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Galletta F, Passanisi S, Manti S, Crisafulli G, Caminiti L. Anaphylaxis during OIT and its impact on treatment adherence: A retrospective study. Pediatr Allergy Immunol 2024; 35:e14200. [PMID: 39003688 DOI: 10.1111/pai.14200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 06/18/2024] [Accepted: 06/25/2024] [Indexed: 07/15/2024]
Affiliation(s)
- Francesca Galletta
- Department of Human Pathology in Adult and Developmental Age 'Gaetano Barresi', Pediatric Unit, University of Messina, Messina, Italy
| | - Stefano Passanisi
- Department of Human Pathology in Adult and Developmental Age 'Gaetano Barresi', Pediatric Unit, University of Messina, Messina, Italy
| | - Sara Manti
- Department of Human Pathology in Adult and Developmental Age 'Gaetano Barresi', Pediatric Unit, University of Messina, Messina, Italy
| | - Giuseppe Crisafulli
- Department of Human Pathology in Adult and Developmental Age 'Gaetano Barresi', Pediatric Unit, University of Messina, Messina, Italy
| | - Lucia Caminiti
- Department of Human Pathology in Adult and Developmental Age 'Gaetano Barresi', Pediatric Unit, University of Messina, Messina, Italy
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2
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Elizur A, Rachel‐Jossefi S, Rachmiel M, Eisenberg E, Katz Y. Consumption of cow's milk formula in the nursery and the development of milk allergy. Clin Transl Allergy 2024; 14:e12352. [PMID: 38613160 PMCID: PMC11015055 DOI: 10.1002/clt2.12352] [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: 12/21/2023] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND The effect of the amount of transient cow's milk formula (CMF) consumed during the first days of life on IgE-cow's milk allergy (IgE-CMA) is unknown. METHODS A cohort of 58 patients with IgE-CMA was identified from a large scale population-based study of 13,019 infants followed from birth. A group of 116 infants matched for sex and breastfeeding only duration (beyond the nursery period), and another random group of 259 healthy infants were used as controls. Parents were interviewed and the infants' medical records were searched to assess CMF consumption in the nursery. RESULTS While 96% of the mothers of the 174 infants (58 with Cow's milk allergy and 116 controls) reported on exclusive breastfeeding during the stay in the nursery, CMF consumption was documented in 96 (55%) of the infants. Of those, most (57; 59%) received one to three feedings, 20 (21%) received four to nine feedings, and 19 (20%) received ≥10 feedings. Fewer formula feeds (1-3) were significantly more common in the allergic group than ≥4 feeds (p = 0.0003) and no feeds at all (p = 0.02) compared to controls (n = 116). Of those exclusively breastfed in the nursery, 13/23 allergic infants (57%) introduced CMF at age 105-194 days (the period with highest-risk for IgE-CMA) compared to 33/98 (34%) from the random control group (n = 259) (p = 0.04). CONCLUSIONS Most infants end up receiving few CMF feeds in the nursery. Transient CMF in the nursery is associated with increased risk of IgE-CMA.
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Affiliation(s)
- Arnon Elizur
- Shamir Medical Center Assaf Harofeh Pediatrics DivisionInstitute of Allergy Immunology and Pediatric PulmonologyTzrifinIsrael
- Tel Aviv University School of MedicineTel AvivIsrael
| | - Shirel Rachel‐Jossefi
- Shamir Medical Center Assaf Harofeh Pediatrics DivisionInstitute of Allergy Immunology and Pediatric PulmonologyTzrifinIsrael
- Tel Aviv University School of MedicineTel AvivIsrael
| | - Marianna Rachmiel
- Tel Aviv University School of MedicineTel AvivIsrael
- Shamir Medical Center Assaf Harofeh Pediatrics DivisionPediatric Endocrinology and Diabetes InstituteTzrifinIsrael
| | - Eli Eisenberg
- Tel Aviv University School of Physics and AstronomyTal AvivIsrael
| | - Yitzhak Katz
- Shamir Medical Center Assaf Harofeh Pediatrics DivisionInstitute of Allergy Immunology and Pediatric PulmonologyTzrifinIsrael
- Tel Aviv University School of MedicineTel AvivIsrael
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3
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Nachshon L, Schwartz N, Levy MB, Goldberg M, Epstein-Rigbi N, Katz Y, Elizur A. Reply to "Intense allergic reactions to personalized oral immunotherapy treatments for food allergies at home". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:797-798. [PMID: 38458704 DOI: 10.1016/j.jaip.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 03/10/2024]
Affiliation(s)
- Liat Nachshon
- Yitzhak Shamir Medical Center, Institute of Allergy, Immunology and Pediatric Pulmonology, Zerifin, Israel; Department of Medicine, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Naama Schwartz
- School of Public Health, University of Haifa, Haifa, Israel
| | - Michael B Levy
- Yitzhak Shamir Medical Center, Institute of Allergy, Immunology and Pediatric Pulmonology, Zerifin, Israel
| | - Michael Goldberg
- Yitzhak Shamir Medical Center, Institute of Allergy, Immunology and Pediatric Pulmonology, Zerifin, Israel; Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Epstein-Rigbi
- Yitzhak Shamir Medical Center, Institute of Allergy, Immunology and Pediatric Pulmonology, Zerifin, Israel; Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yitzhak Katz
- Yitzhak Shamir Medical Center, Institute of Allergy, Immunology and Pediatric Pulmonology, Zerifin, Israel; Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Elizur
- Yitzhak Shamir Medical Center, Institute of Allergy, Immunology and Pediatric Pulmonology, Zerifin, Israel; Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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4
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Mack DP, Upton J, Patel N, Turner PJ. Flex-IT! Applying "Platform Trials" Methodology to Immunotherapy for Food Allergy in Research and Clinical Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:554-561. [PMID: 38218449 DOI: 10.1016/j.jaip.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/27/2023] [Accepted: 01/09/2024] [Indexed: 01/15/2024]
Abstract
There is an increasing trend in the management of food allergy toward active treatment using allergen immunotherapy (AIT). Although AIT is efficacious, treatment-related adverse events are common, particularly with oral immunotherapy in those with high levels of allergen-specific IgE sensitization. In clinical practice, these adverse events inevitably create challenges: clinicians and patients routinely face decisions whether to alter the dose itself, the frequency of dosing, and the pace of escalation, or indeed discontinue AIT altogether. Flexibility is therefore needed to adapt treatment, particularly in clinical practice, so that participants are "treated-to-target." For example, this may entail a significant change in the dosing protocol or even switching from one route of administration to another in response to frequent adverse events. We refer to this approach as flexible immunotherapy. However, there is little evidence to inform clinicians as to what changes to treatment are most likely to result in treatment success. Classical clinical trials rely, by necessity, on relatively rigid updosing protocols. To provide an evidence base to optimize AIT, the food allergy community should adopt adaptive platform trials, where a "master protocol" facilitates more efficient evaluation, including longer-term outcomes of multiple interventions. Within a single clinical trial, participants are able to switch between different treatment arms; interventions can be added or dropped without compromising the integrity of the trial. Developing platform trials for food AIT may initially be costly, but they represent a significant opportunity to grow the evidence base (with respect to both treatment outcomes and biomarker discovery) at scale. In addition, they could help understand longitudinal disease trajectories that are difficult to study in clinical trials for food allergy due to the time needed to demonstrate changes in efficacy. Finally, their adoption would achieve greater collaboration and consistency in approaches to proactive management of food allergy in routine clinical practice. As a community, we need to actively pursue this with funders and established research collaborations to deliver the very best outcomes for our patients and their families.
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Affiliation(s)
- Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Julia Upton
- SickKids Food Allergy and Anaphylaxis Programme, Division of Immunology and Allergy, Department of Pediatrics, the Hospital for Sick Children, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nandinee Patel
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, United Kingdom.
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5
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Goldberg MR, Epstein-Rigbi N, Elizur A. Eosinophil-Associated Gastrointestinal Manifestations During OIT. Clin Rev Allergy Immunol 2023; 65:365-376. [PMID: 37957456 DOI: 10.1007/s12016-023-08974-0] [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] [Accepted: 10/26/2023] [Indexed: 11/15/2023]
Abstract
Gastrointestinal adverse events are common during oral immunotherapy (OIT) for food allergy and range from immediate IgE-mediated reactions to non-anaphylactic clinical presentations. This review aims to summarize recent findings on non-anaphylactic eosinophil-associated gastrointestinal adverse events during OIT. Two clinical presentations of non-anaphylactic eosinophil-associated gastrointestinal adverse events during OIT are identified, each with a different paradigm for treatment, and distinguished by their time of onset. In the first clinical entity, characterized by its onset early in the course of treatment, patients present with abdominal pain, nausea, and/or vomiting. The symptoms become evident typically within weeks to months of starting OIT. These symptoms, however, are not temporally related to the time of dose administration, as in the case of immediate IgE-mediated anaphylactic reactions. While esophageal biopsies, when performed, can demonstrate eosinophilic esophagitis (EoE), baseline esophageal eosinophilia has also been observed in food allergic patients prior to OIT. A potential non-invasive biomarker, the peripheral absolute eosinophil count (AEC), often rises during these reactions and subsides after dose reduction and subsequent resolution of symptoms. OIT can usually then be resumed, albeit at a slower pace, without a recurrence of symptoms. Risk factors for development of symptoms early during OIT include a high starting dose and a baseline AEC of greater than 600. The second, and much less frequently encountered, non-anaphylactic gastrointestinal adverse event related to OIT, presents months to years after initiating OIT. In this latter group, patients present with the classical clinical symptoms and endoscopic findings of EoE. In contrast to the acute onset group, peripheral eosinophilia is usually not observed in these cases. This OIT-associated EoE has shown good response to standard EoE treatment approaches of proton pump inhibitors or swallowed steroids. Most patients with eosinophil-associated adverse reactions are able to continue OIT and remain desensitized. Treatment approaches depend on the specific subtype of these reactions and relate to the stages of OIT treatment.
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Affiliation(s)
- Michael R Goldberg
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center (Assaf Harofeh), Zerifin, 70300, 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 (Assaf Harofeh), Zerifin, 70300, 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 (Assaf Harofeh), Zerifin, 70300, Israel
- Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Mack DP. Standardization of food allergen ladders for optimal effectiveness and patient safety. JOURNAL OF FOOD ALLERGY 2023; 5:49-54. [PMID: 39022756 PMCID: PMC11250552 DOI: 10.2500/jfa.2023.5.230013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
The use of extensively heated (EH) milk and egg products, and dietary advancement therapies such as milk and egg ladders is increasingly common for the management of milk and egg allergies. Although the majority of patients with milk and egg allergies will outgrow their allergies, the ability to tolerate extensively hydrolyzed forms of these allergens is an early indicator of developing long-term tolerance. The denaturation of conformational epitopes during the heating process reduces the allergenicity of these proteins, which makes patients who are EH tolerant more likely to tolerate progressively more of these proteins.
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Affiliation(s)
- Douglas P Mack
- From the Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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7
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Johnson SR, McNamara K, Bjelac J, Kerns LA, Subramanian A, Hoyt AEW, Whitsel R, Hong SJ. Safety and effectiveness of peanut oral immunotherapy in children under 12 months. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3544-3546.e1. [PMID: 37453570 DOI: 10.1016/j.jaip.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/27/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Sarah R Johnson
- Department of Allergy and Clinical Immunology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Kara McNamara
- Food Allergy Center of Excellence, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jaclyn Bjelac
- Food Allergy Center of Excellence, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Leigh Ann Kerns
- Food Allergy Center of Excellence, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahila Subramanian
- Food Allergy Center of Excellence, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Rachel Whitsel
- Food Allergy Center of Excellence, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sandra J Hong
- Food Allergy Center of Excellence, Cleveland Clinic Foundation, Cleveland, Ohio.
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8
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Tsuji G, Matsui T, Takasato Y, Kitamura K, Kubota S, Sugiura S, Ito K. Exercise-Induced Allergic Reactions in Children Desensitized to Hen's Eggs and Cow's Milk by Oral Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3187-3194.e2. [PMID: 37422154 DOI: 10.1016/j.jaip.2023.06.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 06/12/2023] [Accepted: 06/18/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Exercise-induced allergic reactions on desensitization (EIARDs) after successful in-hospital rush oral immunotherapy (OIT) for wheat allergy have been reported. However, the incidence rates of EIARDs after rush OIT for egg allergy and milk allergy have not been determined. OBJECTIVE To determine the frequency of EIARDs and risk factors associated with rush OIT for egg and milk allergy. METHODS This retrospective chart review, conducted in January 2020, enrolled 64 and 43 patients who underwent rush OIT for egg and milk allergy, respectively (in 2010 to 2014). In particular, 48 and 32 desensitized patients underwent exercise-provocation tests (Ex-P) after allergen administration (4,400 mg boiled egg white and 6,600 mg cow's milk protein, respectively). The EIARDs were determined by Ex-P or a suspicious event even after passing the Ex-P. Specific IgE levels to egg white, cow's milk, ovomucoid, casein, α-lactalbumin, and β-lactoglobulin were analyzed using ImmunoCAP. RESULTS At least one episode of EIARD was observed in 10 and 17 patients with egg and milk allergy (21% and 53%), respectively, which persisted for more than 5 years in one patient with egg allergy (2.1%) and 11 patients with milk allergy (34.4%) as of January 2020. We could not find background differences between the EIARD-positive and EIARD-negative groups, except that the egg white-specific IgE/total IgE ratio before rush OIT was significantly higher in patients with egg allergy with EIARD than in those without it. CONCLUSIONS Exercise-induced allergic reactions on desensitization were more frequent and common in patients with milk allergy. Moreover, EIARDs to milk allergy were more likely to persist than those to egg allergy.
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Affiliation(s)
- Genki Tsuji
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
| | - Teruaki Matsui
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
| | - Yoshihiro Takasato
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
| | - Katsumasa Kitamura
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
| | - Shohei Kubota
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
| | - Shiro Sugiura
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
| | - Komei Ito
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan; Comprehensive Pediatric Medicine, Nagoya University Graduate School of Medicine, Obu, Japan.
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9
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Nachshon L, Schwartz N, Levy MB, Goldberg M, Epstein-Rigbi N, Katz Y, Elizur A. Severe Anaphylactic Reactions to Home Doses of Oral Immunotherapy for Food Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2524-2533.e3. [PMID: 36925102 DOI: 10.1016/j.jaip.2023.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND Severe anaphylactic reactions to home doses may occur during food allergy oral immunotherapy (OIT). OBJECTIVE To study the rate and risk factors for such reactions. METHODS We studied all patients aged greater than 3.5 years who completed OIT in a single center between April 2010 and January 2020. All home epinephrine-treated reactions (HETRs) were identified. High-grade HETRs (HG-HETRs) were defined as HETRs involving respiratory (SpO2 of 94% or less), cardiovascular (low blood pressure), or central nervous system impairment (loss of consciousness). We investigated the rate and risk factors for HG-HETRs. RESULTS A total of 1,637 OIT treatments were studied: milk (880), peanut (346), tree nuts (221), sesame (115), and egg (75). Of 390 identified HETRs, 30 HG-HETRs occurred during 27 treatments (1.65% of all treatments). Nearly all (26 of 30) were during milk OIT in patients with house dust mite (HDM) sensitization and asthma (26 of 30 each). Of the 30 patients with HG-HETRs, 21 recovered with one or two epinephrine treatments, but nine (0.55% of all treatments) did not respond to a second dose of epinephrine and were deemed to have refractory anaphylaxis. Three patients required intensive care unit admission and three received epinephrine drip, but none required ventilatory support. Risk factors for HG-HETRs included milk OIT (P = .031), asthma (P = .02) and HDM sensitization (P = .02). No specific triggers for HG-HETR were identified. Of patients with HG-HETRs, 25.9% were fully desensitized, including the four non-milk treated patients; 22.2% were partially desensitized; and 51.9% failed. CONCLUSIONS High-grade HETRs are uncommon, particularly refractory anaphylactic reactions to home OIT doses. Although milk OIT, asthma, and HDM sensitization are the main risk factors for such reactions, identification of patients who are at risk is challenging.
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Affiliation(s)
- Liat Nachshon
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yaakov, Israel; Department of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Naama Schwartz
- School of Public Health, University of Haifa, Haifa, Israel
| | - Michael B Levy
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yaakov, Israel
| | - Michael Goldberg
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yaakov, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Epstein-Rigbi
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yaakov, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yitzhak Katz
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yaakov, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yaakov, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Anagnostou A, Muraro A. Can we identify patients at risk of severe reactions to food? Expert Rev Clin Immunol 2023; 19:1427-1430. [PMID: 37753864 DOI: 10.1080/1744666x.2023.2265069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/26/2023] [Indexed: 09/28/2023]
Affiliation(s)
- Aikaterini Anagnostou
- Department of Pediatrics, Division of Immunology, Allergy and Retrovirology, Texas Children's Hospital, Houston, TX, USA
- Division of Allergy, Immunology & Retrovirology, Baylor College of Medicine, Houston, TX, USA
| | - Antonella Muraro
- UOSD Department of Pediatric and Adult Food Allergies, University Hospital of Padua
- Center for the Study and Cure of Allergies and Food Intolerance of the Veneto Region, University Hospital of Padua
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11
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Morris E, Protudjer JLP, Jeimy S, Edgerley S, Rondilla N, Robertson K, Zhu R, Kim H. Evening ingestion as a potential reaction cofactor during peanut oral immunotherapy in children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1964-1966.e2. [PMID: 36889670 DOI: 10.1016/j.jaip.2023.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/08/2023]
Affiliation(s)
- Emily Morris
- Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer L P Protudjer
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada; Department of Food and Human Nutritional Sciences, Faculty of Agricultural and Food Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada; Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Samira Jeimy
- Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada
| | - Sarah Edgerley
- Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada
| | | | - Kara Robertson
- Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada
| | - Rongbo Zhu
- Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada
| | - Harold Kim
- Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada; Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada.
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12
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Mack DP, Greenhawt M, Anagnostou A. Are There Hidden Dangers Associated With Milk and Egg Dietary Advancement Therapy? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1056-1062. [PMID: 36581070 DOI: 10.1016/j.jaip.2022.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/02/2022] [Accepted: 12/13/2022] [Indexed: 12/28/2022]
Abstract
Dietary advancement therapies (DATs) constitute a continuum spanning extensively heated item ingestion, progressive milk or egg ladders, and oral immunotherapy (OIT). These represent an evolution in food allergy management from strict avoidance to an active therapy that may modulate the immune system to develop tolerance to particular forms of the allergen. Many egg or milk individuals are tolerant to baked egg or milk at baseline, and regular consumption (at home ingestion) of baked milk or egg is a safe process with potential quality of life and immunologic benefit. Milk and egg ladders, developed for non-IgE mediated allergy, are increasingly being adapted to IgE-mediated allergy as a potentially safe at-home option for gradual dietary advancement. However, data are limited regarding how safe and effective these approaches are or what patient is best suited for which DAT. It is also unclear whether extensively heated allergen consumption and ladders are susceptible to the same patient-specific factors that affect day-to-day tolerance and safety in OIT. Several recent events involving near-fatal or fatal reactions to milk or egg products (all among patients with asthma) have highlighted that DATs are not risk-free, and that physician guidance in these therapies is essential. Such guidance may include obtaining informed consent before starting any DAT and instituting the same safe dosing rules for OIT across any form of DAT. This rostrum discusses practical concerns about the safety of DAT, and considerations regarding how clinicians can maximize patient protection while defining the safety and efficacy of real-world implementation of these concepts.
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Affiliation(s)
- Douglas Paul Mack
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Aikaterini Anagnostou
- Section of Immunology, Allergy, and Retrovirology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Section of Immunology, Allergy, and Retrovirology, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
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13
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Nachshon L, Schwartz N, Levy MB, Goldberg MR, Epstein-Rigbi N, Katz Y, Elizur A. Factors associated with home epinephrine-treated reactions during peanut and tree-nut oral immunotherapy. Ann Allergy Asthma Immunol 2023; 130:340-346.e5. [PMID: 36509409 DOI: 10.1016/j.anai.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Home reactions requiring epinephrine administration, a marker of their severity, restrict the widespread use of oral immunotherapy (OIT), but their risk factors are largely not known. OBJECTIVE To identify risk factors for such reactions during OIT to most allergenic foods. METHODS All patients who began OIT for peanut, tree nuts, sesame, or egg allergy at the Shamir Medical Center between April 2010 and January 2020 were enrolled. The patients were instructed to use their epinephrine autoinjectors during reactions consisting of severe abdominal pain, significant shortness of breath, or lethargy, or whenever in uncertainty of reaction severity. Patients with and without home epinephrine-treated reactions (HETRs) were compared. RESULTS A total of 757 OIT treatments for peanut (n = 346), tree nuts (n = 221; walnut n = 147, cashew n = 57, hazelnut n = 16, almond n = 1), sesame (n = 115), and egg (n = 75) allergies were administered to 644 patients. Eighty-three (10.9%) patients experienced HETRs. The highest rate of HETRs was experienced during walnut (20.4%) or hazelnut (25%) OIT, followed by peanut (9.8%), sesame (6.1%), egg (6.7%), and cashew (5.3%) OIT. Risk factors for HETRs included a reaction treated in an emergency department (ER) (P = .005) before starting OIT and a reaction treated with epinephrine during in-clinic induction (P < .001). Significantly fewer patients with (73.6%) than without (88.3%) HETRs achieved full desensitization (P = .001), but only a few patients with HETRs (8.4%) failed treatment. CONCLUSION Previous reaction severity is the main predictor for HETRs during OIT. These reactions are more frequent during walnut and hazelnut OIT than during OIT for other foods studied. Most patients experiencing HETRs achieved desensitization.
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Affiliation(s)
- Liat Nachshon
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Zerifin, Israel; Department of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Naama Schwartz
- School of Public Health-University of Haifa, Haifa, Israel
| | - Michael B Levy
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Zerifin, Israel
| | - Michael R Goldberg
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Epstein-Rigbi
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yitzhak Katz
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Epstein-Rigbi N, Levy MB, Nachshon L, Koren Y, Katz Y, Goldberg MR, Elizur A. Efficacy and safety of food allergy oral immunotherapy in adults. Allergy 2023; 78:803-811. [PMID: 36190349 DOI: 10.1111/all.15537] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Oral immunotherapy (OIT) is an emerging method for treating food allergy in children. However, data regarding adults undergoing this process are lacking. METHODS We retrospectively analyzed the medical records of patients with food allergy aged ≥17 years who completed OIT treatment between April 2010 and December 2020 at Shamir Medical Center. Data were compared with that of children aged 4 to <11 years and adolescents aged ≥11 to 17 treated during the same time period. RESULTS A total of 96 adults at a median age of 22.3 years who underwent OIT for milk (n = 53), peanut (n = 18), sesame (n = 7), egg (n = 5), and tree nuts (n = 13) were analyzed and compared with 1299 children and 309 adolescents. Adults experienced more adverse reactions requiring injectable epinephrine, both during in-clinic up-dosing (49% vs. 15.9% and 26.5% for children and adolescents, respectively, p < 0.0001) and during home treatment (22.9% vs. 12.4%, p = 0.007 for children, and 17.5%, p = 0.23 for adolescents). Most adults (61.5%) were fully desensitized, but the rates of full desensitization were significantly lower than children (73.4%, p = 0.013). Significantly more adults (28.3%) undergoing milk OIT failed treatment than children (14.3%, p = 0.015) and adolescents (14.1%, p = 0.022), while failure rates in adults undergoing OIT for other foods were low (9.3%) and comparable with children and adolescents. CONCLUSIONS OIT is successful in desensitizing most adults with IgE-mediated food allergy. Adults undergoing milk OIT are at increased risk for severe reactions and for OIT failure while failure rates in adults undergoing OIT for other foods are low.
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Affiliation(s)
- Na'ama Epstein-Rigbi
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (former Assaf Harofeh) Medical Center, Zerifin, Israel.,Department of Pediatrics, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael B Levy
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (former Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Liat Nachshon
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (former Assaf Harofeh) Medical Center, Zerifin, Israel.,Department of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Koren
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (former Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Yitzhak Katz
- Department of Pediatrics, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael R Goldberg
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (former Assaf Harofeh) Medical Center, Zerifin, Israel.,Department of Pediatrics, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir (former Assaf Harofeh) Medical Center, Zerifin, Israel.,Department of Pediatrics, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Characteristics of patients diagnosed as non-allergic following food allergy oral immunotherapy referral. Pediatr Res 2023; 93:643-648. [PMID: 35641552 DOI: 10.1038/s41390-022-02119-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/12/2022] [Accepted: 04/27/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Ascribing food allergy diagnosis to patients who are not allergic is well described, but its implications on oral immunotherapy (OIT) have not been studied. The aim was to study non-allergic patients referred for OIT. METHODS All patients who began OIT at Shamir Medical Center between November 2015 and August 2020 were included. Medical records were reviewed, and skin prick tests (SPT) and/or specific IgE were measured. Patients were challenged to the index food. Allergic and non-allergic patients were compared. RESULTS A total of 1073 patients were studied (milk, n = 327; egg, n = 41; peanut, n = 272; sesame, n = 130; and tree nuts, n = 303) and 87 (8.1%) were found non-allergic (milk, n = 21; egg, n = 6; sesame, n = 5; peanut, n = 29; tree nuts, n = 26). Predictors of being not allergic were no previous reaction to the index food (OR = 3.3, p = 0.001), not having asthma (OR = 2.4, p = 0.001), or HDM sensitization (OR = 2.0, p = 0.007), male sex (OR = 2.3, p = 0.004), and a smaller SPT wheal size (OR = 1.5, p < 0.001). CONCLUSIONS A substantial number of patients referred for OIT are mislabeled with food allergy, suffer from unjustly food limitations and impairments in quality of life, and "take up" OIT places of true allergic patients. Awareness of OIT centers to this phenomenon is important. IMPACT A significant number (8.1%) of patients referred for OIT are found not allergic to the food they intended to treat. This study characterizes non-allergic patients referred for OIT (a lack of previous reaction to the index food, a smaller or negative SPT wheal size, and less atopic co-morbidities) and discusses the implications of such referrals. Increased awareness by OIT centers to potential non-allergic patients referred for OIT is required, including screening of patients before treatment initiation, to minimize unnecessary treatments of non-allergic patients.
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16
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Benelli E, Trombetta A, Badina L, Andrade S, Zamagni G, Prisco A, Traini E, Barbi E, Berti I. Risk factors for discontinuing oral immunotherapy in children with persistent cow milk allergy. Immun Inflamm Dis 2022; 10:e668. [PMID: 35759227 PMCID: PMC9208286 DOI: 10.1002/iid3.668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 11/14/2022] Open
Abstract
Background There are no universally accepted criteria for discontinuing milk oral immunotherapy (MOIT) in patients with persistent cow milk allergy (CMA) and little data are available on predictive risk factors for dropping out from oral immunotherapy (OIT), due to allergic reactions or other reasons. Methods We retrospectively reviewed clinical records of patients with persistent severe CMA undergoing MOIT in a tertiary care center hospital to investigate risk factors associated with discontinuation of OIT. Persistent and severe allergy was defined as the history of systemic reactions and any milk protein‐specific IgE level >85 kU/ml. All patients were first admitted for an in‐hospital rush phase eventually followed by an at‐home dose increase. We evaluated the effect of various factors on two primary outcomes: the highest dose of milk ingested during the in‐hospital rush phase and during the home OIT phase. Results We identified 391 patients, of whom 131 met the inclusion criteria for the retrospective study, 54 females and 77 males. Data of the home OIT phase were available for 104 patients (27%). Regarding the home OIT outcome, an association for having a cow milk avoiding diet was found with reaching a dose below 10 ml during the in‐hospital rush phase (relative risks [RR]: 2.33, confidence interval [CI]: 0.85; 6.42), an age above than 10 years from the time of admission (RR: 3.29, CI: 0.85; 12.73), and a higher total number of reactions occurred during the hospitalization (RR: 1.54, CI: 1.02; 2.32), whereas the presence of respiratory reactions with wheezing (RR: 1.93, CI: 0.49; 7.61) and an IM adrenaline use was related to a higher risk of having an OIT still in progress (RR: 5.47, CI: 0.33; 7.73). Conclusions In this cohort of children with persistent CMA undergoing OIT who presented with respiratory reactions with wheezing, the development of anaphylaxis with the need for IM adrenaline, and age above 10 years were predictors of poor long‐term outcome. This study shows that wheezing reactions during the in‐hospital phase admission, discharge with a dose below 10 ml, use of IM epinephrine, and older age (over 10 years) were all risk factors for OIT discontinuation. The provided phenotype of patients with a severe milk allergy who are more likely to fail OIT can help pediatricians to provide to their parents the elements to properly decide the most appropriate approach.
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Affiliation(s)
- Elisa Benelli
- Department of Pediatrics Ca'Foncello Hospital Treviso Italy
- University of Trieste Trieste Italy
| | | | - Laura Badina
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo” Trieste Italy
| | | | - Giulia Zamagni
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo” Trieste Italy
| | - Antonio Prisco
- Department of Pediatrics Università degli Studi della Campania Luigi Vanvitelli Napoli Italy
| | - Eugenio Traini
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo” Trieste Italy
| | - Egidio Barbi
- University of Trieste Trieste Italy
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo” Trieste Italy
| | - Irene Berti
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo” Trieste Italy
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17
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Fitzhugh DJ. Risk factors for reactions and adverse effects during oral immunotherapy. JOURNAL OF FOOD ALLERGY 2022; 4:60-64. [PMID: 39021860 PMCID: PMC11250548 DOI: 10.2500/jfa.2022.4.220028] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Oral immunotherapy (OIT) involves the potential for a variety of adverse events, which range from serious systemic reactions that require epinephrine to minimal oral reactions that require no treatment. This chapter describes common types of reactions seen in the course of OIT, reviews the frequency of and risk factors for different types of events as reported in recent literature (with a focus on real-world reports from private practice), and discusses treatment strategies for these adverse events. As the availability of OIT expands, it is paramount to ensure that allergists who offer OIT have a robust understanding of these reactions and mechanisms, with the overarching goal being the safety and tolerability of the therapy for the individual patient.
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Affiliation(s)
- David J Fitzhugh
- From the Allergy Partners of Chapel Hill, Chapel Hill, North Carolina
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18
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Duman Senol H, Topyildiz E, Ulusoy Severcan E, Eren Akercan S, Cigerci Gunaydin N, Gulen F, Demir E. Could Age and Oral Challenge Outcomes Identify High-Risk Patients During Cow's Milk Oral Immunotherapy? PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2022; 35:95-101. [PMID: 35675663 DOI: 10.1089/ped.2022.0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Objective: Severe immunglobuline E (IgE)-mediated reactions during oral immunotherapy (OIT) are major obstacles to treatment. The present study aimed to evaluate and identify clinical and laboratory biomarkers of adverse events during OIT among children with cow's milk (CM) allergy. Study Design: Eighty-six children older than 36 months who had undergone OIT with milk were enrolled. Clinical data, oral food challenge (OFC) test results, and laboratory data were recorded retrospectively. Results: The median duration of the build-up phase of OIT was 19 weeks (min 10-max 40) and the duration of the maintenance phase was 86.5 (min 1-max 132) months. A total of 11,767 CM doses were administered during the build-up phase and adverse reactions were seen in 62 (73.8%) patients with reactions registered for 157 doses among 11,767 (1/75 doses). The number of reactions during the maintenance phase was 41 (47.6%) in 24 (27.9%) patients. There was a significant reduction in the number of reactions (P = 0.000) between the build-up phase and maintenance phase. Adverse reactions and anaphylaxis were higher for patients who had cough during OFC (P = 0.003, P = 0.002, respectively) during the build-up phase and also during the maintenance phase too (P = 0.000). Evaluation for all reactions and anaphylaxis (during build-up and maintenance) with Kaplan-Meier and Cox regression analysis showed class IV-VI of CM-specific immunoglobulin E (sIgE), casein-sIgE and cough during OFC were significantly associated with increased probability of reaction and anaphylaxis. Younger age at onset of OIT was associated with risk reduction (0.017). Conclusion: Laboratory data and reactions during the OFC (especially cough) can help to identify high-risk patients during OIT.
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Affiliation(s)
- Handan Duman Senol
- Department of Pediatric Allergy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ezgi Topyildiz
- Department of Pediatric Allergy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ezgi Ulusoy Severcan
- Department of Pediatric Allergy, Health Sciences University Dr. Sami Ulus Gynecology, Obstetrics and Gynecology Education and Research Hospital, Ankara, Turkey
| | - Sanem Eren Akercan
- Department of Pediatric Allergy, Health Sciences University Tepecik Education and Research Hospital, Izmir, Turkey
| | - Nursen Cigerci Gunaydin
- Department of Pediatric Allergy, Namik Kemal University Faculty of Medicine, Tekirdağ, Turkey
| | - Figen Gulen
- Department of Pediatric Allergy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Esen Demir
- Department of Pediatric Allergy, Ege University Faculty of Medicine, Izmir, Turkey
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19
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Elizur A, Appel MY, Nachshon L, Levy MB, Epstein‐Rigbi N, Koren Y, Holmqvist M, Porsch H, Lidholm J, Goldberg MR. Cashew oral immunotherapy for desensitizing cashew-pistachio allergy (NUT CRACKER study). Allergy 2022; 77:1863-1872. [PMID: 35000223 DOI: 10.1111/all.15212] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 12/12/2021] [Accepted: 12/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Oral immunotherapy (OIT) is a treatment option for patients with milk, egg, and peanut allergy, but data on the efficacy and safety of cashew OIT are limited. METHODS A cohort of 50 cashew-allergic patients aged ≥4 years, who were consecutively enrolled into cashew OIT (target dose 4000 mg protein) between 4/2016 and 12/2019. Fifteen cashew-allergic patients who continued cashew elimination served as observational controls. Co-allergy to pistachio and walnut was determined. Full desensitization rate and associated immunological changes in both groups were compared. Patients fully desensitized to cashew were instructed to consume a dose of 1200 mg cashew protein for 6 months and were then challenged to a full dose. Patients with co-allergy to pistachio or walnut were challenged to the respective nut. RESULTS Forty-four of 50 OIT-treated patients (88%) compared to 0% in controls tolerated a dose of 4000 mg cashew protein at the end of the study (odds ratio 8.3, 95% CI 3.9-17.7, p < 0.001). An additional three patients were desensitized to 1200 mg cashew protein, and three patients stopped treatment. Three patients (6%) were treated with injectable epinephrine for home reactions. Desensitized patients had decreased SPT, sIgE, basophil reactivity, and increased sIgG4, following treatment. Following cashew desensitization, all pistachio (n = 35) and four of eight walnut co-allergic patients were cross-desensitized to the respective nut. All (n = 44) patients consuming a low cashew dose for ≥6 months following desensitization passed a full-dose cashew OFC. CONCLUSIONS Cashew OIT desensitizes most cashew-allergic patients and cross-desensitizes to pistachio. Safety is similar to OIT for other foods.
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Affiliation(s)
- Arnon Elizur
- Yitzhak Shamir Medical Center Institute of Allergy, Immunology and Pediatric Pulmonology Zerifin Israel
- Department of Pediatrics Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Michael Y. Appel
- Yitzhak Shamir Medical Center Institute of Allergy, Immunology and Pediatric Pulmonology Zerifin Israel
| | - Liat Nachshon
- Yitzhak Shamir Medical Center Institute of Allergy, Immunology and Pediatric Pulmonology Zerifin Israel
- Department of Medicine Sackler Faculty of Medicine Tel Aviv University Israel
| | - Michael B. Levy
- Yitzhak Shamir Medical Center Institute of Allergy, Immunology and Pediatric Pulmonology Zerifin Israel
| | - Naama Epstein‐Rigbi
- Yitzhak Shamir Medical Center Institute of Allergy, Immunology and Pediatric Pulmonology Zerifin Israel
- Department of Pediatrics Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Yael Koren
- Yitzhak Shamir Medical Center Institute of Allergy, Immunology and Pediatric Pulmonology Zerifin Israel
| | | | | | | | - Michael R. Goldberg
- Yitzhak Shamir Medical Center Institute of Allergy, Immunology and Pediatric Pulmonology Zerifin Israel
- Department of Pediatrics Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
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20
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Badina L, Burlo F, Belluzzi B, Babich S, Berti I, Barbi E. Life-threatening anaphylaxis in children with cow's milk allergy during oral immunotherapy and after treatment failure. Immun Inflamm Dis 2022; 10:e607. [PMID: 35349753 PMCID: PMC8962636 DOI: 10.1002/iid3.607] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/09/2022] [Accepted: 02/28/2022] [Indexed: 01/22/2023] Open
Abstract
Background Oral immunotherapy (OIT) is a promising therapeutic approach for children with persistent IgE‐mediated cow's milk allergy (CMA) but data are still limited. Objective To analyze the prevalence of life‐threatening anaphylaxis in children with persistent CMA undergoing OIT and to evaluate potential risk factors. Methods This is a retrospective cohort study among children with persistent CMA undergoing OIT over a 20‐year period, following a specific Oral Tolerance Induction protocol. Adverse reactions during the whole period and data on long‐term outcome were registered. Descriptive and nondescriptive statistics were used to describe data. Results Three hundred forty‐two children were evaluated. During OIT, 12 children (3.5%) presented severe anaphylactic reactions that needed an adrenaline injection. None required intubation, intensive care unit (ICU) admission, or showed a fatal outcome. Five of them abandoned OIT, five reached unrestricted diet and the others are still undergoing OIT. As far as outcome is concerned, 51.2% reached an unrestricted diet; 13.5% are at the build‐up stage; and 28.0% (97 patients) stopped the OIT. Among these 96 children, 6.3% experienced a severe reaction induced by accidental ingestion of milk with two fatal outcomes. Conclusions The risk of life‐threatening reactions was nearly two times lower (3.5% vs. 6.3%) among patients assuming milk during OIT than in those who stopped the protocol. A trend in favor of more severe reactions, requiring ICU admission, or fatal, was shown in patients who stopped OIT.
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Affiliation(s)
- Laura Badina
- Department of Pediatric, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Francesca Burlo
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Beatrice Belluzzi
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Sara Babich
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Irene Berti
- Department of Pediatric, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Egidio Barbi
- Department of Pediatric, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy.,Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
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21
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Nachshon L, Levy MB, Goldberg MR, Epstein-Rigbi N, Schwartz N, Katz Y, Elizur A. Triggers for Home Epinephrine-Treated Reactions During Oral Immunotherapy for Food Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1070-1076.e2. [PMID: 34982978 DOI: 10.1016/j.jaip.2021.12.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Home reactions requiring epinephrine treatment represent a significant obstacle to oral immunotherapy (OIT) and impair treatment outcome. OBJECTIVE To identify potential triggers for such reactions for improvement of patient safety. METHODS All patients aged older than 3.7 years who began an open-label OIT treatment program to milk, peanut, egg, sesame, or tree nuts in the Institute of Allergy, Immunology, and Pediatric Pulmonology at Shamir Medical Center between April 2010 and March 2018 were enrolled. Information on home epinephrine-treated reactions (HETRs) during the up-dosing phase of OIT was collected from the documentation in patients' files and the reports were transmitted by email and via a web reporting system. RESULTS A total 1,270 OIT treatments were included (milk 780; peanut 256; egg 63; sesame 72; and tree nuts 99). Home epinephrine was administered in 200 treatments (15.7%) and in 70 of them a second epinephrine-treated reaction occurred. The leading identified triggers for HETRs were physical exercise temporally associated with administration of home dose (20%), and dose consumption during infectious disease (16.7%), or when fatigued (13.8%). The rate of first HETRs was highest (10.1%) to doses of 500 mg protein or less and particularly to 300 mg or less. The occurrence of first HETRs was highest (35.5%) during the first and decreased to 13.8% by the last of the 4-week home-treatment phase. Second HETRs occurred in a similar rate throughout these 4 weeks. The incidence of HETRs was highest during pollen season and vacation months. CONCLUSIONS The identification of factors, some protocol-dependent, that trigger HETRs should assist in improving OIT safety.
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Affiliation(s)
- Liat Nachshon
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yankov, Zerifin, Israel; Department of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Michael B Levy
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yankov, Zerifin, Israel
| | - Michael R Goldberg
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yankov, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Epstein-Rigbi
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yankov, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Schwartz
- School of Public Health, University of Haifa, Haifa, Israel
| | - Yitzhak Katz
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yankov, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yankov, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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22
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Perrett KP, Sindher SB, Begin P, Shanks J, Elizur A. Advances, Practical Implementation, and Unmet Needs Regarding Oral Immunotherapy for Food Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:19-33. [PMID: 34785391 DOI: 10.1016/j.jaip.2021.10.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/07/2021] [Accepted: 10/25/2021] [Indexed: 06/13/2023]
Abstract
Treatment of food allergy is a rapidly changing landscape, with arguably, the most significant advancement in recent years, the transition of oral immunotherapy (OIT) to clinical practice. As an innovation, OIT is a phase of rapidly increasing demand, particularly for some allergens such as peanut, egg, and milk, which have substantial evidence of efficacy. However, significant questions remain about how to best treat multiple food allergies and less common food allergies and how to optimize long-term safety and efficacy. This review summarizes the currently available resources for integrating food allergy OIT into clinical practice and focuses on the multiple remaining unmet needs such as providing an approach for OIT to food allergens for which there is no or limited evidence; practical issues related to food allergy treatment particularly when it is not going well; long-term outcomes and follow-up after OIT; and strategies to help meet the impending increase in demand.
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Affiliation(s)
- Kirsten P Perrett
- Population Allergy, Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia.
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, California; Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford, California
| | - Philippe Begin
- Division of Allergy, Immunology and Rheumatology, CHU Sainte-Justine, Montréal, Canada
| | - Josiah Shanks
- Population Allergy, Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Be'er Ya'akov, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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23
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Oral Immunotherapy for Children with Cow's Milk Allergy. Pathogens 2021; 10:pathogens10101328. [PMID: 34684278 PMCID: PMC8539286 DOI: 10.3390/pathogens10101328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 09/30/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
Cow's milk allergy (CMA) is one of the most common IgE-dependent food allergies in children. Some children develop severe and persistent CMA, with near-fatal reactions after exposure to trace amounts of cow's milk (CM). Because milk and dairy products are included in various processed food products, it is difficult to completely remove milk, which negatively affects the quality of life of children with CMA. Oral immunotherapy (OIT) can alleviate food allergen-induced anaphylaxis under continuous ingestion of a little of the causative food. Children with severe CMA may benefit from OIT, but the treatment requires a long time and poses a risk of anaphylaxis. Moreover, in recent years, new therapies, including omalizumab, sublingual immunotherapy, and epicutaneous immunotherapy, have played the role of optional OIT. In this review, we present the current methods of and other attempts at OIT, and discuss OIT for safely treating CMA.
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Nachshon L, Goldberg MR, Levy MB, Epstein-Rigbi N, Koren Y, Elizur A. Home epinephrine-treated reactions in food allergy oral immunotherapy: Lessons from the coronavirus disease 2019 lockdown. Ann Allergy Asthma Immunol 2021; 127:451-455.e1. [PMID: 34010698 PMCID: PMC9338684 DOI: 10.1016/j.anai.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/20/2021] [Accepted: 05/09/2021] [Indexed: 11/28/2022]
Abstract
Background Oral immunotherapy (OIT) is effective in desensitizing patients with food allergy but adverse reactions limit its use. Objective To study the effect of the coronavirus disease 2019 lockdown in Israel between March 15, 2020, and April 30, 2020, on the incidence of home epinephrine-treated reactions. Methods All patients who were in the up-dosing phase of OIT for greater than or equal to 1 month during the lockdown, or a respective period in years 2015 to 2019, were studied. The incidence of home-epinephrine treated reactions during the 2020 lockdown was compared with that in the respective period in 2015 to 2019 and to periods before and after the lockdown. Results A total of 1163 OIT treatments were analyzed. Two epinephrine injections occurred during 2020 (0.7%) compared with 29 injections (3.28%) during 2015 to 2019 (P = .03). Patients treated in 2020 were older (8.1 vs 7 years, P < .01) and had a significantly lower single highest tolerated dose (12 vs 20 mg protein, P < .01). The rate of milk-OIT was lower (P = .01), but the total number of milk treatments was higher (99 vs 71 to 82) in 2020 compared with 2015 to 2019. On multivariate analysis, treatments during the 2020 lockdown were performed in older patients (P = .001), primarily for nonmilk (P = .03), began with a lower single highest tolerated dose (P = .006), and were associated with significantly less home epinephrine-treated reactions (P = .05) compared with those in 2015 to 2019. Patients treated in 2020 experienced more epinephrine-treated reactions in adjacent periods before (n = 8) and after (n = 6) the lockdown. Conclusion The lower rate of home epinephrine-treated reactions during the coronavirus disease 2019 lockdown in Israel suggests that potentially avoidable triggers contribute significantly to the rate of adverse reactions during OIT.
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Affiliation(s)
- Liat Nachshon
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel; Department of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Michael R Goldberg
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael B Levy
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel
| | - Naama Epstein-Rigbi
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Koren
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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25
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Graham F, Mack DP, Bégin P. Practical challenges in oral immunotherapy resolved through patient-centered care. Allergy Asthma Clin Immunol 2021; 17:31. [PMID: 33736692 PMCID: PMC7971360 DOI: 10.1186/s13223-021-00533-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/24/2021] [Indexed: 12/14/2022] Open
Abstract
Oral immunotherapy (OIT) is now widely recognized as a valid option for the management of IgE-mediated food allergies. However, in real-life practice, OIT can lead to a variety of unique situations where the best course of action is undetermined. In patient-centered care, individual patient preferences, needs and values, should guide all clinical decisions. This can be achieved by using shared-decision making and treatment customization to navigate areas of uncertainty in a way that is responsive to patient’s needs and preferences. However, in the context of OIT, lack of awareness of potential protocol adaptability or alternatives can become a barrier to treatment personalization. The purpose of this article is to review the theoretical bases of patient-centered care and shared decision-making and their practical implication for the patient-centered delivery of OIT. Clinical cases highlighting common challenges in real-life OIT practice are presented along with a discussion of potential personalized management options to be considered. While the practice of OIT is bound to evolve as additional scientific and experiential knowledge is gained, it should always remain rooted in the general principles of patient-centered care.
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Affiliation(s)
- François Graham
- Allergy and Immunology, Centre Hospitalier de L'Université de Montréal, Hôpital Notre-Dame, Montreal, QC, Canada.,Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, 3175 Chemin de la Cote Sainte-Catherine, Montréal, QC, H3T1C5, Canada
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Philippe Bégin
- Allergy and Immunology, Centre Hospitalier de L'Université de Montréal, Hôpital Notre-Dame, Montreal, QC, Canada. .,Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine, 3175 Chemin de la Cote Sainte-Catherine, Montréal, QC, H3T1C5, Canada.
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