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Li JC, Rotter NS, Stieb ES, Stockbridge JL, Theodorakakis MD, Shreffler WG. Utility of food allergy thresholds. Ann Allergy Asthma Immunol 2024; 132:321-327. [PMID: 38114041 DOI: 10.1016/j.anai.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/05/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023]
Abstract
Food allergy is a prevalent disease worldwide that is a significant quality-of-life burden, and accidental exposures to food allergens may elicit severe, life-threatening reactions such as anaphylaxis. The threshold level, or the dose that triggers an allergic reaction determined by oral food challenges, varies considerably among individuals suffering from food allergies. Moreover, IgE concentration, diversity, or function can only partially explain this variation in threshold; pathogenic effector TH2 cells have also been found to contribute to the eliciting dose. Though very sensitive to cofactors such as physical activity/stress, the threshold is a stable and reproducible feature of an individual's allergy over periods of many months, made clear in the past several years from treatment studies in which repeated threshold determination has been used as a treatment outcome; however, there also seem to be age-related changes at a population level. More routine determination of food allergy thresholds may help patients stratify risk to improve the management of their food allergy. Precautionary allergen labeling, such as "may contain" labels, often causes confusion since they are inconsistent and regularly contain little to trace allergen residues; thus, food products with such labeling may be unnecessarily avoided. Population-based eliciting dose levels have been determined in the literature; patients at lower risk with higher thresholds may be more confident with introducing foods with precautionary allergen labels. Understanding a patient's threshold level could aid in shared decision-making to determine the most suitable treatment options for patients, including the starting dose for oral immunotherapy and/or the use of biologics.
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Affiliation(s)
- Jennifer C Li
- Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nancy S Rotter
- Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Elisabeth S Stieb
- Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer L Stockbridge
- Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts
| | - Maria D Theodorakakis
- Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Wayne G Shreffler
- Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts.
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2
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Nachshon L, Westerhout J, Blom WM, Remington B, Levy MB, Goldberg MR, Epstein-Rigbi N, Katz Y, Elizur A. Sesame eliciting and safe doses in a large sesame allergic population. Allergy 2023; 78:3212-3220. [PMID: 37606275 DOI: 10.1111/all.15863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/02/2023] [Accepted: 07/10/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Sesame is a significant food allergen causing severe and even fatal reactions. Given its increasing prevalence in western diet, sesame is listed as an allergenic food requiring labeling in the United States and EU. However, data on the population reaction doses to sesame are limited. METHODS All sesame oral food challenges (OFCs), performed either for diagnosis or for threshold identification before the beginning of sesame oral immunotherapy (OIT) between November 2011 and July 2021 in Shamir medical center were analyzed for reaction threshold distribution. Safe-dose challenges with 90-120 min intervals were also analyzed. RESULTS Two hundred and fifty patients underwent 338 positive OFCs, and additional 158 safe-dose OFCs were performed. The discrete and cumulative protein amounts estimated to elicit an objective reaction in 1% (ED01) of the entire cohort (n = 250) were 0.8 mg (range 0.3-6.3) and 0.7 mg (range 0.1-7.1), respectively, and those for 5% of the population (ED05) were 3.4 mg (range 1.2-20.6) and 4.5 mg (range 1.2-28.8), respectively. Safe-dose OFCs showed similar values of ED01 (0.8, 0.4-7.5 mg) and ED05 (3.4, 1.2-22.9 mg). While doses of ≤1 mg sesame protein elicited oral pruritus in 11.6% of the patients, no objective reaction was documented to this amount in any of the challenges, including safe-dose OFCs. CONCLUSIONS This study provides data on sesame reaction threshold distribution in the largest population of allergic patients studied, with no right or left censored data, and with validation using a safe-dose OFC. It further supports the current methods for ED determination as appropriate for establishing safety precautions for the food industry.
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Affiliation(s)
- Liat Nachshon
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Be'er Ya'akov, Israel
- Department of Medicine, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joost Westerhout
- The Netherlands Organization for Applied Scientific Research TNO, Utrecht, The Netherlands
| | - W Marty Blom
- The Netherlands Organization for Applied Scientific Research TNO, Utrecht, The Netherlands
| | - Benjamin Remington
- Food Allergy Research and Resource Program, Department of Food Science and Technology, University of Nebraska, Lincoln, Nebraska, USA
| | - Michael B Levy
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Be'er Ya'akov, Israel
| | - Michael R Goldberg
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Be'er Ya'akov, Israel
- Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Epstein-Rigbi
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Be'er Ya'akov, Israel
- Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yitzhak Katz
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Be'er Ya'akov, Israel
- Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Be'er Ya'akov, Israel
- Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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3
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Bartha I, Rodríguez Del Río P. Clinical outcomes of efficacy in food allergen immunotherapy trials. Curr Opin Allergy Clin Immunol 2023; 23:239-245. [PMID: 37185829 DOI: 10.1097/aci.0000000000000905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
PURPOSE OF REVIEW With food allergy affecting millions of children worldwide, the consolidation of food allergen immunotherapy represents an encouraging therapeutic option, that might expand in the next few years to reach greater number of candidates. This review aims at providing a critical overview of the efficacy outcomes employed in food allergen immunotherapy trials (AIT). RECENT FINDINGS Understanding efficacy endpoints rely on identifying what and how these are being measured. Desensitization, as the efficacy of the therapy to increase the patient's reactivity threshold to the food during therapy, and Sustained Unresponsiveness, withholding such efficacy even if the therapy is withdrawn, are nowadays considered the main parameters of efficacy evaluation. Quality of life is a promising variable to capture food AIT impact from the patient's perspective.There is a relevant degree of heterogeneity across studies in outcomes definitions and also in oral food challenges design, the tool that is more spread to assess results, hampering study comparison. SUMMARY Interpreting the results of a clinical trial, and comparing data from different studies is an important task, both for the researcher and the clinician, that should be done after a careful analysis of the outcomes and the evaluation tools used.
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Affiliation(s)
- Irene Bartha
- Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Pablo Rodríguez Del Río
- Allergy Department, Hospital Infantil Universitario Niño Jesús
- FibHNJ, ARADyAL-RETICs RD16/RD16/0006/0026 Instituto de Salud Carlos III
- IIS La Princesa, Madrid, Spain
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4
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Patel N, Shreffler WG, Custovic A, Santos AF. Will Oral Food Challenges Still Be Part of Allergy Care in 10 Years' Time? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:988-996. [PMID: 36822320 PMCID: PMC10698627 DOI: 10.1016/j.jaip.2023.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/05/2023] [Accepted: 02/05/2023] [Indexed: 02/24/2023]
Abstract
Oral food challenges (OFCs) are currently the definitive diagnostic procedure in food allergy. Their design has evolved over the decades to maximize safety, optimize convenience, and address several specific clinical questions. However, they are a resource-intensive investigation that carry a risk for severe allergic reaction in which fatal outcomes, although rare, have been reported. In this review, we explore the many roles that OFC fulfil in the clinical and research settings. We also discuss progress that has been made in developing alternative diagnostic tools and how far these have reached in offering a viable replacement to OFC in clinical practice. Finally, we discuss the ongoing importance of research OFC to improve the future diagnostic capabilities of novel diagnostic tools.
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Affiliation(s)
- Nandinee Patel
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Wayne G Shreffler
- Food Allergy Center and Center for Immunology and Inflammatory Disease, Massachusetts General Hospital/Harvard Medical School, Boston, Mass
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London, Guy's and St Thomas' Hospital, London, United Kingdom.
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5
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Klueber J, Czolk R, Codreanu-Morel F, Montamat G, Revets D, Konstantinou M, Cosma A, Hunewald O, Skov PS, Ammerlaan W, Hilger C, Bindslev-Jensen C, Ollert M, Kuehn A. High-dimensional immune profiles correlate with phenotypes of peanut allergy during food-allergic reactions. Allergy 2022; 78:1020-1035. [PMID: 35700055 DOI: 10.1111/all.15408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Food challenges carry a burden of safety, effort and resources. Clinical reactivity and presentation, such as thresholds and symptoms, are considered challenging to predict ex vivo. AIMS To identify changes of peripheral immune signatures during oral food challenges (OFC) that correlate with the clinical outcome in patients with peanut allergy (PA). METHODS Children with a positive (OFC+ , n = 16) or a negative (OFC- , n = 10) OFC-outcome were included (controls, n = 7). Single-cell mass cytometry/unsupervised analysis allowed unbiased immunophenotyping during OFC. RESULTS Peripheral immune profiles correlated with OFC outcome. OFC+ -profiles revealed mainly decreased Th2 cells, memory Treg and activated NK cells, which had an increased homing marker expression signifying immune cell migration into effector tissues along with symptom onset. OFC- -profiles had also signs of ongoing inflammation, but with a signature of a controlled response, lacking homing marker expression and featuring a concomitant increase of Th2-shifted CD4+ T cells and Treg cells. Low versus high threshold reactivity-groups had differential frequencies of intermediate monocytes and myeloid dendritic cells at baseline. Low threshold was associated with increased CD8+ T cells and reduced memory cells (central memory [CM] CD4+ [Th2] T cells, CM CD8+ T cells, Treg). Immune signatures also discriminated patients with preferential skin versus gastrointestinal symptoms, whereby skin signs correlated with increased expression of CCR4, a molecule enabling skin trafficking, on various immune cell types. CONCLUSION We showed that peripheral immune signatures reflected dynamics of clinical outcome during OFC with peanut. Those immune alterations hold promise as a basis for predictive OFC biomarker discovery to monitor disease outcome and therapy of PA.
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Affiliation(s)
- Julia Klueber
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg.,Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense C, Denmark
| | - Rebecca Czolk
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg.,Faculty of Science, Technology and Medicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Françoise Codreanu-Morel
- Department of Allergology and Immunology, Centre Hospitalier de Luxembourg-Kanner Klinik, Luxembourg, Luxembourg
| | - Guillem Montamat
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg.,Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense C, Denmark
| | - Dominique Revets
- National Cytometry Platform, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Maria Konstantinou
- National Cytometry Platform, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Antonio Cosma
- National Cytometry Platform, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Oliver Hunewald
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
| | - Per Stahl Skov
- RefLab ApS, Copenhagen, Denmark.,Institute of Immunology, National University of Copenhagen, Copenhagen, Denmark
| | - Wim Ammerlaan
- Integrated BioBank of Luxembourg, Luxembourg Institute of Health, Dudelange, Luxembourg
| | - Christiane Hilger
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense C, Denmark
| | - Markus Ollert
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg.,Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense C, Denmark
| | - Annette Kuehn
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
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6
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Blümchen K, Fischl A, Eiwegger T, Hamelmann E, Klimek L, Lange L, Szepfalusi Z, Vogelberg C, Beyer K. White Paper Erdnussallergie - Teil 4: Management und Therapie der Erdnussallergie. ALLERGO JOURNAL 2022. [DOI: 10.1007/s15007-022-5005-z] [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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7
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Dobbertin-Welsch J, Staudacher O, Yürek S, Trendelenburg V, Tschirner S, Ziegert M, Ahrens F, Millner-Uhlemann M, Büsing S, Striegel A, Ott H, Arens A, Gappa M, Lange L, Gernert S, Niggemann B, Beyer K. Organ-specific symptom patterns during oral food challenge in children with peanut and tree nut allergy. Pediatr Allergy Immunol 2022; 33:e13778. [PMID: 35616889 DOI: 10.1111/pai.13778] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 03/30/2022] [Accepted: 04/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Peanut and tree nut allergies are common in childhood and often severe in nature. The clinical picture shows a wide variety of symptoms. OBJECTIVE To analyze the distribution of clinical symptoms and severity during oral food challenges (OFC) in children. METHODS Analysis of 1.013 prospectively recorded, positive OFCs with peanut (n = 607), hazelnut (n = 266), walnut (n = 97), and cashew (n = 43). Symptoms were categorized as immediate-type skin, gastrointestinal, upper and lower respiratory, cardiovascular symptoms, and eczema exacerbation. Symptom severity and treatment were recorded. RESULTS Skin symptoms presented in 78%, followed by gastrointestinal (47%), upper (42%), and lower respiratory symptoms (32%). Cardiovascular symptoms presented in 6%. In three-quarter of the reactions, more than one organ was involved. Importantly, severe reactions occurred at every dose level. Peanut- and cashew-allergic patients had a higher relative risk of gastrointestinal symptoms compared with hazelnut- and walnut-allergic patients. Patients without vomiting had a 1.7 times higher risk developing immediate-type skin and/or lower respiratory symptoms. Three-quarter of the patients ever had eczema but worsening presented in only 10.5% of the OFCs. In patients with multiple food allergies, organs involved, eliciting dose and severity differed between allergens. CONCLUSION Although comparisons between allergen groups with different clinical history, severity, comorbidities and laboratory data are difficult and might contain bias, our data confirm the high allergenic potential of peanut and tree nuts. The rare occurrence of eczema worsening emphasizes that avoidance diets of peanuts and tree nuts to cure eczema seem to be unnecessary and may hamper tolerance maintenance.
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Affiliation(s)
- Josefine Dobbertin-Welsch
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Olga Staudacher
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany.,Department of Immunology, Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Songül Yürek
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Valérie Trendelenburg
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Sebastian Tschirner
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
| | - Mandy Ziegert
- Department of Pediatric Allergology, German Red Cross Clinic Westend, Berlin, Germany
| | | | | | | | - Anne Striegel
- Children's Hospital, University of Cologne, Cologne, Germany
| | - Hagen Ott
- Division of Pediatric Dermatology and Allergology, Children's Hospital Auf der Bult, Hannover, Germany
| | - Alisa Arens
- Division of Pediatric Dermatology and Allergology, Children's Hospital Auf der Bult, Hannover, Germany
| | - Monica Gappa
- Children's Hospital, Evangelisches Krankenhaus Düsseldorf, Formerly Marien hospital Wesel, Wesel, Germany
| | - Lars Lange
- Department for Pediatrics, St. Marien-Hospital, Bonn, Germany
| | - Sunhild Gernert
- Department for Pediatrics, St. Marien-Hospital, Bonn, Germany
| | - Bodo Niggemann
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany.,Department of Pediatric Allergology, German Red Cross Clinic Westend, Berlin, Germany
| | - Kirsten Beyer
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität Berlin, Berlin, Germany
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8
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Datema MR, Lyons SA, Fernández-Rivas M, Ballmer-Weber B, Knulst AC, Asero R, Barreales L, Belohlavkova S, de Blay F, Clausen M, Dubakiene R, Fernández-Perez C, Fritsche P, Gislason D, Hoffmann-Sommergruber K, Jedrzejczak-Czechowicz M, Jongejan L, Kowalski ML, Kralimarkova TZ, Lidholm J, Papadopoulos NG, Popov TA, Del Prado N, Purohit A, Reig I, Seneviratne SL, Sinaniotis A, Vassilopoulou E, Versteeg SA, Vieths S, Welsing PMJ, Mills ENC, Le TM, Zwinderman AH, van Ree R. Estimating the Risk of Severe Peanut Allergy Using Clinical Background and IgE Sensitization Profiles. FRONTIERS IN ALLERGY 2022; 2:670789. [PMID: 35386994 PMCID: PMC8974676 DOI: 10.3389/falgy.2021.670789] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background: It is not well-understood why symptom severity varies between patients with peanut allergy (PA). Objective: To gain insight into the clinical profile of subjects with mild-to-moderate and severe PA, and investigate individual and collective predictive accuracy of clinical background and IgE to peanut extract and components for PA severity. Methods: Data on demographics, patient history and sensitization at extract and component level of 393 patients with probable PA (symptoms ≤ 2 h + IgE sensitization) from 12 EuroPrevall centers were analyzed. Univariable and penalized multivariable regression analyses were used to evaluate risk factors and biomarkers for severity. Results: Female sex, age at onset of PA, symptoms elicited by skin contact with peanut, family atopy, atopic dermatitis, house dust mite and latex allergy were independently associated with severe PA; birch pollen allergy with mild-to-moderate PA. The cross-validated AUC of all clinical background determinants combined (0.74) was significantly larger than the AUC of tests for sensitization to extract (0.63) or peanut components (0.54-0.64). Although larger skin prick test wheal size, and higher IgE to peanut extract, Ara h 1 and Ara h 2/6, were associated with severe PA, and higher IgE to Ara h 8 with mild-to-moderate PA, addition of these measurements of sensitization to the clinical background model did not significantly improve the AUC. Conclusions: Models combining clinical characteristics and IgE sensitization patterns can help establish the risk of severe reactions for peanut allergic patients, but clinical background determinants are most valuable for predicting severity of probable PA in an individual patient.
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Affiliation(s)
- Mareen R Datema
- Department of Experimental Immunology, Amsterdam University Medical Center, Amsterdam, Netherlands.,Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Sarah A Lyons
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Montserrat Fernández-Rivas
- Allergy Department, Hospital Clinico San Carlos, Instituto de Investigacion Sanitario San Carlos, Madrid, Spain
| | - Barbara Ballmer-Weber
- Allergy Unit, Department of Dermatology, University Hospital, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Clinic for Dermatology and Allergology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - André C Knulst
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Riccardo Asero
- Ambulatorio di Allergologia, Clinica San Carlo, Paderno Dugnano, Italy
| | - Laura Barreales
- Clinical Epidemiology Unit, Preventive Medicine Department, Hospital Clinico San Carlos, Instituto de Investigacion Sanitario San Carlos, Madrid, Spain
| | - Simona Belohlavkova
- Department of Allergology and Immunology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Frédéric de Blay
- Allergy Division, Chest Disease Department, Strasbourg University Hospital, Strasbourg, France
| | - Michael Clausen
- Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | | | - Cristina Fernández-Perez
- Clinical Epidemiology Unit, Preventive Medicine Department, Hospital Clinico San Carlos, Instituto de Investigacion Sanitario San Carlos, Madrid, Spain
| | - Philipp Fritsche
- Allergy Unit, Department of Dermatology, University Hospital, Zurich, Switzerland
| | - David Gislason
- Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | | | | | - Laurian Jongejan
- Department of Experimental Immunology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Marek L Kowalski
- Department of Immunology, Rheumatology and Allergy, Faculty of Medicine, Medical University of Lodz, Lodz, Poland
| | | | | | - Nikolaos G Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece.,Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - Todor A Popov
- Clinic of Occupational Diseases, University Hospital Sv. Ivan Rilski, Sofia, Bulgaria
| | - Nayade Del Prado
- Clinical Epidemiology Unit, Preventive Medicine Department, Hospital Clinico San Carlos, Instituto de Investigacion Sanitario San Carlos, Madrid, Spain
| | - Ashok Purohit
- Allergy Division, Chest Disease Department, Strasbourg University Hospital, Strasbourg, France
| | - Isabel Reig
- Allergy Department, Hospital Clinico San Carlos, Instituto de Investigacion Sanitario San Carlos, Madrid, Spain
| | - Suranjith L Seneviratne
- Institute of Immunity and Transplantation, University College London, London, United Kingdom
| | | | - Emilia Vassilopoulou
- Department of Nutritional Sciences and Dietetics, International Hellenic University, Thessaloniki, Greece
| | - Serge A Versteeg
- Department of Experimental Immunology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Stefan Vieths
- Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
| | - Paco M J Welsing
- Division of Internal Medicine and Dermatology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E N Clare Mills
- Division of Infection, Immunity and Respiratory Medicine, Manchester Institute of Biotechnology, University of Manchester, Manchester, United Kingdom
| | - Thuy-My Le
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Ronald van Ree
- Department of Experimental Immunology, Amsterdam University Medical Center, Amsterdam, Netherlands.,Department of Otorhinolaryngology, Amsterdam University Medical Center, Amsterdam, Netherlands
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9
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Álvarez García O, Bartra J, Ruiz‐Garcia M, Skypala IJ, Durham SR, Boyle RJ, Mills EC, Turner PJ. No apparent impact of incremental dosing on eliciting dose at double-blind, placebo-controlled peanut challenge. Allergy 2022; 77:667-670. [PMID: 34614236 DOI: 10.1111/all.15130] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/11/2021] [Accepted: 10/03/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Olaya Álvarez García
- National Heart & Lung Institute Imperial College London London UK
- Complexo Hospitalario Universitario de Ferrol, A Coruña Spain
| | - Joan Bartra
- National Heart & Lung Institute Imperial College London London UK
- Hospital Clínic de Barcelona Barcelona Spain
| | | | - Isabel J. Skypala
- National Heart & Lung Institute Imperial College London London UK
- Royal Brompton and Harefield Hospitals NHS Foundation Trust London UK
| | - Stephen R. Durham
- National Heart & Lung Institute Imperial College London London UK
- Royal Brompton and Harefield Hospitals NHS Foundation Trust London UK
| | - Robert J. Boyle
- National Heart & Lung Institute Imperial College London London UK
| | - E.N. Clare Mills
- Division of Infection, Immunity & Respiratory Medicine Manchester Institute of Biotechnology University of Mancheste Manchester UK
| | - Paul J. Turner
- National Heart & Lung Institute Imperial College London London UK
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10
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Blum LA, Ahrens B, Klimek L, Beyer K, Gerstlauer M, Hamelmann E, Lange L, Nemat K, Vogelberg C, Blümchen K. White Paper Erdnussallergie - Teil 2: Diagnostik der Erdnussallergie unter besonderer Berücksichtigung der molekularen Komponentendiagnostik. ALLERGO JOURNAL 2021. [DOI: 10.1007/s15007-021-4931-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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11
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Lange L, Klimek L, Beyer K, Blümchen K, Novak N, Hamelmann E, Bauer A, Merk HF, Rabe U, Jung K, Schlenter WW, Ring J, Chaker AM, Wehrmann W, Becker S, Mülleneisen NK, Nemat K, Czech W, Wrede H, Brehler R, Fuchs T, Jakob T, Ankermann T, Schmidt SM, Gerstlauer M, Zuberbier T, Spindler T, Vogelberg C. White Paper Erdnussallergie - Teil 1: Epidemiologie, Burden of Disease, gesundheitsökonomische Aspekte. ALLERGO JOURNAL 2021. [DOI: 10.1007/s15007-021-4935-1] [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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12
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Striegel AK, Beyer K, Rietschel E. [Diagnostic and therapeutic approach to anaphylaxis in childhood and adolescence]. Hautarzt 2021; 72:1003-1013. [PMID: 34652490 DOI: 10.1007/s00105-021-04894-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/28/2022]
Abstract
Anaphylaxis is a suddenly occurring potentially life-threatening systemic allergic reaction. In childhood, food allergens play a major role but insect stings and drugs are also potential triggers. The symptoms appear in minutes up to few hours on the skin, airways, gastrointestinal tract and/or the cardiovascular system. Intramuscular adrenaline is the drug of first choice due to its rapid effectiveness and its low side effect potential. A detailed patient history and the determination of potential IgE antibodies must be carried out to identify the triggers. The register for anaphylaxis has improved knowledge on epidemiology. An education in anaphylaxis is useful for every patient as well as parents and caregivers. Allergen-specific immunotherapy is currently the only causal treatment option; however, at the present time it is only available for insect bites and peanut allergy.
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Affiliation(s)
- A K Striegel
- Pädiatrische Pneumologie und Allergologie, Klinik für Kinder- und Jugendmedizin, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - K Beyer
- Klinik für Pädiatrie mit Schwerpunkt Pneumologie, Immunologie und Intensivmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - E Rietschel
- Pädiatrische Pneumologie und Allergologie, Klinik für Kinder- und Jugendmedizin, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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13
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Storage Proteins Are Driving Pediatric Hazelnut Allergy in a Lipid Transfer Protein-Rich Area. Foods 2021; 10:foods10102463. [PMID: 34681512 PMCID: PMC8535272 DOI: 10.3390/foods10102463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 01/07/2023] Open
Abstract
Oral food challenge (OFC) remains the gold standard for the diagnosis of food allergies. However, this test is not without risks, given that severe allergic reactions can be triggered while it is conducted. The purpose of this study is to identify potential demographic variables, clinical characteristics of the patients and biomarkers that may be associated with severe reactions during the hazelnut oral challenge test. The sample included 22 children allergic to hazelnut who underwent a tree nut skin prick test (SPT), specific IgE (sIgE) to hazelnut, component-resolved diagnosis (CRD) with different hazelnut allergens (Cor a 1, Cor a 8, Cor a 9, Cor a 11, Cor a 14), and a single-blind placebo-controlled challenge with hazelnut. A statistically significant relationship was found between the severity of the reaction and the highest values of sIgE to hazelnut, Cor a 11 and Cor a 14, cumulative symptom-triggering dose and sunflower seed sensitization. The use of the CRD is a useful tool to identify patients at higher risk of developing a severe reaction. In this pediatric population sample from Spain, storage proteins were confirmed to be most involved in hazelnut allergy and the development of severe reactions.
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14
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Lange L, Klimek L, Beyer K, Blümchen K, Novak N, Hamelmann E, Bauer A, Merk H, Rabe U, Jung K, Schlenter W, Ring J, Chaker A, Wehrmann W, Becker S, Mülleneisen N, Nemat K, Czech W, Wrede H, Brehler R, Fuchs T, Jakob T, Ankermann T, Schmidt SM, Gerstlauer M, Zuberbier T, Spindler T, Vogelberg C. White paper on peanut allergy - part 1: Epidemiology, burden of disease, health economic aspects. ACTA ACUST UNITED AC 2021; 30:261-269. [PMID: 34603938 PMCID: PMC8477625 DOI: 10.1007/s40629-021-00189-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/21/2021] [Indexed: 01/27/2023]
Abstract
Peanuts are Leguminosae, commonly known as the legume or pea family, and peanut allergy is among the most common food allergies and the most common cause of fatal food reactions and anaphylaxis. The prevalence of peanut allergy increased 3.5-fold over the past two decades reaching 1.4–2% in Europe and the United States. The reasons for this increase in prevalence are likely multifaceted. Sensitization via the skin appears to be associated with the development of peanut allergy and atopic eczema in infancy is associated with a high risk of developing peanut allergy. Until recently, the only possible management strategy for peanut allergy was strict allergen avoidance and emergency treatment including adrenaline auto-injector in cases of accidental exposure and reaction. This paper discusses the various factors that impact the risks of peanut allergy and the burden of self-management on peanut-allergic children and their caregivers.
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Affiliation(s)
- Lars Lange
- Department of Pediatrics, St. Marien-Hospital, GFO Clinics Bonn, Bonn, Germany
| | - Ludger Klimek
- Center for Rhinology and Allergology Wiesbaden, Wiesbaden, Germany
| | - Kirsten Beyer
- Department of Pediatrics m.S. Pneumology, Immunology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Katharina Blümchen
- Center of Pediatric and Adolescent Medicine, Focus on Allergology, Pneumology and Cystic Fibrosis, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt a. M., Germany
| | - Natalija Novak
- Clinic and Polyclinic for Dermatology and Allergology, University Hospital Bonn, Bonn, Germany
| | - Eckard Hamelmann
- Pediatric and Adolescent Medicine, Bethel Children's Center, OWL University Hospital of Bielefeld University, Bielefeld, Germany
| | - Andrea Bauer
- Clinic and Polyclinic for Dermatology, University AllergyCenter, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Hans Merk
- Department of Dermatology & Allergology, RWTH Aachen, Aachen, Germany
| | - Uta Rabe
- Clinic for Allergology, Johanniter-Krankenhaus im Fläming Treuenbrietzen GmbH, Treuenbrietzen, Germany
| | - Kirsten Jung
- Practice for Dermatology, Immunology and Allergology, Erfurt, Germany
| | | | | | - Adam Chaker
- Department of Otolaryngology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,Center for Allergy and Environment (ZAUM), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | | | - Sven Becker
- Department of Otolaryngology, University of Tübingen, Tübingen, Germany
| | | | - Katja Nemat
- Pediatric Pneumology/Allergology Practice, Kinderzentrum Dresden (Kid), Dresden, Germany
| | - Wolfgang Czech
- Practice and clinic for allergology/dermatology, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Holger Wrede
- Practice and clinic for allergology/ear, nose and throat specialist, Herford, Germany
| | - Randolf Brehler
- Clinic for Skin Diseases, Outpatient Clinic for Allergology, Occupational Dermatology and Environmental Medicine, Münster University Hospital, Münster, Germany
| | - Thomas Fuchs
- Department of Dermatology, Venereology and Allergology, University Hospital, Georg-August-University, Göttingen, Germany
| | - Thilo Jakob
- rd Clinic for Dermatology and Allergology University Hospital Giessen, UKGM Justus Liebig University Giessen, Giessen, Germany
| | - Tobias Ankermann
- th Clinic for Pediatric and Adolescent Medicine, Pneumology, Allergology, Neonatology, Intensive Care Medicine, Infectiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Sebastian M Schmidt
- th Center for Pediatric and Adolescent Medicine, Clinic and Polyclinic for Pediatric and Adolescent Medicine, Greifswald University Medical Center, Greifswald, Germany
| | - Michael Gerstlauer
- pediatric pneumologist/pediatric allergologist, II. clinic for children and adolescents, University Hospital Augsburg, Augsburg, Germany
| | - Torsten Zuberbier
- Clinic for Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Spindler
- Department of Pediatrics and Adolescent Medicine, Pediatric Pneumology, Allergology, Sports Medicine, Hochgebirgsklinik Davos, Davos-Wolfgang, Switzerland
| | - Christian Vogelberg
- TU Dresden/UKDD, Pediatric Department, University Hospital Dresden, Dresden, Germany.,Department of Pediatric Pneumology/Allergology, Clinic and Polyclinic for Pediatrics and Adolescent Medicine, University Hospital Carl Gustav Carus, Fetscher Street 74, 01307 Dresden, Germany
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15
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Striegel AK, Beyer K, Rietschel E. Diagnostisches und therapeutisches Vorgehen bei Anaphylaxie. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01264-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Turner PJ, d'Art YM, Duca B, Chastell SA, Marco-Martin G, Vera-Berrios RN, Alvarez O, Bazire R, Rodríguez Del Río P, Vazquez-Ortiz M, Baumert JL, van Ree R, Mills CEN, Fernandez-Rivas M, Hourihane JO. Single-dose oral challenges to validate eliciting doses in children with cow's milk allergy. Pediatr Allergy Immunol 2021; 32:1056-1065. [PMID: 33608940 DOI: 10.1111/pai.13482] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/28/2021] [Accepted: 02/17/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is increasing interest in the use of eliciting doses (EDs) to inform allergen risk management. The ED can be estimated from the distribution of threshold doses for allergic subjects undergoing food challenges within a specified population. Estimated ED05 values for cow's milk (the dose expected to cause objective allergic symptoms in 5% of the milk-allergic population) range from 0.5 mg to 13.9 mg cow's milk protein. We undertook a single-dose challenge study to validate a predicted ED05 for cow's milk of 0.5 mg protein. METHODS Participants were recruited from 4 clinical centres. Predetermined criteria were used to identify patients reacting to 0.5 mg cow's milk protein (approximately 0.015 mL of fresh cow's milk). Children over 1 year underwent formal challenge to cow's milk to confirm clinical reactivity. RESULTS 172 children (median age 6.0 (IQR 0.7-11) years, 57% male) were included in this analysis. Twelve (7.0%, 95% CI 3.7%-11.9%) children experienced objective symptoms that met the predetermined criteria. One participant had mild anaphylaxis that responded to a single dose of adrenaline, the remainder experienced only mild symptoms with no treatment required. We did not identify any baseline predictors of sensitization that were associated with objective reactivity to the single-dose challenge using 0.5 mg cow's milk protein. CONCLUSIONS These data support an estimated ED05 for cow's milk of 0.5 mg protein. Values for ED05 above 0.5 mg for cow's milk protein proposed for allergen risk management need to be reviewed.
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Affiliation(s)
- Paul J Turner
- Section of Inflammation, Repair and Development, National Heart & Lung Institute, Imperial College London, London, UK
| | - Yvonne M d'Art
- Paediatrics and Child Health, University College Cork, Ireland
| | - Bettina Duca
- Section of Inflammation, Repair and Development, National Heart & Lung Institute, Imperial College London, London, UK
| | - Sophia A Chastell
- Section of Inflammation, Repair and Development, National Heart & Lung Institute, Imperial College London, London, UK
| | - Guadalupe Marco-Martin
- Allergy Department, Hospital Clinico San Carlos, IdISSC, Madrid, Spain.,ARADyAL Research Network, Madrid, Spain
| | - Rosialzira N Vera-Berrios
- Allergy Department, Hospital Clinico San Carlos, IdISSC, Madrid, Spain.,ARADyAL Research Network, Madrid, Spain
| | - Olaya Alvarez
- ARADyAL Research Network, Madrid, Spain.,Department of Allergy, Hospital Infantil Universitario Niño Jesus, Madrid, Spain.,Health Research Institute Princesa, Madrid, Spain
| | - Raphaëlle Bazire
- ARADyAL Research Network, Madrid, Spain.,Department of Allergy, Hospital Infantil Universitario Niño Jesus, Madrid, Spain.,Health Research Institute Princesa, Madrid, Spain
| | - Pablo Rodríguez Del Río
- ARADyAL Research Network, Madrid, Spain.,Department of Allergy, Hospital Infantil Universitario Niño Jesus, Madrid, Spain.,Health Research Institute Princesa, Madrid, Spain
| | - Marta Vazquez-Ortiz
- Section of Inflammation, Repair and Development, National Heart & Lung Institute, Imperial College London, London, UK
| | - Joseph L Baumert
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, USA
| | - Ronald van Ree
- Department of Experimental Immunology and Department of Otorhinolaryngology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Clare E N Mills
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Montserrat Fernandez-Rivas
- Allergy Department, Hospital Clinico San Carlos, IdISSC, Madrid, Spain.,ARADyAL Research Network, Madrid, Spain
| | - Jonathan O'B Hourihane
- Paediatrics and Child Health, University College Cork, Ireland.,Paediatrics and Child Health, Royal College of Surgeons in Ireland, Children's Health Ireland, Dublin, Ireland
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17
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Sicherer SH, Abrams EM, Nowak-Wegrzyn A, Hourihane JO. Managing Food Allergy When the Patient Is Not Highly Allergic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:46-55. [PMID: 34098164 DOI: 10.1016/j.jaip.2021.05.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/12/2021] [Accepted: 05/26/2021] [Indexed: 11/30/2022]
Abstract
Few patients with food allergy are "highly allergic," meaning they always have severe reactions and always react to very small amounts of allergen. Standard medical approaches for allergy management have focused on the safety and lifestyle modifications this group truly needs, but consequently families with food allergy are typically advised to strictly avoid any exposure to their implicated allergens. Most food-allergic subjects are actually not reactive to very low doses, and many never experience severe reactions. There are also notable conditions where a different care plan is already commonly offered: patients with pollen-related food allergy syndrome, with food-associated exercise-induced anaphylaxis, and with resolving or mild milk or egg allergy might be advised to ingest the allergens in specific circumstances with detailed instructions. Because oral immunotherapy and allergy prevention by early exposure have emphasized alternatives to strict avoidance, there is increasing interest in prospects to forego strict avoidance in those with food allergy. For patients with a high threshold of reactivity (low-dose tolerant, high-dose mildly reactive), there may be options such as allowing the ingestion of products with precautionary allergen labels, allowing dietary indiscretions with small amounts of the allergen, or even encouraging ingestion of subthreshold amounts with therapeutic intent. These practices have not been extensively studied and could be considered controversial. If these approaches are considered, shared decision making is needed in discussing them with patients and families. This review considers the potential approaches to those who are "not highly allergic": the risks, benefits, shared decision making, and research needs.
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Affiliation(s)
- Scott H Sicherer
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Anna Nowak-Wegrzyn
- New York University Grossman School of Medicine, Allergy and Immunology, Hassenfeld Children's Hospital, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Jonathan O'B Hourihane
- Paediatrics and Child Health, Royal College of Surgeons in Irerland, Dublin, Ireland; Childrens Health Ireland Temple St, Dublin, Ireland
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18
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Burrell S, Patel N, Vazquez-Ortiz M, Campbell DE, DunnGalvin A, Turner PJ. Self-administration of adrenaline for anaphylaxis during in-hospital food challenges improves health-related quality of life. Arch Dis Child 2021; 106:558-563. [PMID: 32948514 PMCID: PMC8142442 DOI: 10.1136/archdischild-2020-319906] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the impact of anaphylaxis on health-related quality of life (HRQL) and self-efficacy in food-allergic patients undergoing in-hospital food challenge. DESIGN Secondary analysis of a randomised controlled trial. SETTING Specialist allergy centre. PATIENTS Peanut-allergic young people aged 8-16 years. INTERVENTIONS Double-blind, placebo-controlled food challenge to peanut, with HRQL and self-efficacy assessed using validated questionnaire, approximately 2 weeks prior to and 2 weeks after challenge. Where possible, anaphylaxis was treated with self-injected adrenaline (epinephrine). MAIN OUTCOME MEASURES Change in HRQL and self-efficacy. RESULTS 56 participants had reactions at food challenge, of whom 16 (29%) had anaphylaxis. Overall, there was an improvement in HRQL (mean 2.6 points (95% CI 0.3 to 4.8); p=0.030) and self-efficacy (mean 4.1 points (95% CI 2.4 to 5.9); p<0.0001), independent of whether anaphylaxis occurred. Parents also reported improved HRQL (mean 10.3 points (95% CI 5.9 to 14.7); p<0.0001). We found evidence of discordance between the improvement in HRQL and self-efficacy as reported by young people and that perceived by parents in their child. CONCLUSIONS Anaphylaxis at food challenge, followed by self-administration of injected adrenaline, was associated with an increase in HRQL and self-efficacy in young people with peanut allergy. We found no evidence that the occurrence of anaphylaxis had a detrimental effect. Young people should be encouraged to self-administer adrenaline using their autoinjector device to treat anaphylaxis at in-hospital challenge. TRIAL REGISTRATION NUMBER NCT02149719.
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Affiliation(s)
- Sarah Burrell
- Section of Inflammation, Repair and Development, National Heart & Lung Institute, Imperial College London, London, UK
| | - Nandinee Patel
- Section of Inflammation, Repair and Development, National Heart & Lung Institute, Imperial College London, London, UK
| | - Marta Vazquez-Ortiz
- Section of Inflammation, Repair and Development, National Heart & Lung Institute, Imperial College London, London, UK
| | - Dianne E. Campbell
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | - Audrey DunnGalvin
- School of Applied Psychology, Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Paul J. Turner
- Section of Inflammation, Repair and Development, National Heart & Lung Institute, Imperial College London, London, UK,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
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19
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Patel N, Adelman DC, Anagnostou K, Baumert JL, Blom WM, Campbell DE, Chinthrajah RS, Mills ENC, Javed B, Purington N, Remington BC, Sampson HA, Smith AD, Yarham RAR, Turner PJ. Using data from food challenges to inform management of consumers with food allergy: A systematic review with individual participant data meta-analysis. J Allergy Clin Immunol 2021; 147:2249-2262.e7. [PMID: 33571537 PMCID: PMC8168954 DOI: 10.1016/j.jaci.2021.01.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/10/2021] [Accepted: 01/27/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Eliciting doses (EDs) (eg, ED01 or ED05 values, which are the amounts of allergen expected to cause objective symptoms in 1% and 5% of the population with an allergy, respectively) are increasingly being used to inform allergen labeling and clinical management. These values are generated from food challenge, but the frequency of anaphylaxis in response to these low levels of allergen exposure and their reproducibility are unknown. OBJECTIVE Our aim was to determine (1) the rate of anaphylaxis in response to low-level peanut exposure and (2) the reproducibility of reaction thresholds (and anaphylaxis) at food challenge. METHODS We conducted a systematic review and individual participant data meta-analysis of studies that reported at least 50 individuals with peanut allergy reacting to peanut at double-blind, placebo-controlled food challenge (DBPCFC) and were published between January 2010 and September 2020. Risk of bias was assessed by using National Institute for Clinical Excellence methodologic checklists. RESULTS A total of 19 studies were included (covering a total of 3151 participants, 534 of whom subsequently underwent further peanut challenge). At individual participant data meta-analysis, 4.5% (95% CI, 1.9% to 10.1%) of individuals reacted to 5 mg or less of peanut protein with anaphylaxis (moderate heterogeneity [I2 = 57%]). Intraindividual thresholds varied by up to 3 logs, although this variation was limited to a half-log change in 71.2% (95% CI, 56.2% to 82.6%) of individuals. In all, 2.4% (95% CI, 1.1% to 5.0%) of patients initially tolerated 5 mg of peanut protein but then reacted to this dose at subsequent challenge (low heterogeneity [I2 = 16%]); none developed anaphylaxis. CONCLUSION Around 5% of individuals reacting to an ED01 or ED05 level of exposure to peanut might develop anaphylaxis in response to that dose. This equates to 1 and 6 anaphylaxis events per 2500 patients exposed to an ED01 or ED05 dose, respectively, in the broader population of individuals with peanut allergy.
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Affiliation(s)
- Nandinee Patel
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Katherine Anagnostou
- Section of Allergy and Immunology, Baylor College of Medicine, Houston, Tex; Section of Allergy and Immunology, Department of Pediatrics, Texas Children's Hospital, Houston, Tex
| | - Joseph L Baumert
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, Neb
| | - W Marty Blom
- The Netherlands Organisation of Applied Scientific Research, Utrecht, The Netherlands
| | - Dianne E Campbell
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Sydney, Australia; DBV Technologies, Montrouge, France
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research, Stanford, Calif; Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, Stanford, Calif
| | - E N Clare Mills
- Division of Infection, Immunity and Respiratory Medicine, Manchester Institute of Biotechnology, University of Manchester, Manchester, United Kingdom
| | - Bushra Javed
- Division of Infection, Immunity and Respiratory Medicine, Manchester Institute of Biotechnology, University of Manchester, Manchester, United Kingdom
| | - Natasha Purington
- Department of Medicine, Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, Calif
| | - Benjamin C Remington
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, Neb
| | - Hugh A Sampson
- DBV Technologies, Montrouge, France; Division of Pediatric Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Paul J Turner
- National Heart and Lung Institute, Imperial College London, London, United Kingdom.
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20
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Turner PJ, Ruiz‐Garcia M, Patel N, Abrantes G, Burrell S, Vazquez‐Ortiz M, Skypala I, Durham SR, Boyle RJ. Delayed symptoms and orthostatic intolerance following peanut challenge. Clin Exp Allergy 2021; 51:696-702. [DOI: 10.1111/cea.13865] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/21/2021] [Accepted: 03/04/2021] [Indexed: 01/27/2023]
Affiliation(s)
- Paul J. Turner
- National Heart & Lung Institute Imperial College London London UK
| | | | - Nandinee Patel
- National Heart & Lung Institute Imperial College London London UK
| | - Gonçalo Abrantes
- National Heart & Lung Institute Imperial College London London UK
| | - Sarah Burrell
- National Heart & Lung Institute Imperial College London London UK
| | | | - Isabel Skypala
- Royal Brompton and Harefield Hospitals NHS Foundation Trust London UK
| | - Stephen R. Durham
- National Heart & Lung Institute Imperial College London London UK
- Royal Brompton and Harefield Hospitals NHS Foundation Trust London UK
| | - Robert J. Boyle
- National Heart & Lung Institute Imperial College London London UK
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21
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Haber LT, Reichard JF, Henning AK, Dawson P, Chinthrajah RS, Sindher SB, Long A, Vincent MJ, Nadeau KC, Allen BC. Bayesian hierarchical evaluation of dose-response for peanut allergy in clinical trial screening. Food Chem Toxicol 2021; 151:112125. [PMID: 33722597 DOI: 10.1016/j.fct.2021.112125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/24/2021] [Accepted: 03/09/2021] [Indexed: 01/01/2023]
Abstract
Risk-based labeling based on the minimal eliciting doses (EDs) in sensitized populations is a potential replacement for precautionary allergen labeling of food allergens. We estimated the dose-response distribution for peanut allergen using data from double-blind placebo-controlled food challenges (DBPCFCs) conducted in the US at multiple sites, testing a population believed to be similar to the general U.S. food allergic population. Our final (placebo-adjusted) dataset included 548 challenges of 481 subjects. Bayesian hierarchical analysis facilitated model fitting, and accounted for variability associated with various levels of data organization. The data are best described using a complex hierarchical structure that accounts for inter-individual variability and variability across study locations or substudies. Bayesian model averaging could simultaneously consider the fit of multiple models, but the Weibull model dominated so strongly that model averaging was not needed. The ED01 and ED05 (and 95% credible intervals) are 0.052 (0.021, 0.13) and 0.49 (0.22, 0.97) mg peanut protein, respectively. Accounting for challenges with severe reactions at the LOAEL, by using the dose prior to the LOAEL as the new LOAEL, the ED01 drops to 0.029 (0.014, 0.074) mg peanut protein. Our results could aid in establishing improved food labeling guidelines in the management of food allergies.
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Affiliation(s)
- Lynne T Haber
- University of Cincinnati, Department of Environmental and Public Health Sciences, 160 Panzeca Way, Cincinnati, OH, 45267, USA.
| | - John F Reichard
- University of Cincinnati, Department of Environmental and Public Health Sciences, 160 Panzeca Way, Cincinnati, OH, 45267, USA
| | - Alice K Henning
- The Emmes Company, LLC, 401 North Washington St., Suite 700, Rockville, MD, 20850, USA
| | - Peter Dawson
- The Emmes Company, LLC, 401 North Washington St., Suite 700, Rockville, MD, 20850, USA
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University and Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Stanford, CA, USA
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University and Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Stanford, CA, USA
| | - Andrew Long
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University and Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Stanford, CA, USA
| | - Melissa J Vincent
- University of Cincinnati, Department of Environmental and Public Health Sciences, 160 Panzeca Way, Cincinnati, OH, 45267, USA
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University and Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Stanford, CA, USA
| | - Bruce C Allen
- Independent Consultant, 101 Corbin Hill Circle, Chapel Hill, NC, 27514, USA
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Chu DK, Baumert JL, Taylor SL, Nordlee JA, Nham T, Bramson J, La Vieille S, Abbott MA, Spill P, Marrin A, Jordana M, Waserman S. Peanut allergen reaction thresholds during controlled food challenges in 2 Canadian randomized studies (Canada-ARM1 and PISCES). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2524-2526.e2. [PMID: 33607344 DOI: 10.1016/j.jaip.2021.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Derek K Chu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, & Impact, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, ON, Canada.
| | - Joseph L Baumert
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, USA
| | - Steve L Taylor
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, USA
| | - Julie A Nordlee
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, USA
| | - Tina Nham
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan Bramson
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Paul Spill
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Andrea Marrin
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Manel Jordana
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Susan Waserman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, ON, Canada.
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Ring J, Beyer K, Biedermann T, Bircher A, Fischer M, Fuchs T, Heller A, Hoffmann F, Huttegger I, Jakob T, Klimek L, Kopp MV, Kugler C, Lange L, Pfaar O, Rietschel E, Rueff F, Schnadt S, Seifert R, Stöcker B, Treudler R, Vogelberg C, Werfel T, Worm M, Sitter H, Brockow K. Guideline (S2k) on acute therapy and management of anaphylaxis: 2021 update: S2k-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Medical Association of German Allergologists (AeDA), the Society of Pediatric Allergology and Environmental Medicine (GPA), the German Academy of Allergology and Environmental Medicine (DAAU), the German Professional Association of Pediatricians (BVKJ), the Society for Neonatology and Pediatric Intensive Care (GNPI), the German Society of Dermatology (DDG), the Austrian Society for Allergology and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), the German Society of Pharmacology (DGP), the German Respiratory Society (DGP), the patient organization German Allergy and Asthma Association (DAAB), the German Working Group of Anaphylaxis Training and Education (AGATE). ALLERGO JOURNAL INTERNATIONAL 2021; 30:1-25. [PMID: 33527068 PMCID: PMC7841027 DOI: 10.1007/s40629-020-00158-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Johannes Ring
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | - Kirsten Beyer
- Department of Pediatrics, Division of Pulmonology, Immunology and Critical Care Medicine, Charité—University Hospital Berlin, Berlin, Germany
| | - Tilo Biedermann
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | - Andreas Bircher
- Department of Dermatology, University Hospital of Basel, Basel, Switzerland
| | - Matthias Fischer
- Clinic for Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, ALB FILS Hospitals Göppingen, Göppingen, Germany
| | - Thomas Fuchs
- Department of Dermatology, University Hospital Göttingen, Göttingen, Germany
| | - Axel Heller
- Department of Anesthesiology and Operative Intensive Care Medicine, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Florian Hoffmann
- Dr. von Hauner Children’s Hospital, Ludwig Maximilians University, Munich, Germany
| | - Isidor Huttegger
- Department of Pediatrics, University Hospital Salzburg, Salzburg, Austria
| | - Thilo Jakob
- Department of Dermatology and Allergology, University Medical Center Gießen (UKGM), Justus-Liebig-University Gießen, Gießen, Germany
| | - Ludger Klimek
- Center of Rhinology and Allergology, Wiesbaden, Germany
| | - Matthias V. Kopp
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudia Kugler
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | | | - Oliver Pfaar
- Section of Rhinology and Allergy, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-University Marburg, Marburg, Germany
| | - Ernst Rietschel
- Department of Pediatrics, University Hospital Cologne, Cologne, Germany
| | - Franziska Rueff
- Department of Dermatology and Allergology, Hospital of the Ludwig Maximilians University, Munich, Germany
| | - Sabine Schnadt
- German Allergy and Asthma Association, Mönchengladbach, Germany
| | - Roland Seifert
- Institute of Pharmacology, Hannover Medical School, Hannover, Germany
| | - Britta Stöcker
- Medical practice for pediatrics and youth medicine, Poppelsdorfer Allee, Bonn, Germany
| | - Regina Treudler
- Department of Dermatology, Venereology, and Allergology, Leipzig Interdisciplinary Allergy Center, University Hospital Leipzig, Leipzig, Germany
| | - Christian Vogelberg
- Department of Pediatric Pneumology and Allergology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Thomas Werfel
- Immunodermatology and Experimental Allergology Unit, Department of Dermatology, Allergology, and Venereology, Medical University Hannover, Hannover, Germany
| | - Margitta Worm
- Department of Dermatology, Venereology, and Allergology, Charité—University Hospital Berlin, Berlin, Germany
| | - Helmut Sitter
- Institute for Surgical Research, Philipps-University Marburg, Marburg, Germany
| | - Knut Brockow
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
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Two Different Composite Markers Predict Severity and Threshold Dose in Peanut Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:275-282.e1. [PMID: 33038591 DOI: 10.1016/j.jaip.2020.09.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Safe and cost-effective biological surrogate markers to evaluate the severity and threshold dose of peanut allergy (PA) reactions during an oral food challenge (OFC) are lacking. OBJECTIVE To evaluate biological markers associated with the severity and threshold dose of an allergic reaction during an OFC in a population of children with PA. METHODS Demographic and biological parameters of children with peanut OFC and basophil activation test (BAT) results were collected. Patients were stratified into 2 severity groups (mild-to-moderate and severe) and 2 cumulative threshold dose groups: low (LCTG) ≤100 mg crushed peanut and high >100 mg. RESULTS Among the 68 children included, there was a 96% concordance between the OFC and BAT result for the diagnosis of PA. Of the 56 children with a positive OFC and BAT to peanut (median age: 8.8 years), the severity of an allergic reaction and the cumulative threshold dose were not correlated (P = .24). Higher Ara h 2-specific IgE and FcεRI-positive control values were both associated with severe reactions to peanut. Combining these 2 markers led to a 92% sensitivity (84%-97%) and an 82% specificity (71%-89%) for severe reactions in all subjects. For children in the LCTG, a 4-variable composite marker, including age, normalized basophil sensitivity (EC50), and FcεRI- and fMLP-positive control values, resulted in a 97% sensitivity (89%-99%) and 61% specificity (49%-71%). CONCLUSION Distinct composite markers including BAT allergen-specific and non-allergen-specific parameters appear to be associated with severity and cumulative threshold dose in children with PA.
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Graham F, Caubet JC, Eigenmann PA. Can my child with IgE-mediated peanut allergy introduce foods labeled with "may contain traces"? Pediatr Allergy Immunol 2020; 31:601-607. [PMID: 32160355 DOI: 10.1111/pai.13244] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/16/2020] [Accepted: 02/25/2020] [Indexed: 01/19/2023]
Abstract
Peanut IgE-mediated food allergy is one of the most common food allergies in children with a prevalence that has increased in the past decades in Westernized countries. Peanut allergies can trigger severe reactions and usually persist over time. Peanut-allergic children and their families are often confronted to processed foods with precautionary allergen labeling (PAL) such as "may contain traces of peanuts," which are frequently used by the food industry. Patients are generally confused as to whether eating such foods entails a risk of allergic reaction, which can ultimately lead to dietary restrictions and decreased quality of life. Thus, guidance toward eviction of foods with PALs such as "may contain traces of peanuts" is a recurring problem that peanut-allergic patients address during pediatric allergy consultations with varying attitudes among allergists. Many studies have evaluated peanut contamination in foods with PALs, with generally less than 10% of foods containing detectable levels of peanuts, albeit heterogeneous amounts, with in rare occasions levels that could trigger allergic reactions in certain patients. The risk of reacting to foods with traces varies significantly with threshold, with patients with the lowest reaction thresholds at highest risk, and a dramatic reduction of risk as threshold increases. Thus, risk stratification based on individual reaction threshold may help stratify patients' risk of reacting to foods with PAL. In clinical practice, a single-dose 30 mg peanut protein oral food challenge may be an option to stratify peanut-allergic patients' risk when introducing foods with PAL, as illustrated by three clinical cases.
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Affiliation(s)
- François Graham
- Pediatric Allergy Unit, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland.,Department of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine and Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland
| | - Philippe A Eigenmann
- Pediatric Allergy Unit, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland
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Santos AF, Du Toit G, O'Rourke C, Becares N, Couto-Francisco N, Radulovic S, Khaleva E, Basting M, Harris KM, Larson D, Sayre P, Plaut M, Roberts G, Bahnson HT, Lack G. Biomarkers of severity and threshold of allergic reactions during oral peanut challenges. J Allergy Clin Immunol 2020; 146:344-355. [PMID: 32311390 PMCID: PMC7417812 DOI: 10.1016/j.jaci.2020.03.035] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 02/10/2020] [Accepted: 03/20/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Oral food challenge (OFC) is the criterion standard to assess peanut allergy (PA), but it involves a risk of allergic reactions of unpredictable severity. OBJECTIVE Our aim was to identify biomarkers for risk of severe reactions or low dose threshold during OFC to peanut. METHODS We assessed Learning Early about Peanut Allergy study, Persistance of Oral Tolerance to Peanut study, and Peanut Allergy Sensitization study participants by administering the basophil activation test (BAT) and the skin prick test (SPT) and measuring the levels of peanut-specific IgE, Arachis hypogaea 2-specific IgE, and peanut-specific IgG4, and we analyzed the utility of the different biomarkers in relation to PA status, severity, and threshold dose of allergic reactions to peanut during OFC. RESULTS When a previously defined optimal cutoff was used, the BAT diagnosed PA with 98% specificity and 75% sensitivity. The BAT identified severe reactions with 97% specificity and 100% sensitivity. The SPT, level of Arachis hypogaea 2-specific IgE, level of peanut-specific IgE, and IgG4/IgE ratio also had 100% sensitivity but slightly lower specificity (92%, 93%, 90%, and 88%, respectively) to predict severity. Participants with lower thresholds of reactivity had higher basophil activation to peanut in vitro. The SPT and the BAT were the best individual predictors of threshold. Multivariate models were superior to individual biomarkers and were used to generate nomograms to calculate the probability of serious adverse events during OFC for individual patients. CONCLUSIONS The BAT diagnosed PA with high specificity and identified severe reactors and low threshold with high specificity and high sensitivity. The BAT was the best biomarker for severity, surpassed only by the SPT in predicting threshold. Nomograms can help estimate the likelihood of severe reactions and reactions to a low dose of allergen in individual patients with PA.
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Affiliation(s)
- Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.
| | - George Du Toit
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Colin O'Rourke
- Immune Tolerance Network, Benaroya Research Institute, Seattle, Wash
| | - Natalia Becares
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Natália Couto-Francisco
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Suzana Radulovic
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Ekaterina Khaleva
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Monica Basting
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | | | | | - Peter Sayre
- Division of Hematology-Oncology, Department of Medicine, University of California, San Francisco, Calif
| | - Marshall Plaut
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | - Graham Roberts
- David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, Southampton, United Kingdom; National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and Clinical and Experimental Sciences Academic Unit, University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Henry T Bahnson
- Immune Tolerance Network, Benaroya Research Institute, Seattle, Wash
| | - Gideon Lack
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.
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28
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Buyuktiryaki B, Santos AF. Food allergy severity predictions based on cellular in vitro tests. Expert Rev Mol Diagn 2020; 20:679-692. [PMID: 32536279 DOI: 10.1080/14737159.2020.1782192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Food allergy is increasing in prevalence and the severity of allergic reactions is unpredictable. Identifying food-allergic patients at high risk of severe reactions would allow us to offer a personalized and improved management for these patients. AREAS COVERED We review the evidence for using the levels of specific IgE, the nature of the allergen, and cellular tests to identify patients at high risk of developing severe allergic reactions to foods. EXPERT OPINION The evidence about whether the quantity of allergen-specific IgE reflects the severity of allergic reactions to foods is conflicting, with some positive and some negative studies. For some foods, specific IgE to individual components (e.g. Ara h 2 in peanut) can provide additional information. However, more important than the quantity of IgE is possibly the quality of IgE, which can be captured by individual measurements of affinity/avidity, diversity, and specific activity, but is best measured overall using the basophil and mast cell activation tests, which assess the function of IgE in its ability to induce cell activation, degranulation, and mediator release. Biomarkers look at a single aspect of the allergic response and should be interpreted in the broader clinical context for each individual patient assessed.
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Affiliation(s)
- Betul Buyuktiryaki
- Division of Pediatric Allergy, Koc University Hospital , İstanbul, Turkey.,Department of Paediatric Allergy, Evelina London, Guy's and ST Thomas' Hospital NHS Foundation Trust , London, UK
| | - Alexandra F Santos
- Department of Paediatric Allergy, Evelina London, Guy's and ST Thomas' Hospital NHS Foundation Trust , London, UK.,Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London , London, UK.,Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London , London, UK.,Asthma UK Centre in Allergic Mechanisms of Asthma , London, UK
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29
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Venter C, Sicherer SH, Greenhawt M. Management of Peanut Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:345-355.e2. [PMID: 30717865 DOI: 10.1016/j.jaip.2018.10.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 01/14/2023]
Abstract
Peanut allergy is a growing public health concern in westernized countries. Peanut allergy is characterized as an often severe and lifelong allergy, which can have detrimental effects on quality of life and trigger anxiety. Although multiple therapeutic options are emerging, the focus of current management strategies is strict peanut avoidance and carriage of self-injectable epinephrine. The greatest risk of reacting to peanut comes from direct ingestion, whereas casual skin contact or airborne exposure is highly unlikely to provoke significant symptoms. Patients and families must be educated about how to best execute strict peanut avoidance through careful label reading as well as how to understand and address likely and unlikely risk with regard to peanut exposure in public, in particular when dining outside of the home and for children attending school or child care. This review discusses the risk of exposure in public such as at school or on an airplane and how such risk can be abated, situations and scenarios when dining out of the house that may pose more risks than others, the essentials of US and EU label reading laws with particular emphasis on precautionary labeling and the risk implied by such, quality of life and psychosocial issues that may affect the peanut allergic individual and family, and a discussion of how risk may differ and evolve based on the patient's age.
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Affiliation(s)
- Carina Venter
- Section of Allergy and Immunology, Children's Hospital Colorado, Food Challenge and Research Unit, University of Colorado School of Medicine, Aurora, Colo; The David Hide Asthma and Allergy Research Centre, Newport, Isle of Wight, United Kingdom.
| | - Scott H Sicherer
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai and the Jafee Food Allergy Institute, New York, NY
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Food Challenge and Research Unit, University of Colorado School of Medicine, Aurora, Colo
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30
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Affiliation(s)
- Alexandra F Santos
- Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London , London, UK.,Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London , London, UK.,Children's Allergy Service, Evelina London, Guy's and St Thomas' Hospital , London, UK.,Asthma UK Centre in Allergic Mechanisms of Asthma , London, UK
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31
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Trendelenburg V, Blumchen K, Bellach J, Ahrens F, Gruebl A, Hamelmann E, Hansen G, Heinzmann A, Nemat K, Holzhauser T, Röder M, Niggemann B, Beyer K. Peanut oral immunotherapy protects patients from accidental allergic reactions to peanut. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2437-2441.e3. [PMID: 32304836 DOI: 10.1016/j.jaip.2020.03.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Valérie Trendelenburg
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Katharina Blumchen
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Children and Adolescent Medicine, Division of Pneumology, Allergology and Cystic fibrosis, Goethe University, Frankfurt am Main, Germany
| | - Johanna Bellach
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Armin Gruebl
- Department of Pediatrics, Technical University Munich, Munich, Germany
| | - Eckard Hamelmann
- Children's Center Bethel, EvKB, University Bielefeld, Bielefeld, Germany
| | - Gesine Hansen
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Andrea Heinzmann
- Center for Pediatrics, Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Katja Nemat
- Department of Pediatrics, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | | | - Martin Röder
- Paul-Ehrlich-Institut, Division of Allergology, Langen, Germany; Institut für Produktqualität GmbH, Berlin, Germany
| | - Bodo Niggemann
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kirsten Beyer
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
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32
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Sugita K, Akdis CA. Recent developments and advances in atopic dermatitis and food allergy. Allergol Int 2020; 69:204-214. [PMID: 31648922 DOI: 10.1016/j.alit.2019.08.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 02/07/2023] Open
Abstract
This review highlights recent advances in atopic dermatitis (AD) and food allergy (FA), particularly on molecular mechanisms and disease endotypes, recent developments in global strategies for the management of patients, pipeline for future treatments, primary and secondary prevention and psychosocial aspects. During the recent years, there has been major advances in personalized/precision medicine linked to better understanding of disease pathophysiology and precision treatment options of AD. A greater understanding of the molecular and cellular mechanisms of AD through substantial progress in epidemiology, genetics, skin immunology and psychological aspects resulted in advancements in the precision management of AD. However, the implementation of precision medicine in the management of AD still requires the validation of reliable biomarkers, which will provide more tailored management, starting from prevention strategies towards targeted therapies for more severe diseases. Cutaneous exposure to food via defective barriers is an important route of sensitization to food allergens. Studies on the role of the skin barrier genes demonstrated their association with the development of IgE-mediated FA, and suggest novel prevention and treatment strategies for type 2 diseases in general because of their link to barrier defects not only in AD and FA, but also in asthma, chronic rhinosinusitis, allergic rhinitis and inflammatory bowel disease. The development of more accurate diagnostic tools, biomarkers for early prediction, and innovative solutions require a better understanding of molecular mechanisms and the pathophysiology of FA. Based on these developments, this review provides an overview of novel developments and advances in AD and FA, which are reported particularly during the last two years.
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33
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Remington BC, Westerhout J, Meima MY, Blom WM, Kruizinga AG, Wheeler MW, Taylor SL, Houben GF, Baumert JL. Updated population minimal eliciting dose distributions for use in risk assessment of 14 priority food allergens. Food Chem Toxicol 2020; 139:111259. [PMID: 32179163 DOI: 10.1016/j.fct.2020.111259] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 01/08/2023]
Abstract
Food allergy and allergen management are important global public health issues. In 2011, the first iteration of our allergen threshold database (ATDB) was established based on individual NOAELs and LOAELs from oral food challenge in roughly 1750 allergic individuals. Population minimal eliciting dose (EDp) distributions based on this dataset were published for 11 allergenic foods in 2014. Systematic data collection has continued (2011-2018) and the dataset now contains over 3400 data points. The current study provides new and updated EDp values for 14 allergenic foods and incorporates a newly developed Stacked Model Averaging statistical method for interval-censored data. ED01 and ED05 values, the doses at which 1%, and respectively 5%, of the respective allergic population would be predicted to experience any objective allergic reaction were determined. The 14 allergenic foods were cashew, celery, egg, fish, hazelnut, lupine, milk, mustard, peanut, sesame, shrimp (for crustacean shellfish), soy, walnut, and wheat. Updated ED01 estimates ranged between 0.03 mg for walnut protein and 26.2 mg for shrimp protein. ED05 estimates ranged between 0.4 mg for mustard protein and 280 mg for shrimp protein. The ED01 and ED05 values presented here are valuable in the risk assessment and subsequent risk management of allergenic foods.
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Affiliation(s)
- Benjamin C Remington
- The Netherlands Organisation for Applied Scientific Research TNO, Zeist, the Netherlands
| | - Joost Westerhout
- The Netherlands Organisation for Applied Scientific Research TNO, Zeist, the Netherlands
| | - Marie Y Meima
- The Netherlands Organisation for Applied Scientific Research TNO, Zeist, the Netherlands
| | - W Marty Blom
- The Netherlands Organisation for Applied Scientific Research TNO, Zeist, the Netherlands.
| | - Astrid G Kruizinga
- The Netherlands Organisation for Applied Scientific Research TNO, Zeist, the Netherlands
| | - Matthew W Wheeler
- Risk Evaluation Branch, National Institute for Occupational Safety and Health, Cincinnati, OH, United States
| | - Steve L Taylor
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, USA
| | - Geert F Houben
- The Netherlands Organisation for Applied Scientific Research TNO, Zeist, the Netherlands
| | - Joseph L Baumert
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, USA
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Kelleher MM, Jay N, Perkin MR, Haines RH, Batt R, Bradshaw LE, Montgomery AA, Chalmers JR, Williams HC, Boyle RJ. An algorithm for diagnosing IgE‐mediated food allergy in study participants who do not undergo food challenge. Clin Exp Allergy 2020; 50:334-342. [DOI: 10.1111/cea.13577] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/11/2020] [Accepted: 01/27/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Maeve M. Kelleher
- Section of Inflammation, Repair & Development National Heart & Lung Institute Imperial College London London UK
| | - Nicola Jay
- Children’s Allergy Dept. Sheffield Children’s NHS Foundation Trust Sheffield UK
| | - Michael R. Perkin
- Population Health Research Institute St George's University of London London UK
| | - Rachel H. Haines
- Nottingham Clinical Trials Unit University of Nottingham Nottingham UK
| | - Rebecca Batt
- Children’s Allergy Service Evelina Children’s Hospital London London UK
| | - Lucy E. Bradshaw
- Nottingham Clinical Trials Unit University of Nottingham Nottingham UK
| | | | - Joanne R. Chalmers
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
| | - Hywel C. Williams
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
| | - Robert J. Boyle
- Section of Inflammation, Repair & Development National Heart & Lung Institute Imperial College London London UK
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
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Chan ES, Dinakar C, Gonzales-Reyes E, Green TD, Gupta R, Jones D, Wang J, Winders T, Greenhawt M. Unmet needs of children with peanut allergy: Aligning the risks and the evidence. Ann Allergy Asthma Immunol 2020; 124:479-486. [PMID: 32007568 DOI: 10.1016/j.anai.2020.01.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/05/2020] [Accepted: 01/22/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Peanut allergy is a potentially severe and lifelong allergy, with few effective treatments or preventive measures. OBJECTIVE To convene an expert panel of allergists, pediatricians, and advocates to discuss and highlight unmet needs in the prevention and management of peanut allergies. METHODS Literature searches of PubMed were performed. The panel evaluated published data on the prevention of peanut allergy, treatment of existing peanut allergy, and management of reactions after unintentional peanut exposures. RESULTS The following key unmet needs in the prevention and management of peanut allergy were identified: (1) enhancing and optimizing implementation of early peanut introduction as a means of preventing the development of peanut allergy, (2) developing knowledge translation strategies regarding the safety and efficacy data for current and emerging immunotherapies for peanut-allergic children to support their use in clinical practice, and (3) promoting understanding of true exposure risk in allergic individuals and ensuring access to epinephrine for unintentional exposures that provoke severe reactions. Practitioners should help educate caregivers about the actual risks associated with peanut allergy and its prevention and management so that treatment decisions can be evidence based rather than fear based. Support tools are needed to help address caregiver goals, expectations, and psychological barriers, as well as identify facilitators for prevention and treatment strategies. CONCLUSION There are significant unmet needs in our understanding of peanut allergy; addressing these needs will help to enhance understanding of how to most effectively prevent and treat peanut allergy, as well as educate the food-allergic and nonallergic community regarding current evidence-based practices.
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Affiliation(s)
- Edmond S Chan
- BC Children's Hospital, The University of British Columbia, Vancouver, Canada
| | | | | | - Todd D Green
- UPMC Children's Hospital of Pittsburgh, Pennsylvania; DBV Technologies, Montrouge, France
| | - Ruchi Gupta
- Center for Food Allergy and Asthma Research, Northwestern Medicine Feinberg School of Medicine, Chicago, Illinois; Ann & Robert H Lurie Children's Hospital of Chicago, Illinois
| | | | - Julie Wang
- The Mount Sinai Hospital, New York, New York
| | | | - Matthew Greenhawt
- Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.
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Capucilli P, Wang KY, Spergel JM. Food reactions during avoidance: Focus on peanut. Ann Allergy Asthma Immunol 2020; 124:459-465. [PMID: 32001367 DOI: 10.1016/j.anai.2020.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/20/2019] [Accepted: 01/13/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Peanut allergy has historically been difficult to manage, with most cases persisting into adulthood. Novel therapies for peanut allergy treatment are on the horizon, yet allergists must maintain a robust understanding of the risks and benefits of the current standard of therapy, avoidance diet. DATA SOURCES A comprehensive literature search using PubMed of reviews and clinical articles was performed. STUDY SELECTIONS Articles discussing peanut or other food-related allergic reactions, accidental exposures or anaphylaxis pertinent to avoidance diet or comparative to oral immunotherapy trials were selected. RESULTS Peanut remains a leading allergen associated with accidental ingestions responsible for food-related reactions, both mild and severe. Fatal reactions, however, are rare and measures such as anaphylaxis plans can significantly decrease the risk of accidental anaphylaxis. Patients may over estimate situations thought to increase risk for reactions to peanut, such as inhalation or contact through skin. In oral immunotherapy trials, the rate of anaphylaxis secondary to treatment was significantly higher than avoidance practices. CONCLUSION Clinicians should continue to discuss avoidance as a viable option for long-term peanut allergy management and empower patients to differentiate relevant situations in which accidental reactions might occur.
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Affiliation(s)
- Peter Capucilli
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Kathleen Y Wang
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jonathan M Spergel
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
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The Role of Food Challenges in Clinical Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019. [PMID: 29524990 DOI: 10.1016/j.jaip.2017.12.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Food challenges are the criterion standard for establishing the presence or absence of food allergy. However, they remain underused because of their resource-intensive nature, inadequate reimbursement, and concern for the risk of anaphylaxis. Here, we review indications for performing food challenges, including scenarios of uncertain diagnosis, quality-of-life effects following food challenges, and the impact on office practice including coding and reimbursement issues. Demand for food challenges is likely to increase and allergists should be capable of providing this service to their patients when indicated.
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38
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Westerhout J, Baumert JL, Blom WM, Allen KJ, Ballmer-Weber B, Crevel RW, Dubois AE, Fernández-Rivas M, Greenhawt MJ, Hourihane JO, Koplin JJ, Kruizinga AG, Le TM, Sampson HA, Shreffler WG, Turner PJ, Taylor SL, Houben GF, Remington BC. Deriving individual threshold doses from clinical food challenge data for population risk assessment of food allergens. J Allergy Clin Immunol 2019; 144:1290-1309. [DOI: 10.1016/j.jaci.2019.07.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/24/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
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Calvani M, Bianchi A, Reginelli C, Peresso M, Testa A. Oral Food Challenge. ACTA ACUST UNITED AC 2019; 55:medicina55100651. [PMID: 31569825 PMCID: PMC6843825 DOI: 10.3390/medicina55100651] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/15/2019] [Accepted: 09/20/2019] [Indexed: 01/04/2023]
Abstract
Oral food challenge (OFC) is the gold standard for diagnosis of IgE-mediated and non-IgE mediated food allergy. It is usually conducted to make diagnosis, to monitor for resolution of a food allergy, or to identify the threshold of responsiveness. Clinical history and lab tests have poor diagnostic accuracy and they are not sufficient to make a strict diagnosis of food allergy. Higher concentrations of food-specific IgE or larger allergy prick skin test wheal sizes correlate with an increased likelihood of a reaction upon ingestion. Several cut-off values, to make a diagnosis of some food allergies (e.g., milk, egg, peanut, etc.) without performing an OFC, have been suggested, but their use is still debated. The oral food challenge should be carried out by experienced physicians in a proper environment equipped for emergency, in order to carefully assess symptoms and signs and correctly manage any possible allergic reaction. This review does not intend to analyse comprehensively all the issues related to the diagnosis of food allergies, but to summarize some practical information on the OFC procedure, as reported in a recent issue by The Expert Review of Food Allergy Committee of Italian Society of Pediatric Allergy and Immunology (SIAIP).
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Affiliation(s)
- Mauro Calvani
- Operative Unit of Paediatrics, S. Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy.
| | - Annamaria Bianchi
- Operative Unit of Paediatrics, S. Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy.
| | - Chiara Reginelli
- Department of Paediatrics, Sapienza University of Rome, Viale Del Policlinico 155, 00161 Roma, Italy.
| | - Martina Peresso
- Department of Paediatrics, Sapienza University of Rome, Viale Del Policlinico 155, 00161 Roma, Italy.
| | - Alessia Testa
- Department of Paediatrics, Sapienza University of Rome, Viale Del Policlinico 155, 00161 Roma, Italy.
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40
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Dua S, Ruiz-Garcia M, Bond S, Durham SR, Kimber I, Mills C, Roberts G, Skypala I, Wason J, Ewan P, Boyle R, Clark A. Effect of sleep deprivation and exercise on reaction threshold in adults with peanut allergy: A randomized controlled study. J Allergy Clin Immunol 2019; 144:1584-1594.e2. [PMID: 31319102 DOI: 10.1016/j.jaci.2019.06.038] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 06/11/2019] [Accepted: 06/17/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Peanut allergy causes severe and fatal reactions. Current food allergen labeling does not address these risks adequately against the burden of restricting food choice for allergic patients because of limited data on thresholds of reactivity and the influence of everyday factors. OBJECTIVE We estimated peanut threshold doses for a United Kingdom population with peanut allergy and examined the effect of sleep deprivation and exercise. METHODS In a crossover study, after blind challenge, participants with peanut allergy underwent 3 open peanut challenges in random order: with exercise after each dose, with sleep deprivation preceding challenge, and with no intervention. Primary outcome was the threshold dose triggering symptoms (in milligrams of protein). Primary analysis estimated the difference between the nonintervention challenge and each intervention in log threshold (as percentage change). Dose distributions were modeled, deriving eliciting doses in the population with peanut allergy. RESULTS Baseline challenges were performed in 126 participants, 100 were randomized, and 81 (mean age, 25 years) completed at least 1 further challenge. The mean threshold was 214 mg (SD, 330 mg) for nonintervention challenges, and this was reduced by 45% (95% CI, 21% to 61%; P = .001) and 45% (95% CI, 22% to 62%; P = .001) for exercise and sleep deprivation, respectively. Mean estimated eliciting doses for 1% of the population were 1.5 mg (95% CI, 0.8-2.5 mg) during nonintervention challenge (n = 81), 0.5 mg (95% CI, 0.2-0.8 mg) after sleep, and 0.3 mg (95% CI, 0.1-0.6 mg) after exercise. CONCLUSION Exercise and sleep deprivation each significantly reduce the threshold of reactivity in patients with peanut allergy, putting them at greater risk of a reaction. Adjusting reference doses using these data will improve allergen risk management and labeling to optimize protection of consumers with peanut allergy.
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Affiliation(s)
- Shelley Dua
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom; Department of Allergy, Addenbrooke's Hospital, Cambridge, United Kingdom.
| | - Monica Ruiz-Garcia
- Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Stephen R Durham
- Allergy and Clinical Immunology, Section Inflammation Repair and Development National heart and Lung Institute, Faculty of Medicine, Imperial College, London and Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Ian Kimber
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Clare Mills
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, United Kingdom
| | - Graham Roberts
- NIHR Southampton Respiratory Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Isabel Skypala
- National Heart and Lung Institute, Imperial College London and Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - James Wason
- MRC Biostatistics Unit, Cambridge Institute of Public Health, Cambridge, United Kingdom; Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Pamela Ewan
- Department of Allergy, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Robert Boyle
- Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom; Centre of Evidence-based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Andrew Clark
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom; Department of Allergy, Addenbrooke's Hospital, Cambridge, United Kingdom
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Elegbede CF, Papadopoulos A, Just J, Moneret-Vautrin DA, Deschildre A, Crépet A. Gender, prick test size and rAra h 2 sIgE level may predict the eliciting dose in patients with peanut allergy: Evidence from the Mirabel survey. Clin Exp Allergy 2019; 49:677-689. [PMID: 30689235 DOI: 10.1111/cea.13348] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/30/2018] [Accepted: 12/02/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Peanut allergy management is based on active avoidance and access to emergency treatment including self-injectable adrenaline. Knowing the dose at which a patient is likely to react is crucial for risk assessment and could significantly improve management by integrating a personalized approach. OBJECTIVE To develop a threshold dose distribution curve model from routinely collected data. METHODS The MIRABEL survey is an observational study of 785 patients with peanut allergy/sensitization conducted in France, Belgium and Luxemburg. The current analysis included the 238 participants for whom medical and oral food challenge data were available. Several statistical models (Kaplan-Meier, Cox model, Weibull and Lognormal with predictive factors, basic Weibull and Lognormal) were compared to select the best model and predictive factor combination associated with the threshold doses. Inferences were made with a Bayesian approach. RESULTS Patients were mainly children (mean age: 9 years [IQR: 6-11]; 87% < 16 years) and males (62%). Median Ara h2 s IgE was of 8kUA/L [IQR: 1-55] and median skin prick test size of 10 mm [IQR: 7-13]. OFC was positive in 204 patients (86%). The median threshold dose was of 67 mg of peanut protein [IQR: 16-244]. The dose at which 1% of the patients are likely to react with objective symptoms was 0.26 [0.03; 2.24] mg of peanut protein. Gender, size of the skin prick test (SPT) and Ara h 2 specific IgE level had a significant impact on the threshold dose distribution curve. The Cox model was the most effective to predict threshold doses with this combination of factors. Girls react to lower doses than boys with a beta coefficient associated to the risk and a 95% credible interval of 0.44 [0.04; 0.77]. The higher the size of the SPT and the Ara h 2 specific IgE level are, the higher the risk of reacting to a small amount of peanut, with beta coefficients associated to the risk and 95% credible intervals of 0.05 [0.02; 0.08] and 0.01 [0.01; 0.02], respectively. CONCLUSION AND CLINICAL RELEVANCE According to the model, routinely collected data could be used to estimate the threshold dose. The consequences could be the identification of high-risk patients who are susceptible to react to small amounts of peanut and a personalized management of peanut allergy integrating the risk of allergic reaction. Limitations of this study are that assessors of OFC outcome were aware of SPT and Arah2 results, and a further validation study is required to confirm the predictive value of these parameters.
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Affiliation(s)
- Chabi Fabrice Elegbede
- French Agency for Food, Environmental and Occupational Health Safety (ANSES), Risk Assessment Department (DER), Methology and Studies Unit, Maisons-Alfort, France.,French National Institute for Agricultural Research (INRA), Paris Institute of Technology for Life, Food and Environmental Sciences (AgroParisTech), UMR Economie Publique INRA-AgroParisTech, Thiverval-Grignon, France
| | - Alexandra Papadopoulos
- French Agency for Food, Environmental and Occupational Health Safety (ANSES), Risk Assessment Department (DER), Methology and Studies Unit, Maisons-Alfort, France
| | - Jocelyne Just
- Asthma and Allergy Center, Hôpital d'Enfants Armand-Trousseau, Paris, France.,INSERM, UMR_S 1136, Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,Institut Pierre Louis d'Epidémiologie et de Santé Publique, Equipe EPAR, Paris, France
| | - Denise Anne Moneret-Vautrin
- Allergy Department, Centre Hospitalier E Durckheim, Epinal, France.,Allergyvigilance Network, Vandoeuvre les Nancy, France.,Lorraine University, Nancy, France
| | - Antoine Deschildre
- Pediatric Pulmonology and Allergy Department, CHU Lille, Hôpital Jeanne de Flandre, Lille, France
| | - Amélie Crépet
- French Agency for Food, Environmental and Occupational Health Safety (ANSES), Risk Assessment Department (DER), Methology and Studies Unit, Maisons-Alfort, France
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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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Datema MR, Eller E, Zwinderman AH, Poulsen LK, Versteeg SA, van Ree R, Bindslev-Jensen C. Ratios of specific IgG 4 over IgE antibodies do not improve prediction of peanut allergy nor of its severity compared to specific IgE alone. Clin Exp Allergy 2018; 49:216-226. [PMID: 30269403 PMCID: PMC7379576 DOI: 10.1111/cea.13286] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 07/15/2018] [Accepted: 08/01/2018] [Indexed: 01/04/2023]
Abstract
Background IgG4 antibodies have been suggested to play a protective role in the translation of peanut sensitization into peanut allergy. Whether they have added value as diagnostic read‐out has not yet been reported. Objective To evaluate whether (a) peanut‐specific IgG, IgG4 and/or IgA antibodies are associated with tolerance and/or less severe reactions and (b) they can improve IgE‐based diagnostic tests. Methods Sera of 137 patients with challenge‐proven peanut allergy and of 25 subjects that tolerated peanut, both with known IgE profiles to peanut extract and five individual peanut allergens, were analyzed for specific IgG and IgG4. Antibody levels and ratios thereof were associated with challenge outcome including symptom severity grades. For comparison of the discriminative performance, receiver operating characteristic curve (ROC) analysis was used. Results IgE against Ara h 2 was significantly higher in allergic than in tolerant patients and associated with severity of reactions (P < 0.001) with substantial diagnostic capability (AUC 0.91, 95%CI 0.87‐0.96 and 0.80, 95%CI 0.73‐0.87, respectively). IgG and IgG4 were also positively associated albeit significantly weaker (AUCs from 0.65 to 0.72). On the other hand, ratios of IgG and IgG4 over IgE were greater in patients that were tolerant or had mild symptoms as compared to severe patients but they did not predict challenge outcomes better than IgE alone (AUCs from 0.54 to 0.89). Conclusion IgE against Ara h 2 is the best biomarker for predicting peanut challenge outcomes including severity and IgG and IgG4 antibody ratios over IgE do not improve these outcomes.
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Affiliation(s)
- Mareen R Datema
- Department of Experimental Immunology, Academic Medical Center, Amsterdam, the Netherlands.,Department of Clinical Epidemiology, Academic Medical Centre, Biostatistics and Bioinformatics, Amsterdam, the Netherlands
| | - Esben Eller
- Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Academic Medical Centre, Biostatistics and Bioinformatics, Amsterdam, the Netherlands
| | - Lars K Poulsen
- Allergy Clinic, Copenhagen University Hospital at Gentofte, Copenhagen, Denmark
| | - Serge A Versteeg
- Department of Experimental Immunology, Academic Medical Center, Amsterdam, the Netherlands
| | - Ronald van Ree
- Department of Experimental Immunology, Academic Medical Center, Amsterdam, the Netherlands.,Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, the Netherlands
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
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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: 130] [Impact Index Per Article: 21.7] [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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Abstract
PURPOSE OF REVIEW This review incorporates findings from studies of oral food challenges (OFC) over the last decade and highlights the latest innovations and understanding of the procedure. RECENT FINDINGS PRACTALL guidelines are widely used in OFC research, but there is still no international consensus on the OFC protocol in clinical practice. Guidelines for performing OFC in clinical practice have been updated to include oral food challenges for infants. There have been advances in predictive models for outcomes and severity of reaction during OFC that take into account multiple clinical data as well as newer laboratory modalities. Low-dose OFC and eliciting threshold dose determination are being examined for additional diagnostic and therapeutic use in the management of food allergy. Quality-of-life considerations have also been reviewed, as well as post-OFC assessment and care. The OFC remains an important diagnostic tool in the management of food allergy and in clinical research. Advances in the field should improve safety and broaden the clinical applications of this essential procedure.
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46
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Dubois AEJ, Turner PJ, Hourihane J, Ballmer-Weber B, Beyer K, Chan CH, Gowland MH, O'Hagan S, Regent L, Remington B, Schnadt S, Stroheker T, Crevel RWR. How does dose impact on the severity of food-induced allergic reactions, and can this improve risk assessment for allergenic foods?: Report from an ILSI Europe Food Allergy Task Force Expert Group and Workshop. Allergy 2018; 73:1383-1392. [PMID: 29331070 PMCID: PMC6032860 DOI: 10.1111/all.13405] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 11/29/2022]
Abstract
Quantitative risk assessment (QRA) for food allergens has made considerable progress in recent years, yet acceptability of its outcomes remains stymied because of the limited extent to which it has been possible to incorporate severity as a variable. Reaction severity, particularly following accidental exposure, depends on multiple factors, related to the allergen, the host and any treatments, which might be administered. Some of these factors are plausibly still unknown. Quantitative risk assessment shows that limiting exposure through control of dose reduces the rates of reactions in allergic populations, but its impact on the relative frequency of severe reactions at different doses is unclear. Food challenge studies suggest that the relationship between dose of allergenic food and reaction severity is complex even under relatively controlled conditions. Because of these complexities, epidemiological studies provide very limited insight into this aspect of the dose-response relationship. Emerging data from single-dose challenges suggest that graded food challenges may overestimate the rate of severe reactions. It may be necessary to generate new data (such as those from single-dose challenges) to reliably identify the effect of dose on severity for use in QRA. Success will reduce uncertainty in the susceptible population and improve consumer choice.
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Affiliation(s)
- A. E. J. Dubois
- University Medical Centre Groningen; Groningen The Netherlands
| | | | | | | | - K. Beyer
- Charité Universitätsmedizin Berlin; Berlin Germany
| | | | | | | | - L. Regent
- Anaphylaxis Campaign; Farnborough UK
| | - B. Remington
- The Netherlands Organisation for Applied Scientific Research (TNO); Zeist The Netherlands
| | - S. Schnadt
- German Allergy and Asthma Association (DAAB); Mönchengladbach DE
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Pettersson ME, Koppelman GH, Flokstra-de Blok BMJ, Kollen BJ, Dubois AEJ. Prediction of the severity of allergic reactions to foods. Allergy 2018; 73:1532-1540. [PMID: 29380392 PMCID: PMC6033096 DOI: 10.1111/all.13423] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2018] [Indexed: 12/14/2022]
Abstract
Background There is currently considerable uncertainty regarding what the predictors of the severity of diagnostic or accidental food allergic reactions are, and to what extent the severity of such reactions can be predicted. Objective To identify predictors for the severity of diagnostic and accidental food allergic reactions and to quantify their impact. Methods The study population consisted of children with a double‐blind, placebo‐controlled food challenge (DBPCFC)–confirmed food allergy to milk, egg, peanut, cashew nut, and/or hazelnut. The data were analyzed using multiple linear regression analysis. Missing values were imputed using multiple imputation techniques. Two scoring systems were used to determine the severity of the reactions. Results A total of 734 children were included. Independent predictors for the severity of the DBPCFC reaction were age (B = 0.04, P = .001), skin prick test ratio (B = 0.30, P < .001), eliciting dose (B = −0.09, P < .001), level of specific immunoglobulin E (B = 0.15, P < .001), reaction time during the DBPCFC (B = −0.01, P = .004), and severity of accidental reaction (B = 0.08, P = .015). The total explained variance of this model was 23.5%, and the eliciting dose only contributed 4.4% to the model. Independent predictors for more severe accidental reactions with an explained variance of 7.3% were age (B = 0.03, P = .014), milk as causative food (B = 0.77, P < .001), cashew as causative food (B = 0.54, P < .001), history of atopic dermatitis (B = −0.47, P = .006), and severity of DBPCFC reaction (B = 0.12, P = .003). Conclusions The severity of DBPCFCs and accidental reactions to food remains largely unpredictable. Clinicians should not use the eliciting dose obtained from a graded food challenge for the purposes of making risk‐related management decisions.
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Affiliation(s)
- M. E. Pettersson
- Department of Pediatric Pulmonology and Pediatric Allergy; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
- GRIAC Research Institute; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
| | - G. H. Koppelman
- Department of Pediatric Pulmonology and Pediatric Allergy; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
- GRIAC Research Institute; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
| | - B. M. J. Flokstra-de Blok
- GRIAC Research Institute; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
- Department of General Practice; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
| | - B. J. Kollen
- Department of General Practice; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
| | - A. E. J. Dubois
- Department of Pediatric Pulmonology and Pediatric Allergy; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
- GRIAC Research Institute; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
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Abstract
PURPOSE OF REVIEW This review aims to provide an update of recent advances in the epidemiology, clinical features and diagnosis, and management of food-induced anaphylaxis (FIA). RECENT FINDINGS Food allergy prevalence and FIA rates continue to rise, but FIA fatalities are stable. Basophil and mast cell activation tests promise more accurate identification of food triggers. Oral, sublingual, and epicutaneous immunotherapy can desensitize a significant portion of subjects. Epinephrine use for FIA remains sub-optimal. As the burden of food allergy continues to increase, it appears that the corresponding increase in research focused on this epidemic is beginning to bear fruit. The stable number of FIA fatalities in the face of an ongoing epidemic indicates lives have already been saved. The emergence of new diagnostic tests and interventional therapies may transform the management of FIA in the coming years.
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Affiliation(s)
- Christopher P Parrish
- Department of Pediatrics and Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX, 75390-9063, USA.
| | - Heidi Kim
- Department of Pediatrics, University of Texas Southwestern Medical School, Dallas, TX, USA
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49
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Ballmer-Weber BK, Beyer K. Reply. J Allergy Clin Immunol 2018; 141:2323. [DOI: 10.1016/j.jaci.2018.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 02/23/2018] [Indexed: 10/14/2022]
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50
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Graham F, Eigenmann PA. Clinical implications of food allergen thresholds. Clin Exp Allergy 2018; 48:632-640. [DOI: 10.1111/cea.13144] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- F. Graham
- Pediatric Allergy Unit; University Hospitals of Geneva and University of Geneva; Geneva Switzerland
| | - P. A. Eigenmann
- Pediatric Allergy Unit; University Hospitals of Geneva and University of Geneva; Geneva Switzerland
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