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Trendelenburg V, Dölle-Bierke S, Unterleider N, Alexiou A, Kalb B, Meixner L, Heller S, Lau S, Lee YA, Fauchère F, Braun J, Babina M, Altrichter S, Birkner T, Roll S, Dobbertin-Welsch J, Worm M, Beyer K. Tolerance induction through non-avoidance to prevent persistent food allergy (TINA) in children and adults with peanut or tree nut allergy: rationale, study design and methods of a randomized controlled trial and observational cohort study. Trials 2022; 23:236. [PMID: 35346330 PMCID: PMC8962184 DOI: 10.1186/s13063-022-06149-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Peanuts (PN) and tree nuts (TN) are among the most frequent elicitors of food allergy and can lead to life-threatening reactions. The current advice for allergic patients is to strictly avoid the offending food independently of their individual threshold level, whereas sensitized patients without allergic symptoms should frequently consume the food to avoid (re-)development of food allergy. The aim of this trial is to investigate (I) whether the consumption of low allergen amounts below the individual threshold may support natural tolerance development and (II) to what extent regular allergen consumption in sensitized but tolerant subjects prevents the (re-)development of PN or TN allergy. METHODS The TINA trial consisting of (part I) a randomized, controlled, open, parallel group, single-center, superiority trial (RCT), and (part II) a prospective observational exploratory cohort study. Children and adults (age 1-67 years) with suspected or known primary PN and/or TN allergy will undergo an oral food challenge (OFC) to determine their clinical reactivity and individual threshold. In the RCT, 120 PN or TN allergic patients who tolerate ≥100 mg of food protein will be randomized (1:1 ratio) to consumption of products with low amounts of PN or TN on a regular basis or strict avoidance for 1 year. The consumption group will start with 1/100 of their individual threshold, increasing the protein amount to 1/50 and 1/10 after 4 and 8 months, respectively. The primary endpoint is the clinical tolerance to PN or TN after 1 year assessed by OFC. In the cohort study, 120 subjects sensitized to PN and/or TN but tolerant are advised to regularly consume the food and observed for 1 year. The primary endpoint is the maintenance of clinical tolerance to PN and/or TN after 1 year assessed by challenging with the former tolerated cumulative dose. DISCUSSION This clinical trial will help to determine the impact of allergen consumption versus avoidance on natural tolerance development and whether the current dietary advice for PN or TN allergic patients with higher threshold levels is still valid. TRIAL REGISTRATION German Clinical Trials Register; ID: DRKS00016764 (RCT), DRKS00020467 (cohort study). Registered on 15 January 2020, http://www.drks.de .
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Affiliation(s)
- Valérie Trendelenburg
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburgplatz 1, 13353, Berlin, Germany
| | - Sabine Dölle-Bierke
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany
| | - Nathalie Unterleider
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburgplatz 1, 13353, Berlin, Germany
| | - Aikaterina Alexiou
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany
| | - Birgit Kalb
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburgplatz 1, 13353, Berlin, Germany
| | - Lara Meixner
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburgplatz 1, 13353, Berlin, Germany
| | - Stephanie Heller
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburgplatz 1, 13353, Berlin, Germany
| | - Susanne Lau
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburgplatz 1, 13353, Berlin, Germany
| | - Young- Ae Lee
- Max Delbrück Center For Molecular Medicine in the Helmholtz Association, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Florent Fauchère
- Si-M / "Der Simulierte Mensch" a science framework of Technische Universität Berlin and Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, (BCRT), Germany
| | - Julian Braun
- Si-M / "Der Simulierte Mensch" a science framework of Technische Universität Berlin and Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, (BCRT), Germany
| | - Magda Babina
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany
| | - Sabine Altrichter
- Division of Dermatological Allergy, Department of Dermatology, Venerology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Universitätsklinikum für Dermatologie und Venerologie, Kepler Uniklinikum, Linz, Austria
| | - Till Birkner
- Experimental and Clinical Research Center, a cooperation between the Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association and the Charité - Universitätsmedizin, Berlin, Germany.,Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Experimental and Clinical Research Center, Lindenberger Weg 80, 13125, Berlin, Germany
| | - Stephanie Roll
- Institute for Epidemiology, Social Medicine and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Josefine Dobbertin-Welsch
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburgplatz 1, 13353, Berlin, Germany
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany
| | - Kirsten Beyer
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburgplatz 1, 13353, Berlin, Germany.
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Perrett KP, Sindher SB, Begin P, Shanks J, Elizur A. Advances, Practical Implementation, and Unmet Needs Regarding Oral Immunotherapy for Food Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:19-33. [PMID: 34785391 DOI: 10.1016/j.jaip.2021.10.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/07/2021] [Accepted: 10/25/2021] [Indexed: 06/13/2023]
Abstract
Treatment of food allergy is a rapidly changing landscape, with arguably, the most significant advancement in recent years, the transition of oral immunotherapy (OIT) to clinical practice. As an innovation, OIT is a phase of rapidly increasing demand, particularly for some allergens such as peanut, egg, and milk, which have substantial evidence of efficacy. However, significant questions remain about how to best treat multiple food allergies and less common food allergies and how to optimize long-term safety and efficacy. This review summarizes the currently available resources for integrating food allergy OIT into clinical practice and focuses on the multiple remaining unmet needs such as providing an approach for OIT to food allergens for which there is no or limited evidence; practical issues related to food allergy treatment particularly when it is not going well; long-term outcomes and follow-up after OIT; and strategies to help meet the impending increase in demand.
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Affiliation(s)
- Kirsten P Perrett
- Population Allergy, Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia.
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, California; Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford, California
| | - Philippe Begin
- Division of Allergy, Immunology and Rheumatology, CHU Sainte-Justine, Montréal, Canada
| | - Josiah Shanks
- Population Allergy, Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Be'er Ya'akov, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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3
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Graham F, Mack DP, Bégin P. Practical challenges in oral immunotherapy resolved through patient-centered care. Allergy Asthma Clin Immunol 2021; 17:31. [PMID: 33736692 PMCID: PMC7971360 DOI: 10.1186/s13223-021-00533-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/24/2021] [Indexed: 12/14/2022] Open
Abstract
Oral immunotherapy (OIT) is now widely recognized as a valid option for the management of IgE-mediated food allergies. However, in real-life practice, OIT can lead to a variety of unique situations where the best course of action is undetermined. In patient-centered care, individual patient preferences, needs and values, should guide all clinical decisions. This can be achieved by using shared-decision making and treatment customization to navigate areas of uncertainty in a way that is responsive to patient’s needs and preferences. However, in the context of OIT, lack of awareness of potential protocol adaptability or alternatives can become a barrier to treatment personalization. The purpose of this article is to review the theoretical bases of patient-centered care and shared decision-making and their practical implication for the patient-centered delivery of OIT. Clinical cases highlighting common challenges in real-life OIT practice are presented along with a discussion of potential personalized management options to be considered. While the practice of OIT is bound to evolve as additional scientific and experiential knowledge is gained, it should always remain rooted in the general principles of patient-centered care.
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Affiliation(s)
- François Graham
- Allergy and Immunology, Centre Hospitalier de L'Université de Montréal, Hôpital Notre-Dame, Montreal, QC, Canada.,Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, 3175 Chemin de la Cote Sainte-Catherine, Montréal, QC, H3T1C5, Canada
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Philippe Bégin
- Allergy and Immunology, Centre Hospitalier de L'Université de Montréal, Hôpital Notre-Dame, Montreal, QC, Canada. .,Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, 3175 Chemin de la Cote Sainte-Catherine, Montréal, QC, H3T1C5, Canada.
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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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