - Danit Shahar
- Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel; Allergy and Clinical Immunology Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Michal Deutch
- Allergy and Clinical Immunology Unit, Sheba Medical Center, Tel Hashomer, Israel
| | | | | | - Avner Reshef
- Allergy and Clinical Immunology Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Nancy Agmon-Levin
- Clinical Allergy and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Allergy and Clinical Immunology Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Ron S Kenett
- KPA Group and Institute for Drug Research, School of Pharmacy, Hebrew University, Jerusalem, Israel
| | - Mona I Kidon
- Clinical Allergy and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Clalit Health Services, Tel Aviv, Israel; Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel; Allergy and Clinical Immunology Unit, Sheba Medical Center, Tel Hashomer, Israel
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212
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Abstract
PURPOSE OF REVIEW This review examines the current literature and provides insight into the role of food immunotherapy in the management of food-allergic children. Key food immunotherapy trials, benefits, and risks of the intervention, as well as areas requiring further study are all discussed. RECENT FINDINGS Research studies have reported encouraging results regarding the efficacy of food immunotherapy in desensitizing food-allergic patients with an acceptable safety profile and a documented improvement in quality of life. The role of biologics and long-term effects of food immunotherapy are still under investigation. SUMMARY The burden of food allergy is significant, multifaceted, and well documented. Food immunotherapy is a novel treatment option and an exciting area of research that has seen tremendous progress over the last decade, presenting encouraging results for the treatment of children with food allergies.
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213
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Keet CA, Allen KJ. Advances in food allergy in 2017. J Allergy Clin Immunol 2018; 142:1719-1729. [DOI: 10.1016/j.jaci.2018.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/01/2018] [Accepted: 10/19/2018] [Indexed: 12/31/2022]
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214
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Orgel K, Burk C, Smeekens J, Suber J, Hardy L, Guo R, Burks AW, Kulis M. Blocking antibodies induced by peanut oral and sublingual immunotherapy suppress basophil activation and are associated with sustained unresponsiveness. Clin Exp Allergy 2018; 49:461-470. [PMID: 30383313 PMCID: PMC6438743 DOI: 10.1111/cea.13305] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 10/10/2018] [Accepted: 10/15/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Oral and sublingual immunotherapies for peanut allergy have demonstrated efficacy in small clinical trials; however, mechanisms and biomarkers correlating with clinical outcomes remain elusive. Previous studies have demonstrated a role for IgG in post-OIT plasma in the suppression of IgE-mediated mast cell reactions. OBJECTIVE The aim of this study was to characterize the role that peanut oral and sublingual immunotherapy-induced plasma factors play in the inhibition of ex vivo basophil activation and whether inhibitory activity is associated with clinical outcomes. METHODS Plasma samples from subjects on placebo, peanut oral immunotherapy (OIT) or peanut sublingual immunotherapy (SLIT), and IgG-depleted plasma or the IgG fraction were incubated with sensitized basophils, and the inhibition of basophil activation following stimulation with peanut extract was measured. Basophil inhibition results were compared between the two routes of immunotherapy, time on treatment and clinical outcomes. RESULTS Plasma from subjects after 12 months of active peanut OIT, but not placebo, inhibits basophil activation ex vivo. Depletion of IgG abrogated the blocking effect of OIT plasma, while the IgG fraction substantially blocked basophil activation. Basophils are inhibited to a similar extent by undiluted OIT and SLIT plasma; however, diluted OIT plasma from the time of desensitization challenge inhibited basophils more than diluted SLIT plasma from time of desensitization challenge. Plasma from subjects who experienced sustained unresponsiveness following OIT inhibited basophils to a greater extent than plasma from subjects who were desensitized, but this was not true for SLIT. CONCLUSIONS AND CLINICAL RELEVANCE Peanut immunotherapy induces IgG-dependent functional changes in plasma that are associated with OIT but not SLIT clinical outcomes. Understanding the mechanisms of peanut OIT and SLIT may help derive informative biomarkers.
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Affiliation(s)
- Kelly Orgel
- Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina.,UNC Food Allergy Initiative, Chapel Hill, North Carolina
| | - Caitlin Burk
- Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina.,UNC Food Allergy Initiative, Chapel Hill, North Carolina
| | - Johanna Smeekens
- Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina.,UNC Food Allergy Initiative, Chapel Hill, North Carolina
| | - Jada Suber
- Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina.,UNC Food Allergy Initiative, Chapel Hill, North Carolina
| | - Lakeya Hardy
- Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina.,UNC Food Allergy Initiative, Chapel Hill, North Carolina
| | - Rishu Guo
- Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina.,UNC Food Allergy Initiative, Chapel Hill, North Carolina
| | - A Wesley Burks
- Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina.,UNC Food Allergy Initiative, Chapel Hill, North Carolina
| | - Michael Kulis
- Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina.,UNC Food Allergy Initiative, Chapel Hill, North Carolina
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215
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Sindher S, Long AJ, Purington N, Chollet M, Slatkin S, Andorf S, Tupa D, Kumar D, Woch MA, O'Laughlin KL, Assaad A, Pongracic J, Spergel JM, Tam J, Tilles S, Wang J, Galli SJ, Nadeau KC, Chinthrajah RS. Analysis of a Large Standardized Food Challenge Data Set to Determine Predictors of Positive Outcome Across Multiple Allergens. Front Immunol 2018; 9:2689. [PMID: 30538699 PMCID: PMC6277531 DOI: 10.3389/fimmu.2018.02689] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/31/2018] [Indexed: 12/12/2022] Open
Abstract
Background: Double-blind placebo-controlled food challenges (DBPCFCs) remain the gold standard for the diagnosis of food allergy; however, challenges require significant time and resources and place the patient at an increased risk for severe allergic adverse events. There have been continued efforts to identify alternative diagnostic methods to replace or minimize the need for oral food challenges (OFCs) in the diagnosis of food allergy. Methods: Data was extracted for all IRB-approved, Stanford-initiated clinical protocols involving standardized screening OFCs to a cumulative dose of 500 mg protein to any of 11 food allergens in participants with elevated skin prick test (SPT) and/or specific IgE (sIgE) values to the challenged food across 7 sites. Baseline population characteristics, biomarkers, and challenge outcomes were analyzed to develop diagnostic criteria predictive of positive OFCs across multiple allergens in our multi-allergic cohorts. Results: A total of 1247 OFCs completed by 427 participants were analyzed in this cohort. Eighty-five percent of all OFCs had positive challenges. A history of atopic dermatitis and multiple food allergies were significantly associated with a higher risk of positive OFCs. The majority of food-specific SPT, sIgE, and sIgE/total IgE (tIgE) thresholds calculated from cumulative tolerated dose (CTD)-dependent receiver operator curves (ROC) had high discrimination of OFC outcome (area under the curves > 0.75). Participants with values above the thresholds were more likely to have positive challenges. Conclusions: This is the first study, to our knowledge, to not only adjust for tolerated allergen dose in predicting OFC outcome, but to also use this method to establish biomarker thresholds. The presented findings suggest that readily obtainable biomarker values and patient demographics may be of use in the prediction of OFC outcome and food allergy. In the subset of patients with SPT or sIgE values above the thresholds, values appear highly predictive of a positive OFC and true food allergy. While these values are relatively high, they may serve as an appropriate substitute for food challenges in clinical and research settings.
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Affiliation(s)
- Sayantani Sindher
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Andrew J Long
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States.,Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Stanford, CA, United States
| | - Natasha Purington
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Madeleine Chollet
- Department of Medicine, School of Medicine, Stanford, CA, United States
| | - Sara Slatkin
- Department of Medicine, School of Medicine, Stanford, CA, United States
| | - Sandra Andorf
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Dana Tupa
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Divya Kumar
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Margaret A Woch
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Katherine L O'Laughlin
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Amal Assaad
- Division of Allergy and Immunology, Cincinnati Children's Medical Center, Cincinnati, OH, United States
| | - Jacqueline Pongracic
- Division of Allergy and Immunology, The Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Jonathan M Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, United States
| | - Jonathan Tam
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Stephen Tilles
- ASTHMA Inc. Clinical Research Center, Northwest Asthma and Allergy Center, University of Washington, Seattle, WA, United States
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Stephen J Galli
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States.,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States.,Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, United States
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
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Wright BL, Fernandez-Becker NQ, Kambham N, Purington N, Tupa D, Zhang W, Rank MA, Kita H, Shim KP, Bunning BJ, Doyle AD, Jacobsen EA, Boyd SD, Tsai M, Maecker H, Manohar M, Galli SJ, Nadeau KC, Chinthrajah RS. Baseline Gastrointestinal Eosinophilia Is Common in Oral Immunotherapy Subjects With IgE-Mediated Peanut Allergy. Front Immunol 2018; 9:2624. [PMID: 30524424 PMCID: PMC6261984 DOI: 10.3389/fimmu.2018.02624] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/25/2018] [Indexed: 12/14/2022] Open
Abstract
Rationale: Oral immunotherapy (OIT) is an emerging treatment for food allergy. While desensitization is achieved in most subjects, many experience gastrointestinal symptoms and few develop eosinophilic gastrointestinal disease. It is unclear whether these subjects have subclinical gastrointestinal eosinophilia (GE) at baseline. We aimed to evaluate the presence of GE in subjects with food allergy before peanut OIT. Methods: We performed baseline esophagogastroduodenoscopies on 21 adults before undergoing peanut OIT. Subjects completed a detailed gastrointestinal symptom questionnaire. Endoscopic findings were assessed using the Eosinophilic Esophagitis (EoE) Endoscopic Reference Score (EREFS) and biopsies were obtained from the esophagus, gastric antrum, and duodenum. Esophageal biopsies were evaluated using the EoE Histologic Scoring System. Immunohistochemical staining for eosinophil peroxidase (EPX) was also performed. Hematoxylin and eosin and EPX stains of each biopsy were assessed for eosinophil density and EPX/mm2 was quantified using automated image analysis. Results: All subjects were asymptomatic. Pre-existing esophageal eosinophilia (>5 eosinophils per high-power field [eos/hpf]) was present in five participants (24%), three (14%) of whom had >15 eos/hpf associated with mild endoscopic findings (edema, linear furrowing, or rings; median EREFS = 0, IQR 0–0.25). Some subjects also demonstrated basal cell hyperplasia, dilated intercellular spaces, and lamina propria fibrosis. Increased eosinophils were noted in the gastric antrum (>12 eos/hpf) or duodenum (>26 eos/hpf) in 9 subjects (43%). EPX/mm2 correlated strongly with eosinophil counts (r = 0.71, p < 0.0001). Conclusions: Pre-existing GE is common in adults with IgE-mediated peanut allergy. Eosinophilic inflammation (EI) in these subjects may be accompanied by mild endoscopic and histologic findings. Longitudinal data collection during OIT is ongoing.
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Affiliation(s)
- Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Nielsen Q Fernandez-Becker
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Neeraja Kambham
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States.,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Natasha Purington
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Dana Tupa
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Wenming Zhang
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Hirohito Kita
- Division of Allergic Diseases, Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kelly P Shim
- Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Bryan J Bunning
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Alfred D Doyle
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Elizabeth A Jacobsen
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Scott D Boyd
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States.,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Mindy Tsai
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Holden Maecker
- Institute for Immunity, Transplantation, and Infection, Stanford University School of Medicine, Stanford, CA, United States
| | - Monali Manohar
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Stephen J Galli
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States.,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States.,Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, United States
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
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Blumchen K, Trendelenburg V, Ahrens F, Gruebl A, Hamelmann E, Hansen G, Heinzmann A, Nemat K, Holzhauser T, Roeder M, Rosenfeld L, Hartmann O, Niggemann B, Beyer K. Efficacy, Safety, and Quality of Life in a Multicenter, Randomized, Placebo-Controlled Trial of Low-Dose Peanut Oral Immunotherapy in Children with Peanut Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:479-491.e10. [PMID: 30423449 DOI: 10.1016/j.jaip.2018.10.048] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 10/23/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Only 2 small placebo-controlled trials on peanut oral immunotherapy (OIT) have been published. OBJECTIVE We examined the efficacy, safety, immunologic parameters, quality of life (QOL), and burden of treatment (BOT) of low-dose peanut OIT in a multicenter, double-blind, randomized placebo-controlled trial. METHODS A total of 62 children aged 3 to 17 years with IgE-mediated, challenge-proven peanut allergy were randomized (1:1) to receive peanut OIT with a maintenance dose of 125 to 250 mg peanut protein or placebo. The primary outcome was the proportion of children tolerating 300 mg or more peanut protein at oral food challenge (OFC) after 16 months of OIT. We measured the occurrence of adverse events (AEs), immunologic changes, and QOL before and after OIT and BOT during OIT. RESULTS Twenty-three of 31 (74.2%) children of the active group tolerated at least 300 mg peanut protein at final OFC compared with 5 of 31 (16.1%) in the placebo group (P < .001). Thirteen of 31 (41.9%) children of the active versus 1 of 31 (3.2%) of the placebo group tolerated the highest dose of 4.5 g peanut protein at final OFC (P < .001). There was no significant difference between the groups in the occurrence of AE-related dropouts or in the number, severity, and treatment of objective AEs. In the peanut-OIT group, we noted a significant reduction in peanut-specific IL-4, IL-5, IL-10, and IL-2 production by PBMCs compared with the placebo group, as well as a significant increase in peanut-specific IgG4 levels and a significant improvement in QOL; 86% of children evaluated the BOT positively. DISCUSSION Low-dose OIT is a promising, effective, and safe treatment option for peanut-allergic children, leading to improvement in QOL, a low BOT, and immunologic changes showing tolerance development.
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Affiliation(s)
- Katharina Blumchen
- Department of Children and Adolescent Medicine, Division of Pneumology, Allergology and Cystic fibrosis, University Hospital Frankfurt, Frankfurt am Main, Germany; Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Valerie Trendelenburg
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Armin Gruebl
- Department of Pediatrics, Technical University Munich, Munich, Germany
| | - Eckard Hamelmann
- Department of Pediatrics, Allergy Center, Ruhr-University Bochum, Bochum, Germany; Children's Center Bethel, EvKB, Bielefeld, Germany
| | - Gesine Hansen
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Andrea Heinzmann
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Katja Nemat
- Department of Pediatrics, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | | | - Martin Roeder
- Paul-Ehrlich-Institut, Division of Allergology, Langen, Germany; Institute for Product Quality (IFP), Berlin, Germany
| | - Leonard Rosenfeld
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Bodo Niggemann
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kirsten Beyer
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
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218
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Arkwright PD, MacMahon J, Koplin J, Rajput S, Cross S, Fitzsimons R, Davidson N, Deshpande V, Rao N, Lumsden C, Lacy D, Allen KJ, Vance G, Mwenechanya J, Fox AT, Erlewyn-Lajeunesse M, Mistry H, Hourihane JO. Severity and threshold of peanut reactivity during hospital-based open oral food challenges: An international multicenter survey. Pediatr Allergy Immunol 2018; 29:754-761. [PMID: 30022517 DOI: 10.1111/pai.12959] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 06/12/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Peanut allergy is classically managed by food avoidance. Immunotherapy programs are available at some academic centers for selected patients reacting to small amounts of peanut during food challenge. We aimed to determine and compare reaction thresholds and prevalence of anaphylaxis during peanut oral challenges at multiple specialist allergy centers. METHODS A retrospective, international survey of anonymized case records from seven specialist pediatric allergy centers from the UK and Ireland, as well as the Australian HealthNuts study. Demographic information, allergy test results, reaction severity and threshold during open oral peanut challenges were collated and analyzed. RESULTS Of the 1634 children aged 1-18 years old included, 525 (32%) failed their peanut challenge. Twenty-eight percent reacted to 25 mg, while 38% only reacted after consuming 1 g or more of whole peanut. Anaphylaxis (55 [11%]) was 3 times more common in teenagers than younger children and the likelihood increased at all ages as children consuming more peanut at the challenge. Children who developed anaphylaxis to 25-200 mg of whole peanut were significantly older. Previous history of reaction did not predict reaction threshold or severity. CONCLUSIONS More than a third of the children in this large international cohort tolerated the equivalent of one peanut in an oral challenge. Anaphylaxis, particularly to small amounts of peanut, was more common in older children. Tailored immunotherapy programs might be considered not only for children with low, but also higher reaction thresholds. Whether these programs could prevent heightened sensitivity and anaphylaxis to peanut with age also deserves further study.
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Affiliation(s)
- Peter D Arkwright
- Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | | | - Jennifer Koplin
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Vic., Australia
| | - Shelly Rajput
- Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | | | | | - Neil Davidson
- Great North Children's Hospital, Newcastle upon Tyne, UK
| | | | - Naveen Rao
- University Hospital of South Manchester, Manchester, UK
| | | | - David Lacy
- Wirral University Teaching Hospital, Wirral, UK
| | - Katrina J Allen
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Vic., Australia
| | - Gillian Vance
- Great North Children's Hospital, Newcastle upon Tyne, UK
| | | | - Adam T Fox
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | | | - Hitesh Mistry
- Division of Pharmacy, University of Manchester, Manchester, UK
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219
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Nowak-Węgrzyn A, Wood RA, Nadeau KC, Pongracic JA, Henning AK, Lindblad RW, Beyer K, Sampson HA. Multicenter, randomized, double-blind, placebo-controlled clinical trial of vital wheat gluten oral immunotherapy. J Allergy Clin Immunol 2018; 143:651-661.e9. [PMID: 30389226 DOI: 10.1016/j.jaci.2018.08.041] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 07/11/2018] [Accepted: 08/06/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Wheat is a common food allergen that can cause anaphylaxis. OBJECTIVE We sought to determine the efficacy and safety of vital wheat gluten (VWG) oral immunotherapy (OIT). METHODS After baseline double-blind, placebo-controlled food challenge (DBPCFC), 46 patients with wheat allergy (median age, 8.7 years; range, 4.2-22.3 years) were randomized 1:1 to low-dose VWG OIT or placebo, with biweekly escalation to 1445 mg of wheat protein (WP). After a year 1 DBPCFC, active subjects continued low-dose VWG OIT for another year and underwent a year 2 DBPCFC and, if passed, a subsequent off-therapy DBPCFC. Placebo-treated subjects crossed over to high-dose VWG OIT (maximum, 2748 mg of WP). RESULTS The median baseline successfully consumed dose (SCD) was 43 mg of WP in both groups. At year 1, 12 (52.2%) of 23 low-dose VWG OIT-treated and 0 (0%) of 23 placebo-treated subjects achieved the primary end point of an SCD of 4443 mg of WP or greater (P < .0001); median SCDs were 4443 and 143 mg, respectively. At year 2, 7 (30.4%) of 23 low-dose VWG OIT-treated subjects were desensitized to an SCD of 7443 mg of WP; 3 (13%) achieved sustained unresponsiveness 8 to 10 weeks off therapy. Among placebo-treated subjects who crossed over to high-dose VWG OIT, 12 (57.1%) of 21 were desensitized after 1 year (median SCD, 7443 mg of WP; nonsignificant vs low-dose VWG OIT). At year 1, skin prick test responses and wheat- and omega-5 gliadin-specific IgE levels did not differ between groups; the low-dose VWG OIT median specific IgG4 level was greater than placebo (wheat, P = .0005; omega-5 gliadin, P = .0001). Year 1 SCDs correlated with wheat-specific (rho = 0.55, P = .0003) and omega-5 gliadin-specific (rho = 0.51, P = .001) IgG4 levels in all subjects. Among 7822 low-dose VWG OIT doses in year 1, 15.4% were associated with adverse reactions: 0.04% were severe, and 0.08% subjects received epinephrine. Among 7921 placebo doses, 5.8% were associated with adverse reactions; none were severe. CONCLUSIONS Low- and high-dose VWG OIT induced desensitization in about one half of the subjects after 1 year of treatment. Two years of low-dose VWG OIT resulted in 30% desensitization, and 13% had sustained unresponsiveness.
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Affiliation(s)
- Anna Nowak-Węgrzyn
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, NY
| | - Robert A Wood
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Kari C Nadeau
- Division of Allergy and Immunology, Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Palo Alto, Calif
| | - Jacqueline A Pongracic
- Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | | | | | - Kirsten Beyer
- Charité Universitätsmedizin Berlin, Department of Pediatric Pneumology and Immunology, Berlin, Germany
| | - Hugh A Sampson
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, NY.
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220
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Chiang WC. Induction of Tolerance Through Early Weaning and Oral Immunotherapy. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0189-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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221
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Orgel K, Smeekens JM, Ye P, Fotsch L, Guo R, Miller DR, Pardo-Manuel de Villena F, Burks AW, Ferris MT, Kulis MD. Genetic diversity between mouse strains allows identification of the CC027/GeniUnc strain as an orally reactive model of peanut allergy. J Allergy Clin Immunol 2018; 143:1027-1037.e7. [PMID: 30342892 PMCID: PMC7252586 DOI: 10.1016/j.jaci.2018.10.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 09/17/2018] [Accepted: 10/01/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Improved animal models are needed to understand the genetic and environmental factors that contribute to food allergy. OBJECTIVE We sought to assess food allergy phenotypes in a genetically diverse collection of mice. METHODS We selected 16 Collaborative Cross (CC) mouse strains, as well as the classic inbred C57BL/6J, C3H/HeJ, and BALB/cJ strains, for screening. Female mice were sensitized to peanut intragastrically with or without cholera toxin and then challenged with peanut by means of oral gavage or intraperitoneal injection and assessed for anaphylaxis. Peanut-specific immunoglobulins, T-cell cytokines, regulatory T cells, mast cells, and basophils were quantified. RESULTS Eleven of the 16 CC strains had allergic reactions to intraperitoneal peanut challenge, whereas only CC027/GeniUnc mice reproducibly experienced severe symptoms after oral food challenge (OFC). CC027/GeniUnc, C3H/HeJ, and C57BL/6J mice all mounted a TH2 response against peanut, leading to production of IL-4 and IgE, but only the CC027/GeniUnc mice reacted to OFC. Orally induced anaphylaxis in CC027/GeniUnc mice was correlated with serum levels of Ara h 2 in circulation but not with allergen-specific IgE or mucosal mast cell protease 1 levels, indicating systemic allergen absorption is important for anaphylaxis through the gastrointestinal tract. Furthermore, CC027/GeniUnc, but not C3H/HeJ or BALB/cJ, mice can be sensitized in the absence of cholera toxin and react on OFC to peanut. CONCLUSIONS We have identified and characterized CC027/GeniUnc mice as a strain that is genetically susceptible to peanut allergy and prone to severe reactions after OFC. More broadly, these findings demonstrate the untapped potential of the CC population in developing novel models for allergy research.
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Affiliation(s)
- Kelly Orgel
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC; University of North Carolina Food Allergy Initiative, Chapel Hill, NC
| | - Johanna M Smeekens
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC; University of North Carolina Food Allergy Initiative, Chapel Hill, NC
| | - Ping Ye
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC; University of North Carolina Food Allergy Initiative, Chapel Hill, NC
| | - Lauren Fotsch
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC; University of North Carolina Food Allergy Initiative, Chapel Hill, NC
| | - Rishu Guo
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC; University of North Carolina Food Allergy Initiative, Chapel Hill, NC
| | - Darla R Miller
- Department of Genetics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Fernando Pardo-Manuel de Villena
- Department of Genetics, University of North Carolina School of Medicine, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - A Wesley Burks
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC; University of North Carolina Food Allergy Initiative, Chapel Hill, NC
| | - Martin T Ferris
- Department of Genetics, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Michael D Kulis
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC; University of North Carolina Food Allergy Initiative, Chapel Hill, NC.
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Wagenaar L, Bol‐Schoenmakers M, Giustarini G, Vonk MM, van Esch BC, Knippels LM, Garssen J, Smit JJ, Pieters RH. Dietary Supplementation with Nondigestible Oligosaccharides Reduces Allergic Symptoms and Supports Low Dose Oral Immunotherapy in a Peanut Allergy Mouse Model. Mol Nutr Food Res 2018; 62:e1800369. [PMID: 30102006 PMCID: PMC6766954 DOI: 10.1002/mnfr.201800369] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 06/15/2018] [Indexed: 12/31/2022]
Abstract
SCOPE A major downside of oral immunotherapy (OIT) for food allergy is the risk of severe side effects. Non-digestible short- and long-chain fructo-oligosaccharides (scFOS/lcFOS) reduce allergy development in murine models. Therefore, it is hypothesized that scFOS/lcFOS can also support the efficacy of OIT in a peanut allergy model. METHODS AND RESULTS After sensitization to peanut extract (PE) using cholera toxin, C3H/HeOuJ mice are fed a 1% scFOS/lcFOS or control diet and receive OIT (1.5 or 15 mg PE). Hereafter, mice are exposed to PE via different routes to determine the safety and efficacy of treatment in clinical outcomes, PE-specific antibody production, and numbers of various immune cells. scFOS/lcFOS increases short-chain fatty acid levels in the caecum and reduce the acute allergic skin response and drop in body temperature after PE exposure. Interestingly, 15 mg and 1.5 mg OIT with scFOS/lcFOS induce protection against anaphylaxis, whereas 1.5 mg OIT alone does not. OIT, with or without scFOS/lcFOS, induces PE-specific immunoglobulin (Ig) IgG and IgA levels and increases CD103+ dendritic cells in the mesenteric lymph nodes. CONCLUSIONS scFOS/lcFOS and scFOS/lcFOS combined with low dose OIT are able to protect against a peanut-allergic anaphylactic response.
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Affiliation(s)
- Laura Wagenaar
- Department of ImmunotoxicologyInstitute for Risk Assessment SciencesUtrecht UniversityYalelaan 104, NL‐3584 CMUtrechtThe Netherlands
| | - Marianne Bol‐Schoenmakers
- Department of ImmunotoxicologyInstitute for Risk Assessment SciencesUtrecht UniversityYalelaan 104, NL‐3584 CMUtrechtThe Netherlands
| | - Giulio Giustarini
- Department of ImmunotoxicologyInstitute for Risk Assessment SciencesUtrecht UniversityYalelaan 104, NL‐3584 CMUtrechtThe Netherlands
| | - Marlotte M. Vonk
- Division of PharmacologyUtrecht Institute for Pharmaceutical SciencesUtrecht UniversityUniversiteitsweg 99, NL‐3584 CGUtrechtThe Netherlands
- Immunology PlatformNutricia ResearchUppsalalaan 12, NL‐3584 CTUtrechtThe Netherlands
| | - Betty C.A.M. van Esch
- Division of PharmacologyUtrecht Institute for Pharmaceutical SciencesUtrecht UniversityUniversiteitsweg 99, NL‐3584 CGUtrechtThe Netherlands
- Immunology PlatformNutricia ResearchUppsalalaan 12, NL‐3584 CTUtrechtThe Netherlands
| | - Leon M.J. Knippels
- Division of PharmacologyUtrecht Institute for Pharmaceutical SciencesUtrecht UniversityUniversiteitsweg 99, NL‐3584 CGUtrechtThe Netherlands
- Immunology PlatformNutricia ResearchUppsalalaan 12, NL‐3584 CTUtrechtThe Netherlands
| | - Johan Garssen
- Division of PharmacologyUtrecht Institute for Pharmaceutical SciencesUtrecht UniversityUniversiteitsweg 99, NL‐3584 CGUtrechtThe Netherlands
- Immunology PlatformNutricia ResearchUppsalalaan 12, NL‐3584 CTUtrechtThe Netherlands
| | - Joost J. Smit
- Department of ImmunotoxicologyInstitute for Risk Assessment SciencesUtrecht UniversityYalelaan 104, NL‐3584 CMUtrechtThe Netherlands
| | - Raymond H.H. Pieters
- Department of ImmunotoxicologyInstitute for Risk Assessment SciencesUtrecht UniversityYalelaan 104, NL‐3584 CMUtrechtThe Netherlands
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223
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Kulis M, Yue X, Guo R, Zhang H, Orgel K, Ye P, Li Q, Liu Y, Kim E, Burks AW, Vickery BP. High- and low-dose oral immunotherapy similarly suppress pro-allergic cytokines and basophil activation in young children. Clin Exp Allergy 2018; 49:180-189. [PMID: 30126028 DOI: 10.1111/cea.13256] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/31/2018] [Accepted: 07/31/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Mechanisms underlying oral immunotherapy (OIT) are unclear and the effects on immune cells at varying maintenance doses are unknown. OBJECTIVE We aimed to determine the immunologic changes caused by peanut OIT in preschool aged children and determine the effect on these immune responses in groups ingesting low or high-dose peanut OIT (300 mg or 3000 mg, respectively) as maintenance therapy. METHODS Blood was drawn at several time-points throughout the OIT protocol and PBMCs isolated and cultured with peanut antigens. Secreted cytokines were quantified via multiplex assay, whereas Treg and peanut-responsive CD4 T cells were studied with flow cytometry. Basophil activation assays were also conducted. RESULTS Th2-, Th1-, Th9- and Tr1-type cytokines decreased over the course of OIT in groups on high- and low-dose OIT. There were no significant differences detected in cytokine changes between the high- and low-dose groups. The initial increase in both the number of peanut-responsive CD4 T cells and the number of Tregs was transient and no significant differences were found between groups. Basophil activation following peanut stimulation was decreased over the course of OIT and associated with increased peanut-IgG4/IgE ratios. No differences were found between high- and low-dose groups in basophil activation at the time of desensitization or sustained unresponsiveness oral food challenges. CONCLUSIONS AND CLINICAL RELEVANCE Peanut OIT leads to decreases in pro-allergic cytokines, including IL-5, IL-13, and IL-9 and decreased basophil activation. No differences in T cell or basophil responses were found between subjects on low or high-dose maintenance OIT, which has implications for clinical dosing strategies.
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Affiliation(s)
- Michael Kulis
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,University of North Carolina Food Allergy Initiative, Chapel Hill, NC, USA
| | - Xiaohong Yue
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,University of North Carolina Food Allergy Initiative, Chapel Hill, NC, USA
| | - Rishu Guo
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,University of North Carolina Food Allergy Initiative, Chapel Hill, NC, USA
| | - Huamei Zhang
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,University of North Carolina Food Allergy Initiative, Chapel Hill, NC, USA
| | - Kelly Orgel
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,University of North Carolina Food Allergy Initiative, Chapel Hill, NC, USA
| | - Ping Ye
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,University of North Carolina Food Allergy Initiative, Chapel Hill, NC, USA
| | - Quefeng Li
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Yutong Liu
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Edwin Kim
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,University of North Carolina Food Allergy Initiative, Chapel Hill, NC, USA
| | - Arvil Wesley Burks
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,University of North Carolina Food Allergy Initiative, Chapel Hill, NC, USA
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224
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Ramesh M, Karagic M. New modalities of allergen immunotherapy. Hum Vaccin Immunother 2018; 14:2848-2863. [PMID: 30183485 PMCID: PMC6343630 DOI: 10.1080/21645515.2018.1502126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 06/27/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022] Open
Abstract
Allergen immunotherapy is a rapidly evolving field. Although subcutaneous immunotherapy has been practiced for over a hundred years, improved understanding of the underlying immunological mechanisms has led to the development of new, efficacious and better tolerated allergen-derivatives, adjuvants and encapsulated allergens. Diverse routes of allergen immunotherapy - oral, sublingual, epicutanoeus and intralymphatic - are enabling immunotherapy for anaphylactic food allergies and pollen-food allergy syndrome, while improving the tolerability and effectiveness of aeroallergen immunotherapy. The addition of Anti-IgE therapy decreases adverse effects of subcutaneous and oral immunotherapy.
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225
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Wasserman RL, Jones DH, Windom HH. Oral immunotherapy for food allergy. Ann Allergy Asthma Immunol 2018; 121:272-275. [DOI: 10.1016/j.anai.2018.06.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 05/28/2018] [Accepted: 06/08/2018] [Indexed: 10/28/2022]
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226
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Zhang W, Sindher SB, Sampath V, Nadeau K. Comparison of sublingual immunotherapy and oral immunotherapy in peanut allergy. ALLERGO JOURNAL 2018. [DOI: 10.1007/s15007-018-1688-6] [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]
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227
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Abstract
Peanut allergens have the potential to negatively impact on the health and quality of life of millions of consumers worldwide. The seeds of the peanut plant Arachis hypogaea contain an array of allergens that are able to induce the production of specific IgE antibodies in predisposed individuals. A lot of effort has been focused on obtaining the sequences and structures of these allergens due to the high health risk they represent. At present, 16 proteins present in peanuts are officially recognized as allergens. Research has also focused on their in-depth immunological characterization as well as on the design of modified hypoallergenic derivatives for potential use in clinical studies and the formulation of strategies for immunotherapy. Detailed research protocols are available for the purification of natural allergens as well as their recombinant production in bacterial, yeast, insect, and algal cells. Purified allergen molecules are now routinely used in diagnostic multiplex protein arrays for the detection of the presence of allergen-specific IgE. This review gives an overview on the wealth of knowledge that is available on individual peanut allergens.
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Affiliation(s)
- Chiara Palladino
- Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Heimo Breiteneder
- Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria.
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228
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Nachshon L, Goldberg MR, Katz Y, Levy MB, Elizur A. Long-term outcome of peanut oral immunotherapy-Real-life experience. Pediatr Allergy Immunol 2018; 29:519-526. [PMID: 29698554 DOI: 10.1111/pai.12914] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Oral immunotherapy (OIT) is currently recommended as a treatment option for peanut-allergic patients. Data regarding its long-term compliance and efficacy in real life are required. METHODS Peanut-allergic patients aged ≥4 years were enrolled in a single-center clinical OIT program. Buildup to 3000 mg peanut protein was performed. Patients reaching this dose before or after 12/2014 were instructed to consume 3000 or 1200 mg daily, respectively. Patients were followed ≥6 months after reaching maintenance and rechallenged to 3000 mg. RESULTS Of the 145 patients studied, 113 (77.9%) were fully desensitized to 3000 mg and 133 (91.7%) were desensitized to ≥300 mg. 21/145 patients (14.5%) required adrenaline for home-dose reactions during buildup. Non-anaphylactic gastrointestinal symptoms, experienced by 9 patients (6.2%), reversed with dose reduction. Of the 111 patients available for analysis 6 months after reaching 3000 mg, 97 (87.4%) continued regular peanut consumption. Only 2/111 patients (1.8%) required adrenaline over the long-term (median, range; 18, 6-75 months) follow-up. Adherence to treatment was significantly higher in patients consuming 1200 mg (73/76, 96.1%) vs those consuming 3000 mg (24/35, 72.2%), (P = .001). A higher maintenance dosage and home adrenaline requirement during buildup predicted adherence cessation (OR 12.5, P = .001; and OR 7.8, P = .02, respectively). 63/64 patients (98.4%) consuming 1200 mg maintenance dose were successfully rechallenged to 3000 mg. CONCLUSIONS This real-life experience demonstrates the efficacy of peanut OIT long-term. A lower maintenance dose minimized treatment cessation while maintaining desensitization. OIT should be performed in qualified centers given the prevalence of adverse reactions, particularly during buildup.
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Affiliation(s)
- Liat Nachshon
- Institute of Allergy, Immunology and Pediatric Pulmonology, Assaf-Harofeh Medical Center, Zerifin, Israel
| | - Michael R Goldberg
- Institute of Allergy, Immunology and Pediatric Pulmonology, Assaf-Harofeh Medical Center, Zerifin, Israel
| | - Yitzhak Katz
- Institute of Allergy, Immunology and Pediatric Pulmonology, Assaf-Harofeh Medical Center, Zerifin, Israel.,Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael B Levy
- Institute of Allergy, Immunology and Pediatric Pulmonology, Assaf-Harofeh Medical Center, Zerifin, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Assaf-Harofeh Medical Center, Zerifin, Israel.,Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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229
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Nagakura KI, Yanagida N, Sato S, Nishino M, Asaumi T, Ogura K, Ebisawa M. Low-dose oral immunotherapy for children with anaphylactic peanut allergy in Japan. Pediatr Allergy Immunol 2018; 29:512-518. [PMID: 29603410 DOI: 10.1111/pai.12898] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Oral immunotherapy (OIT) is a promising treatment for persons with allergy; however, it can also cause adverse allergic reactions. In this study, we investigated the efficacy of low-dose OIT for anaphylactic peanut allergy. METHODS Twenty-four children (median age, 9.6 years) with anaphylaxis to peanuts were hospitalized for 5 days and then gradually fed increasing amounts of peanut powder up to 133 mg/day. One year later, they underwent an oral food challenge after 2 weeks of peanut avoidance. Those who were asymptomatic after ingesting 795 mg of peanut protein were defined as having achieved sustained unresponsiveness. We measured peanut- and Ara h2-specific immunoglobulin (Ig) E, IgG, and IgG4 levels at 0, 1, 3, 6, and 12 months in the OIT group and at 0 and 12 months in the control group. RESULTS At baseline, all children in the OIT group and 8 in the control group had a history of anaphylaxis. The median peanut-/Ara h2-specific IgE levels in the OIT and control groups were 55.4/48.6 and 58.2/38.1 kUa/L, respectively. One year later, 8 (33.3%) children in the OIT group exhibited sustained unresponsiveness, while none in the control group did. In the OIT group, the median peanut-specific IgE levels significantly increased to 194.0 kUa/L, after 1 month and then significantly decreased to 57.5 kUa/L at 12 months. Meanwhile, the median peanut- and Ara h2-specific IgG and IgG4 levels increased significantly after 1 month. CONCLUSION Low-dose OIT induces immunological changes and has the capability of achieving sustained unresponsiveness in children with peanut anaphylaxis.
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Affiliation(s)
- Ken-Ichi Nagakura
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan.,Department of Pediatrics, Jikei University School of Medicine, Tokyo, Japan
| | - Noriyuki Yanagida
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Sakura Sato
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan
| | - Makoto Nishino
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Tomoyuki Asaumi
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Kiyotake Ogura
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan
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230
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Arasi S, Caminiti L, Crisafulli G, Pajno GB. A general strategy for de novo immunotherapy design: the active treatment of food allergy. Expert Rev Clin Immunol 2018; 14:665-671. [PMID: 29984605 DOI: 10.1080/1744666x.2018.1498784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION IgE-mediated food allergy (FA) has been emerging as a public health priority. It is a potentially life-threatening condition with negative impact on the quality of life of patients and their family and its prevalence is increasing in westernized countries in the recent two decades. The current standard approach to FA consists of the strict avoidance of the triggering food. However, an elimination diet may be difficult and frustrating, above all for those foods (e.g. milk and egg) that are pivotal in the common diet. Oral immunotherapy (OIT) may increase the amount of food that the patient can intake without reaction and reduce the risk of potential life-threatening allergic reactions. It is currently considered the most promising treatment for FA. However, many gaps are still unsolved. Areas covered: The aim of this review is to shed light on the current evidence and the main needs in OIT in order to stimulate the development of longitudinal, prospective, and well-designed studies with the final goal of a 'precision medicine.' Expert commentary: Clinical trials for OIT conducted so far are extremely heterogeneous. The aim in the near future is to identify the most suitable candidates to OIT and algorithms for treatments tailored on well-characterized subpopulations of patients.
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Affiliation(s)
- Stefania Arasi
- a Department of Pediatrics- Allergy Unit , University of Messina , Messina , Italy.,b SIAF- Schweizerischers Institut für Allergie- und Asthmaforschung , Davos , Switzerland.,c Pediatric Allergy Unit , Bambino Gesù Children's Hospital, IRCCS , Rome , Italy
| | - Lucia Caminiti
- a Department of Pediatrics- Allergy Unit , University of Messina , Messina , Italy
| | - Giuseppe Crisafulli
- a Department of Pediatrics- Allergy Unit , University of Messina , Messina , Italy
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231
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Rudman Spergel AK, Minnicozzi M, Wheatley LM, Togias A. Is Allergen Immunotherapy in Children Disease Modifying? A Review of the Evidence. Curr Allergy Asthma Rep 2018; 18:47. [PMID: 29995257 DOI: 10.1007/s11882-018-0801-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Although evidence supports a beneficial effect of allergen immunotherapy on the symptoms of allergic respiratory disease and food allergy, it is not clear whether immunotherapy modifies the natural history of these conditions. RECENT FINDINGS In aeroallergen immunotherapy, studies suggest that prevention of asthma can be attained. Less evident is the ability of immunotherapy to prevent new allergen sensitizations and more studies are needed to test whether immunotherapy can continue suppressing airway symptoms after treatment discontinuation. In food allergen immunotherapy, there is evidence that unresponsiveness to a food challenge can be sustained in some treatment recipients, but little knowledge exists as to the dose and duration of treatment that can optimize this effect. Suggestive evidence exists that allergen immunotherapy can modify allergic disease in children, but definitive studies are lacking. More research in the field is required.
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Affiliation(s)
- Amanda K Rudman Spergel
- Division of Allergy, Immunology and Transplantation, Allergy, Asthma and Airway Biology Branch, National Institute of Allergy and Infectious Diseases, NIH, 5601 Fishers Lane, Rockville, MD, 20892, USA.
| | - Michael Minnicozzi
- Division of Allergy, Immunology and Transplantation, Allergy, Asthma and Airway Biology Branch, National Institute of Allergy and Infectious Diseases, NIH, 5601 Fishers Lane, Rockville, MD, 20892, USA
| | - Lisa M Wheatley
- Division of Allergy, Immunology and Transplantation, Allergy, Asthma and Airway Biology Branch, National Institute of Allergy and Infectious Diseases, NIH, 5601 Fishers Lane, Rockville, MD, 20892, USA
| | - Alkis Togias
- Division of Allergy, Immunology and Transplantation, Allergy, Asthma and Airway Biology Branch, National Institute of Allergy and Infectious Diseases, NIH, 5601 Fishers Lane, Rockville, MD, 20892, USA
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232
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Chaudhari M, Kim EH, Withana Gamage PW, McMahan CS, Kosorok MR. Study design with staggered sampling times for evaluating sustained unresponsiveness to peanut sublingual immunotherapy. Stat Med 2018; 37:3944-3958. [PMID: 29974494 DOI: 10.1002/sim.7857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 04/12/2018] [Accepted: 06/04/2018] [Indexed: 11/08/2022]
Abstract
In this work, we delineate an altered study design of a pre-existing clinical trial that is currently being implemented in the Department of Pediatrics at the University of North Carolina at Chapel Hill. The purpose of the ongoing investigation of the desensitized pediatric cohort is to address the effectiveness of sublingual immunotherapy in achieving sustained unresponsiveness (SU) as assessed by repeated double-blind placebo-controlled food challenges (DBPCFC). With scarce published literature characterizing SU, the length of time off-therapy that would represent clinically meaningful benefit remains undefined. We use the new design features to assess time to loss of SU, an important efficacy endpoint, that to our knowledge, no prior study has investigated. Our work has two-fold objectives: first is to propose and discuss aspects of the altered design that would allow us to study SU and second is to explore methodology to evaluate the time to loss of SU and its association with risk factors in the context of the data originating from the trial. The salient feature of the new design is the allocation scheme of study subjects to staggered sampling timepoints when a subsequent DBPCFC is administered. Due to this feature, the time to loss of SU is either left or right censored. Additionally, some participants at study entry fail the DBPCFC, leading to what can be construed as an instantaneous failure. Through in-depth numerical studies, we examine the performance and power of a recently proposed mixture proportional hazards model specifically designed for the analysis of interval-censored data subject to instantaneous failures.
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Affiliation(s)
- Monica Chaudhari
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Edwin H Kim
- Division of Allergy and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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233
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Peck JL, Larson EK, Silvers SK. One Child's Food Fight: A Case Study of Oral Immunotherapy Treatment for Food Allergies. J Pediatr Health Care 2018. [PMID: 29540279 DOI: 10.1016/j.pedhc.2018.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The prevalence of food allergy has risen dramatically in the last two decades. Primary care providers encounter food-allergic children on a daily basis. Although the standard of care has traditionally been strict avoidance of the allergen and advisement to carry an epinephrine autoinjector in case of an accidental exposure resulting in a severe reaction, food allergy research has progressed in the past decade concerning various immunotherapies that may provide an alternate treatment strategy. Oral immunotherapy (OIT), performed under the supervision of an allergist, is the most widely studied of these therapies. In the past, OIT has been available in the realm of clinical trials, but it is now being offered by a small but increasing number of allergists in private practice throughout the United States. Pediatric primary care clinicians should be aware of both the risks and possible benefits of this treatment, because they are likely to encounter patients who may inquire about OIT in their practices. In this case report, use of OIT will be reviewed in the treatment of a food-allergic child.
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234
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Jimenez-Rodriguez TW, Garcia-Neuer M, Alenazy LA, Castells M. Anaphylaxis in the 21st century: phenotypes, endotypes, and biomarkers. J Asthma Allergy 2018; 11:121-142. [PMID: 29950872 PMCID: PMC6016596 DOI: 10.2147/jaa.s159411] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Anaphylaxis is the most serious of all allergic reactions and can be fatal. The diagnosis is frequently delayed, and misdiagnosis often occurs with asthma or urticaria. Biomarkers such as tryptase are not routinely checked, and appropriate treatment with epinephrine is not administered in a majority of cases, increasing the risk of poor outcomes. The objective of this review is to provide a better understanding of the pathophysiology of anaphylaxis with a description of phenotypes, endotypes, and biomarkers available in both the clinical and research settings. Expanding knowledge with regard to the presentation, causes, and triggers for anaphylaxis among health care providers will improve its diagnosis and management, increase patient safety, and decrease morbidity and mortality.
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Affiliation(s)
- Teodorikez Wilfox Jimenez-Rodriguez
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Allergy Section, Alicante General University Hospital, Alicante, Spain
- PhD Program in Public Health, Medical and Surgical Sciences, Miguel Hernandez University, Alicante, Spain
| | - Marlene Garcia-Neuer
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Leila A Alenazy
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mariana Castells
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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235
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Abstract
Anaphylaxis is a severe and potentially life-threatening allergic reaction. There are numerous potential causes, with food allergy being the leading cause in children and the focus of this review. Most reactions involve an IgE-mediated mechanism, although non-IgE-mediated and nonimmunologic reactions can occur. Various cofactors to be discussed can place certain individuals at an increased risk of severe or fatal anaphylaxis. The clinical manifestations of anaphylaxis are broad and may involve multiple body systems. Diagnosis of food-related anaphylaxis is primarily based on signs and symptoms and supported, wherever possible, by identification and confirmation of a culprit food allergen. First-line treatment of anaphylaxis is intramuscular administration of epinephrine. Long-term management is generally focused on strict allergen avoidance and more recently on food desensitization using immunotherapy. This review provides an overview of anaphylaxis with a specific focus on food allergy.
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Affiliation(s)
- David Yue
- Division of Clinical Immunology & Allergy, Department of Medicine, Health Sciences Centre, McMaster University, Hamilton, ON, Canada
| | - Amanda Ciccolini
- Division of Clinical Immunology & Allergy, Department of Medicine, Health Sciences Centre, McMaster University, Hamilton, ON, Canada
| | - Ernie Avilla
- Division of Clinical Immunology & Allergy, Department of Medicine, Health Sciences Centre, McMaster University, Hamilton, ON, Canada
| | - Susan Waserman
- Division of Clinical Immunology & Allergy, Department of Medicine, Health Sciences Centre, McMaster University, Hamilton, ON, Canada
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236
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Zhang W, Sindher SB, Sampath V, Nadeau K. Comparison of sublingual immunotherapy and oral immunotherapy in peanut allergy. ACTA ACUST UNITED AC 2018; 27:153-161. [PMID: 31440440 DOI: 10.1007/s40629-018-0067-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The prevalence of food allergy has been increasing over the past few decades at an alarming rate with peanut allergy affecting about 2% of children. Both oral immunotherapy (OIT) and sublingual immunotherapy (SLIT) have shown promise as a treatment option for peanut allergy. Immunotherapy induces desensitization and reduces the risk of reaction during accidental ingestion and may also enable those who are successfully desensitized to include the food allergen in their diet. OIT has been very well studied and has been found to be more efficacious that SLIT with an acceptable safety profile. However, SLIT is associated with fewer side effects. Studies indicate that a combination of SLIT and OIT may together induce a significant increase in challenge thresholds with fewer adverse events. More head-to-head clinical trials that direct compare OIT and SLIT as well as SLIT and OIT combination studies are warranted.
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Affiliation(s)
- Wenming Zhang
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University, Stanford, USA.,Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University, Stanford, USA.,Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA
| | - Vanitha Sampath
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University, Stanford, USA.,Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA
| | - Kari Nadeau
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University, Stanford, USA.,Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA.,Division of Allergy, Immunology and Rheumatology, Department of Medicine, Stanford University, Stanford, USA
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237
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Pecora V, Mennini M, Calandrelli V, Patriarca G, Valluzzi R, Fierro V. How to actively treat food allergy. Curr Opin Allergy Clin Immunol 2018; 18:248-257. [DOI: 10.1097/aci.0000000000000450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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238
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Application of precision medicine to the treatment of anaphylaxis. Curr Opin Allergy Clin Immunol 2018; 18:190-197. [DOI: 10.1097/aci.0000000000000435] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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239
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Fauquert JL, Michaud E, Pereira B, Bernard L, Gourdon-Dubois N, Rouzaire PO, Rochette E, Merlin E, Evrard B. Peanut gastrointestinal delivery oral immunotherapy in adolescents: Results of the build-up phase of a randomized, double-blind, placebo-controlled trial (PITA study). Clin Exp Allergy 2018; 48:862-874. [PMID: 29665158 DOI: 10.1111/cea.13148] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 04/06/2018] [Accepted: 04/10/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Oral immunotherapy to peanut is effective in desensitizing patients but has significant side effects including anaphylaxis and gastrointestinal symptoms. In most protocols, peanut is administered in a vehicle food. OBJECTIVE In an exclusively adolescent population, we tested a new approach using sealed capsules of peanut (gastrointestinal delivery oral immunotherapy or GIDOIT) to bypass the upper gastrointestinal tract. The primary aim was to assess the efficacy of the oral build-up phase of GIDOIT and the secondary aim to analyse its safety. METHODS Adolescents with a history of a clinical allergic reaction after peanut ingestion were included in a 2-armed, parallel-design, individually randomized, double-blind, placebo-controlled, multicentre trial after a positive double-blind placebo-controlled oral food challenge (DBPCFC1). A central randomization centre used computer-generated tables to allocate treatments. Peanut (or placebo) capsules were ingested daily over a period of 24 weeks with increments every 2 weeks from 2 to 400 mg of peanut protein (pp). Primary outcome was tolerance of 400 mg of pp at DBPCFC2. RESULTS Thirty patients were included between September 2013 and May 2014. At DBPCFC2, unresponsiveness to 400 mg of pp was achieved in 17/21 peanut group patients (2 withdrawn patients) and 1/9 in the placebo group (Intention-to-treat analysis, P < .001, absolute difference = 0.7, 95%IC 0.43 0.96). Oropharyngeal symptoms were equally frequent in both groups. No dysphagia or other signs of eosinophilic oesophagitis occurred. Digestive adverse events (AE) were more frequent in the treated group (P = .02), but mild and without compliance issues. Only one severe advent event led to withdrawal in a patient who ingested twice the investigated treatment. Peanut-specific humoral immune responses were modulated. CONCLUSION The GIDOIT protocol demonstrated clinical and immunological efficacy and had an acceptable level of safety with weak oropharyngeal symptoms, no dysphagia, mild digestive events and few severe systemic AE.
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Affiliation(s)
- J-L Fauquert
- Unité d'allergologie de l'enfant, CHU Estaing, Pole pédiatrique, CHU Clermont-Ferrand, Clermont-Ferrand, France.,INSERM CIC 1405, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - E Michaud
- Unité d'allergologie de l'enfant, CHU Estaing, Pole pédiatrique, CHU Clermont-Ferrand, Clermont-Ferrand, France.,INSERM CIC 1405, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - B Pereira
- Unité de Biostatistiques, Direction de la Recherche Clinique et Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - L Bernard
- Département de Pharmacie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - N Gourdon-Dubois
- Unité d'allergologie de l'enfant, CHU Estaing, Pole pédiatrique, CHU Clermont-Ferrand, Clermont-Ferrand, France.,INSERM CIC 1405, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - P-O Rouzaire
- Service d'Immunologie, CHU Gabriel-Montpied, CHU Clermont-Ferrand, Clermont-Ferrand, France.,UFR Pharmacie, ERTICa, Université Clermont Auvergne, Clermont-Ferrand, France
| | - E Rochette
- INSERM CIC 1405, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - E Merlin
- Unité d'allergologie de l'enfant, CHU Estaing, Pole pédiatrique, CHU Clermont-Ferrand, Clermont-Ferrand, France.,INSERM CIC 1405, CHU Clermont-Ferrand, Clermont-Ferrand, France.,UFR Médecine, UMR1019 UNH, Université Clermont Auvergne, Clermont-Ferrand, France
| | - B Evrard
- Service d'Immunologie, CHU Gabriel-Montpied, CHU Clermont-Ferrand, Clermont-Ferrand, France.,UFR Pharmacie, ERTICa, Université Clermont Auvergne, Clermont-Ferrand, France
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240
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Renand A, Shamji MH, Harris KM, Qin T, Wambre E, Scadding GW, Wurtzen PA, Till SJ, Togias A, Nepom GT, Kwok WW, Durham SR. Synchronous immune alterations mirror clinical response during allergen immunotherapy. J Allergy Clin Immunol 2018; 141:1750-1760.e1. [PMID: 29128670 PMCID: PMC5938141 DOI: 10.1016/j.jaci.2017.09.041] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/25/2017] [Accepted: 09/18/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Three years of treatment with either sublingual or subcutaneous allergen immunotherapy has been shown to be effective and to induce long-term tolerance. The Gauging Response in Allergic Rhinitis to Sublingual and Subcutaneous Immunotherapy (GRASS) trial demonstrated that 2 years of treatment through either route was effective in suppressing the response to nasal allergen challenge, although it was insufficient for inhibition 1 year after discontinuation. OBJECTIVE We sought to examine in the GRASS trial the time course of immunologic changes during 2 years of sublingual and subcutaneous immunotherapy and for 1 year after treatment discontinuation. METHODS We performed multimodal immunomonitoring to assess allergen-specific CD4 T-cell properties in parallel with analysis of local mucosal cytokine responses induced by nasal allergen exposure and humoral immune responses that included IgE-dependent basophil activation and measurement of serum inhibitory activity for allergen-IgE binding to B cells (IgE-facilitated allergen binding). RESULTS All 3 of these distinct arms of the immune response displayed significant and coordinate alterations during 2 years of allergen desensitization, followed by reversal at 3 years, reflecting a lack of a durable immunologic effect. Although frequencies of antigen-specific TH2 cells in peripheral blood determined by using HLA class II tetramer analysis most closely paralleled clinical outcomes, IgE antibody-dependent functional assays remained inhibited in part 1 year after discontinuation. CONCLUSION Two years of allergen immunotherapy were effective but insufficient for long-term tolerance. Allergen-specific TH2 cells most closely paralleled the transient clinical outcome, and it is likely that recurrence of the T-cell drivers of allergic immunity abrogated the potential for durable tolerance. On the other hand, the persistence of IgE blocking antibody 1 year after discontinuation might be an early indicator of a protolerogenic mechanism.
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Affiliation(s)
- Amedee Renand
- Benaroya Research Institute at Virginia Mason, Seattle, Wash
| | - Mohamed H Shamji
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Section of Inflammation Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom; MRC and Asthma UK, Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | | | | | - Erik Wambre
- Benaroya Research Institute at Virginia Mason, Seattle, Wash
| | - Guy W Scadding
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Section of Inflammation Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Stephen J Till
- Asthma, Allergy and Lung Biology, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom; MRC and Asthma UK, Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | - Gerald T Nepom
- Benaroya Research Institute at Virginia Mason, Seattle, Wash; Immune Tolerance Network, Bethesda, Md
| | - William W Kwok
- Benaroya Research Institute at Virginia Mason, Seattle, Wash
| | - Stephen R Durham
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology, Section of Inflammation Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom; MRC and Asthma UK, Centre in Allergic Mechanisms of Asthma, London, United Kingdom.
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241
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O'Konek JJ, Landers JJ, Janczak KW, Goel RR, Mondrusov AM, Wong PT, Baker JR. Nanoemulsion adjuvant-driven redirection of T H2 immunity inhibits allergic reactions in murine models of peanut allergy. J Allergy Clin Immunol 2018; 141:2121-2131. [PMID: 29655584 DOI: 10.1016/j.jaci.2018.01.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 01/17/2018] [Accepted: 01/27/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Immunotherapy for food allergies involves progressive increased exposures to food that result in desensitization to food allergens in some subjects but not tolerance to the food. Therefore new approaches to suppress allergic immunity to food are necessary. Previously, we demonstrated that intranasal immunization with a nanoemulsion (NE) adjuvant induces robust mucosal antibody and TH17-polarized immunity, as well as systemic TH1-biased cellular immunity with suppression of pre-existing TH2-biased immunity. OBJECTIVE We hypothesized that immunization with food in conjunction with the nanoemulsion adjuvant could lead to modulation of allergic reactions in food allergy by altering pre-existing allergic immunity and enhancing mucosal immunity. METHODS Mice were sensitized to peanut with aluminum hydroxide or cholera toxin. The animals were then administered 3 monthly intranasal immunizations with peanut in the nanoemulsion adjuvant or saline. Mice were then challenged with peanut to examine allergen reactivity. RESULTS The NE intranasal immunizations resulted in marked decreases in TH2 cytokine, IgG1, and IgE levels, whereas TH1 and mucosal TH17 immune responses were increased. After allergen challenge, these mice showed significant reductions in allergic hypersensitivity. Additionally, the NE immunizations significantly increased antigen-specific IL-10 production and regulatory T-cell counts, and the protection induced by NE was dependent in part on IL-10. Control animals immunized with intranasal peanut in saline had no modulation of their allergic response. CONCLUSIONS NE adjuvant-mediated induction of mucosal TH17 and systemic TH1-biased immunity can suppress TH2-mediated allergy through multiple mechanisms and protect against anaphylaxis. These results suggest the potential therapeutic utility of this approach in the setting of food allergy.
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Affiliation(s)
- Jessica J O'Konek
- Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, Mich.
| | - Jeffrey J Landers
- Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, Mich
| | | | - Rishi R Goel
- Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, Mich
| | - Anna M Mondrusov
- Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, Mich
| | - Pamela T Wong
- Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, Mich
| | - James R Baker
- Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, Mich.
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Abstract
PURPOSE OF REVIEW The goal of this review is to present an updated summary of the natural history of major childhood and adult food allergies and report recent advances in potential treatments for food allergy. RECENT FINDINGS The most common childhood food allergies are typically outgrown by adolescence or adulthood. However, peanut/tree nut allergies appear to more commonly persist into adulthood. Adults can develop new IgE-mediated food allergies; the most common is oral allergy syndrome. There are multiple different approaches being tried as possible treatments for food allergy. The prevalence of food allergy appears to be increasing but the varied approaches to treatment are being actively pursued such that an approved modality may not be too far in the future.
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243
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Abstract
PURPOSE OF REVIEW The goal of this review is to present an updated summary of the natural history of major childhood and adult food allergies and report recent advances in potential treatments for food allergy. RECENT FINDINGS The most common childhood food allergies are typically outgrown by adolescence or adulthood. However, peanut/tree nut allergies appear to more commonly persist into adulthood. Adults can develop new IgE-mediated food allergies; the most common is oral allergy syndrome. There are multiple different approaches being tried as possible treatments for food allergy. The prevalence of food allergy appears to be increasing but the varied approaches to treatment are being actively pursued such that an approved modality may not be too far in the future.
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244
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Anvari S, Anagnostou K. The Nuts and Bolts of Food Immunotherapy: The Future of Food Allergy. CHILDREN-BASEL 2018; 5:children5040047. [PMID: 29617351 PMCID: PMC5920393 DOI: 10.3390/children5040047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 11/16/2022]
Abstract
Food allergies are on the rise and have a major impact on the quality of life of the food allergic child and their family. Currently, the mainstream treatment for food allergies is strict avoidance and elimination of the allergenic food(s) from the patient's diet in order to prevent an allergic reaction. However, recent advances in research have presented new therapeutic options for food allergic patients that are potentially becoming promising alternatives to traditional treatment. Food immunotherapy is the most popular of these new emerging interventions and has been studied intensively over the last decade for various foods. In this review, we discuss this exciting new development that is aspiring to become part of the mainstream therapy for food allergy.
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Affiliation(s)
- Sara Anvari
- Department of Pediatrics, Section of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, TX 77030, USA.
- Department of Pediatrics, Section of Immunology, Allergy and Rheumatology, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Katherine Anagnostou
- Department of Pediatrics, Section of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, TX 77030, USA.
- Department of Pediatrics, Section of Immunology, Allergy and Rheumatology, Baylor College of Medicine, Houston, TX 77030, USA.
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245
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Pajno GB, Fernandez-Rivas M, Arasi S, Roberts G, Akdis CA, Alvaro-Lozano M, Beyer K, Bindslev-Jensen C, Burks W, Ebisawa M, Eigenmann P, Knol E, Nadeau KC, Poulsen LK, van Ree R, Santos AF, du Toit G, Dhami S, Nurmatov U, Boloh Y, Makela M, O'Mahony L, Papadopoulos N, Sackesen C, Agache I, Angier E, Halken S, Jutel M, Lau S, Pfaar O, Ryan D, Sturm G, Varga EM, van Wijk RG, Sheikh A, Muraro A. EAACI Guidelines on allergen immunotherapy: IgE-mediated food allergy. Allergy 2018; 73:799-815. [PMID: 29205393 DOI: 10.1111/all.13319] [Citation(s) in RCA: 351] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2017] [Indexed: 02/05/2023]
Abstract
Food allergy can result in considerable morbidity, impairment of quality of life, and healthcare expenditure. There is therefore interest in novel strategies for its treatment, particularly food allergen immunotherapy (FA-AIT) through the oral (OIT), sublingual (SLIT), or epicutaneous (EPIT) routes. This Guideline, prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Task Force on Allergen Immunotherapy for IgE-mediated Food Allergy, aims to provide evidence-based recommendations for active treatment of IgE-mediated food allergy with FA-AIT. Immunotherapy relies on the delivery of gradually increasing doses of specific allergen to increase the threshold of reaction while on therapy (also known as desensitization) and ultimately to achieve post-discontinuation effectiveness (also known as tolerance or sustained unresponsiveness). Oral FA-AIT has most frequently been assessed: here, the allergen is either immediately swallowed (OIT) or held under the tongue for a period of time (SLIT). Overall, trials have found substantial benefit for patients undergoing either OIT or SLIT with respect to efficacy during treatment, particularly for cow's milk, hen's egg, and peanut allergies. A benefit post-discontinuation is also suggested, but not confirmed. Adverse events during FA-AIT have been frequently reported, but few subjects discontinue FA-AIT as a result of these. Taking into account the current evidence, FA-AIT should only be performed in research centers or in clinical centers with an extensive experience in FA-AIT. Patients and their families should be provided with information about the use of FA-AIT for IgE-mediated food allergy to allow them to make an informed decision about the therapy.
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246
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Abstract
Advances in food allergy diagnosis, management, prevention, and therapeutic interventions have been significant over the past 2 decades. Evidence-based national and international guidelines have streamlined food allergy diagnosis and management, whereas paradigm-shifting work in primary prevention of peanut allergy has resulted in significant modifications in the approach to early food introduction in infants and toddlers. Innovative investigation of food allergy epidemiology, systems biology, effect, and management has provided important insights. Although active therapeutic approaches to food allergy remain experimental, progress toward licensed therapies has been substantial. Mechanistic understanding of the immunologic processes underlying food allergy and immunotherapy will inform the future design of therapeutic approaches targeting the food-induced allergic response. Global strategies to mitigate the substantial medical, economic, and psychosocial burden of food allergy in affected subjects and families will require engagement of stakeholders across multiple sectors in research, health care, public health, government, educational institutions, and industry. However, the relationship between the well-informed allergy care provider and the patient and family remains fundamental for optimizing the care of the patient with food allergy.
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Affiliation(s)
- Amy M Scurlock
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Stacie M Jones
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark.
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247
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Rachid R, Keet CA. Current Status and Unanswered Questions for Food Allergy Treatments. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:377-382. [DOI: 10.1016/j.jaip.2017.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/10/2017] [Accepted: 10/16/2017] [Indexed: 01/19/2023]
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248
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Chen M, Welch M, Laubach S. Preventing Peanut Allergy. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2018; 31:2-8. [PMID: 29588872 DOI: 10.1089/ped.2017.0826] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/04/2017] [Indexed: 12/21/2022]
Abstract
The rising prevalence of food allergy and specifically peanut allergy has had significant implications for affected patients, families, and society. The current standard of care remains strict avoidance and the use of emergency medications for accidental ingestions. There is recent evidence-based information to suggest that one approach to preventing peanut allergy lies in early introduction of peanut. This represents a paradigm shift from previous recommendations and has led to updated guidelines in the United States, Europe, and Australasia on the introduction of potentially allergenic foods in the infant diet. This new approach to prevention has some practical obstacles and challenges associated with its implementation. There is also growing interest in the role of maintaining a healthy skin barrier in prevention of sensitization and food allergy. Other approaches, including pro- and prebiotics, prenatal maternal dietary avoidance, breastfeeding, and the use of specific formulas, have not shown reproducibly favorable results. As children with peanut allergy are unlikely to outgrow their food allergy, early oral immunotherapy in those with established peanut allergy is being investigated with the hopes of altering the natural history of an otherwise lifelong disease.
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Affiliation(s)
- Meng Chen
- Department of Medicine, University of California, San Diego, San Diego, California
| | - Michael Welch
- Division of Allergy, Immunology, and Rheumatology, Rady Children's Hospital, San Diego, California.,Allergy & Asthma Medical Group & Research Center, San Diego, California
| | - Susan Laubach
- Department of Pediatrics, University of California, San Diego, San Diego, California.,Division of Allergy, Immunology, and Rheumatology, Rady Children's Hospital, San Diego, California.,Allergy & Asthma Medical Group & Research Center, San Diego, California
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249
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Sampath V, Sindher SB, Zhang W, Nadeau KC. New treatment directions in food allergy. Ann Allergy Asthma Immunol 2018; 120:254-262. [PMID: 29508712 PMCID: PMC5978756 DOI: 10.1016/j.anai.2018.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/03/2018] [Accepted: 01/04/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Vanitha Sampath
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, California; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, California; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California
| | - Wenming Zhang
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, California; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, California; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California; Division of Allergy, Immunology and Rheumatology, Department of Medicine, Stanford University, Stanford, California.
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250
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Abstract
PURPOSE OF REVIEW The goal of this review is to provide the reader with an updated summary of published trial data regarding the use of oral immunotherapy (OIT), sublingual immunotherapy (SLIT), and epicutaneous immunotherapy (EPIT) for treatment of IgE-mediated food allergies. RECENT FINDINGS Data from phase 2 trials for treatment of peanut allergy with OIT and EPIT reveal an increase in the threshold of reactivity for peanut-allergic children. Compared to EPIT, OIT promotes a greater increase in the threshold of reactivity; however, adverse events are more common with OIT. OIT, EPIT, and SLIT appear to modulate the immune response for some food-allergic individuals. Data regarding utility for treatment of food allergies regardless of modality is limited to few foods, as is investigation into treatment of food-allergic infants, young children, and adults. Future trials are likely to focus on young children, food allergies other than peanut, and treatment of multifood-allergic individuals.
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