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Trevisonno J, Venter C, Pickett-Nairne K, Bégin P, Cameron SB, Chan ES, Cook VE, Factor JM, Groetch M, Hanna MA, Jones DH, Wasserman RL, Mack DP. Age-Related Food Aversion and Anxiety Represent Primary Patient Barriers to Food Oral Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1809-1818.e3. [PMID: 38492666 DOI: 10.1016/j.jaip.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/01/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Although oral immunotherapy (OIT) for food allergy is a reasonable treatment option, barriers to this procedure's implementation have not been extensively evaluated from a patient perspective. OBJECTIVE We evaluated the barriers patients face during OIT administration, including anxiety and taste aversion, and the role of health care professionals, especially dietitians. METHODS A survey in Canada and the United States involved families currently enrolled in food OIT programs. RESULTS Of responses from 379 participants, fear of reaction was the most common barrier to OIT initiation, with 45.6% reporting it being a "very significant" barrier with other fears reported. However, taste aversion represented the prominent obstacle to continuation. Taste aversion was associated with a slower buildup (P = .02) and a reduction in dose (P = .002). Taste aversion was a strongly age-dependent barrier for initiation (P < .001) and continuation (P < .002), with older children over 6 years of age reporting it as a very significant barrier (P < .001). Boredom was reported as a concern for specific allergens such as peanut, egg, sesame, and hazelnuts (P < .05), emphasizing the need for diverse food options. Notably, 59.9% of respondents mixed OIT foods with sweet items. Despite these dietary concerns, dietitians were underutilized, with only 9.5% of respondents having seen a dietitian and the majority finding dietitian support helpful with greater certainty about the exact dose (P < .001). CONCLUSIONS Taste aversion and anxiety represent primary patient-related barriers to OIT. Taste aversion was highly age dependent, with older patients being more affected. Dietitians and psychology support were underutilized, representing a critical target to improve adherence and OIT success.
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Affiliation(s)
| | - Carina Venter
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado, Aurora, Colo
| | - Kaci Pickett-Nairne
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Philippe Bégin
- Section of Allergy, Department of Pediatrics, CHU Sainte-Justine, Montréal, QC, Canada; Section of Allergy, Department of Medicine, CHUM, Montréal, QC, Canada
| | - Scott B Cameron
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Victoria E Cook
- Division of Allergy, Department of Pediatrics, British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | | | - Marion Groetch
- Division of Pediatric Allergy & Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mariam A Hanna
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | | | | | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
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2
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Uhl C, Klevebro S, Sverremark-Ekström E, Tedner SG, Brandström J, Papageorgiou C, Melén E, Konradsen JR, Nilsson C, Asarnoj A. High Degree of Desensitization After 1 Year of Early-Life Peanut Oral Immunotherapy: Small Children Oral Immunotherapy (SmaChO) Randomized Controlled Trial. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1297-1305. [PMID: 38428524 DOI: 10.1016/j.jaip.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/02/2024] [Accepted: 02/21/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND The prevalence of peanut allergy is about 2% and mostly lifelong. Studies of oral immunotherapy (OIT) with peanut (the daily oral intake of an initially low and then increasing dose of peanut) often show problematic side effects, but there are indications of better safety and effect in younger children compared with older children and adults. OBJECTIVE To determine the safety and effectiveness of peanut OIT with a slow up-dosing strategy and low maintenance dose in children aged 1 to 3 years who were allergic to peanut, through a 1-year interim analysis. METHOD In a randomized controlled trial (2:1 ratio), 75 children, median age 31 months (interquartile range [IQR], 23-40 months) were assigned to receive peanut OIT (n = 50) or peanut avoidance (n = 25). RESULTS In the OIT and avoidance groups, 43 of 50 and 20 of 25 children, respectively, performed the 1-year open oral peanut challenge. A cumulative dose of 750 mg peanut protein after 1 year was tolerated by 72% (36 of 50 children) in the OIT group compared with 4% (1 of 25) in the avoidance group (P < .001). Median tolerated cumulative dose was 2,750 mg (IQR, 275-5,000 mg) peanut protein in the OIT group compared with 2.8 mg (IQR, 0.3-27.8 mg) in the avoidance group (P < .001). Of the doses administered at home during the first year of OIT, 1.4% resulted in adverse events and 79% were mild, and three doses of epinephrine were given at home to two individuals. CONCLUSION In children aged 1 to 3 years, peanut OIT with the combination of slow up-dosing and low maintenance dose seems safe and effective after 1 year.
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Affiliation(s)
- Carina Uhl
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Susanna Klevebro
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.
| | - Eva Sverremark-Ekström
- Department of Molecular Biosciences, Wenner-Gren Institute, Stockholm University, Stockholm, Sweden
| | - Sandra G Tedner
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Josef Brandström
- Department of Neonatology, Astrid Lindgrens Childreńs Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Chrystalleni Papageorgiou
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Erik Melén
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Jon R Konradsen
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Pediatric Allergy and Pulmonology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Nilsson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Anna Asarnoj
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Pediatric Allergy and Pulmonology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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3
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Sampson HA, Bird JA, Fleischer D, Shreffler WG, Spergel JM. Who are the potential patients for omalizumab for food allergy? Ann Allergy Asthma Immunol 2024; 132:569-571. [PMID: 38479711 DOI: 10.1016/j.anai.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 03/24/2024]
Affiliation(s)
- Hugh A Sampson
- Division of Pediatric Allergy and Immunology, Jaffe Food Allergy Institute, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - J Andrew Bird
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David Fleischer
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Wayne G Shreffler
- Division of Pediatric Allergy and Immunology and Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania.
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4
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Ezhuthachan ID, Beaudoin M, Nowak-Wegrzyn A, Vickery BP. The Future of Food Allergy Management: Advancements in Therapies. Curr Allergy Asthma Rep 2024; 24:161-171. [PMID: 38393624 DOI: 10.1007/s11882-024-01133-1] [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: 02/05/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE OF REVIEW To review current and future treatment options for IgE-mediated food allergy. RECENT FINDINGS Recent years have seen major developments in both allergen-specific and allergen-non-specific treatment options, with the first FDA-approved peanut oral immunotherapy (OIT) product becoming available in 2020. In addition to OIT, other immunotherapy modalities, biologics, adjunct therapies, and novel therapeutics are under investigation. Food allergy is a potentially life-threatening condition associated with a significant psychosocial impact. Numerous products and protocols are under investigation, with most studies focusing on OIT. A high rate of adverse events, need for frequent office visits, and cost remain challenges with OIT. Further work is needed to unify outcome measures, develop treatment protocols that minimize adverse events, establish demographic and clinical factors that influence candidate selection, and identify patient priorities.
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Affiliation(s)
- Idil D Ezhuthachan
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.
- Children's Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA, 30329, USA.
| | - Michele Beaudoin
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, NY, USA
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, NY, USA
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Brian P Vickery
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Children's Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA, 30329, USA
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5
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Dantzer JA, Kim EH. New Approaches to Food Allergy Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:546-552. [PMID: 37852441 DOI: 10.1016/j.jaip.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/04/2023] [Indexed: 10/20/2023]
Abstract
Food allergy is an increasing public health problem in children and adults. In addition to the risk of potentially severe reactions, food allergy can have a significant burden on quality of life, nutrition, cost of living, and social activities. Traditionally, treatment has primarily included strict food allergen avoidance and use of emergency medications to treat an allergic reaction. However, in recent years, there have been significant strides in the advancement of food allergy treatment, including the approval of the first and only approved therapy (peanut oral immunotherapy) for food allergy in 2020. Clinical trials have primarily focused on food allergen immunotherapy (oral, epicutaneous, sublingual). Building off of a foundation of promising data supporting the efficacy of food oral immunotherapy and our greater understanding of the underlying mechanism of immunotherapy, newer approaches, including alternative routes of delivery, adjuncts to therapy, modified allergens, and utilization in younger patients, aim to provide safer and more effective treatment approaches to the millions of patients burdened by food allergy.
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Affiliation(s)
- Jennifer A Dantzer
- Johns Hopkins University School of Medicine, Division of Pediatric Allergy, Immunology, and Rheumatology, Baltimore, Md.
| | - Edwin H Kim
- University of North Carolina School of Medicine, Division of Pediatric Allergy and Immunology, Chapel Hill, NC
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Bartha I, Almulhem N, Santos AF. Feast for thought: A comprehensive review of food allergy 2021-2023. J Allergy Clin Immunol 2024; 153:576-594. [PMID: 38101757 PMCID: PMC11096837 DOI: 10.1016/j.jaci.2023.11.918] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 11/19/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023]
Abstract
A review of the latest publications in food allergy over the past couple of years confirmed that food allergy is a major public health concern, affecting about 8% of children and 10% of adults in developed countries. The prevalence of food allergy varies around the world, with the increase being driven mainly by environmental factors, possibly together with genetic susceptibility to environmental changes. A precise diagnosis of food allergy is extremely important. Both new tests (eg, the basophil activation test) and improved optimization of information provided by existing tests (eg, the skin prick test and measurement of specific IgE level) can contribute to improving the accuracy and patients' comfort of food allergy diagnosis. Understanding the underlying immune mechanisms is fundamental to designing allergen-specific treatments that can be safe and effective in the long term. New discoveries of the immune response to food allergens, including T-cell and B-cell responses, have emerged. Novel therapeutic approaches are being trialed at various stages of development as attempts to allow for more active intervention to treat food allergy. Prevention is key to reducing the increase in prevalence. Early introduction of allergenic foods seems to be the most effective intervention, but others are being studied, and will, it is hoped, lead to modification of the epidemiologic trajectory of food allergy over time.
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Affiliation(s)
- Irene Bartha
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences King's College London, London, United Kingdom
| | - Noorah Almulhem
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; Department of Otolaryngology Head and Neck Surgery, King Fahad Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Alexandra F Santos
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences 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.
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7
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Chua GT, Soller L, Kapur S, McHenry M, Rex GA, Cook VE, Cameron SB, Chan ES, Yeung J, Erdle SC. Real-world safety and effectiveness analysis of low-dose preschool sesame oral immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100171. [PMID: 37915725 PMCID: PMC10616424 DOI: 10.1016/j.jacig.2023.100171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/04/2023] [Accepted: 07/20/2023] [Indexed: 11/03/2023]
Abstract
Background Previous studies support the effectiveness of sesame oral immunotherapy (S-OIT) in patients >4 years old using maintenance doses of 1200 mg protein. However, tahini is often not palatable to children, and high-maintenance doses may not be possible for preschoolers. Objective We studied the safety and effectiveness outcomes of preschoolers with sesame allergy who underwent low-dose S-OIT of 200 mg protein. Methods Preschoolers with sesame allergy, with a history of objective reaction to sesame, and with either a positive skin prick test result (wheal diameter ≥3 mm) or sesame-specific IgE level ≥0.35 kU/L were included. Doses were escalated every 2 to 4 weeks until the maintenance dose of 200 mg of sesame protein was reached. The maintenance dose was continued daily for 1 year, followed by exit oral food challenge (OFC). Primary safety outcomes included allergic reactions grade 2 or higher and the need for epinephrine therapy during buildup. The primary effectiveness outcome was proportion of patients tolerating a minimum of 2000 mg sesame protein at exit OFC. Results Twenty-eight preschoolers (median age, 33.5 months) were enrolled to receive S-OIT. During the buildup phase, 9 subjects (32.1%) had no reaction, and 8 (28.6%) and 11 (39.3%) had grade 1 and 2 reactions, respectively. One patient (3.57%) received epinephrine for a grade 2 reaction. Twenty-one (91.3%) of 23 eligible subjects underwent exit OFC; 18 (85.7%) of these 21 patients successfully completed exit OFC. One (4.8%) and 2 (9.5%) subjects had grade 1 and 2 reactions, respectively, during OFC. Conclusions A lower and age-appropriate maintenance dose is safe and effective in desensitizing preschoolers with sesame allergy.
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Affiliation(s)
- Gilbert T. Chua
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Allergy Centre, Union Hospital, Hong Kong, China
- Department of Paediatrics, The University of Hong Kong–Shenzhen Hospital, Shenzhen, China
| | - Lianne Soller
- Division of Allergy, Department of Pediatrics, University of British Columbia, BC Children’s Hospital, Vancouver, British Columbia
| | - Sandeep Kapur
- Division of Allergy, Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada
- Halifax Allergy and Asthma Associates, Halifax, Nova Scotia, Canada
| | - Mary McHenry
- Division of Allergy, Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada
- Halifax Allergy and Asthma Associates, Halifax, Nova Scotia, Canada
| | - Gregory A. Rex
- Division of Allergy, Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada
- Halifax Allergy and Asthma Associates, Halifax, Nova Scotia, Canada
| | - Victoria E. Cook
- Division of Allergy, Department of Pediatrics, University of British Columbia, BC Children’s Hospital, Vancouver, British Columbia
- Community Allergy Clinic, Victoria, British Columbia
| | - Scott B. Cameron
- Division of Allergy, Department of Pediatrics, University of British Columbia, BC Children’s Hospital, Vancouver, British Columbia
- Community Allergy Clinic, Victoria, British Columbia
| | - Edmond S. Chan
- Division of Allergy, Department of Pediatrics, University of British Columbia, BC Children’s Hospital, Vancouver, British Columbia
| | - Joanne Yeung
- Division of Allergy, Department of Pediatrics, University of British Columbia, BC Children’s Hospital, Vancouver, British Columbia
| | - Stephanie C. Erdle
- Division of Allergy, Department of Pediatrics, University of British Columbia, BC Children’s Hospital, Vancouver, British Columbia
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8
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Barten LJC, Zuurveld M, Faber J, Garssen J, Klok T. Oral immunotherapy as a curative treatment for food-allergic preschool children: Current evidence and potential underlying mechanisms. Pediatr Allergy Immunol 2023; 34:e14043. [PMID: 38010006 DOI: 10.1111/pai.14043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/10/2023] [Accepted: 10/19/2023] [Indexed: 11/29/2023]
Abstract
The worldwide rising prevalence of food allergy is a major public health concern. Standard care consists of allergen avoidance and rescue medication upon accidental exposure. Oral immunotherapy (OIT) is increasingly being studied as a treatment option. Although desensitization (an increased reaction threshold) is often achieved during OIT, sustained unresponsiveness (SU; clinical nonreactivity after finishing OIT) is not achieved in most patients. A few studies have investigated the effectiveness of OIT in children younger than 4 years of age (early = e-OIT) and have shown a much more favorable outcome in terms of SU development. Together with food allergy prevention studies, which have demonstrated high efficacy of early oral allergen exposure, the outcomes of e-OIT studies indicate an early-life window of opportunity to achieve SU, allowing unrestricted dietary intake. However, the underlying mechanism of the high effectiveness of e-OIT is not understood yet. Both cohort and OIT studies indicate early-life immune plasticity. An immature food-allergic response in the first years of life seems to be a major driver of this immune plasticity, along with a higher tolerogenic immunological state. Allergy maturation can likely be disrupted effectively by early intervention, preventing the development of persistent food allergy. Upcoming studies will provide important additional data on the safety, feasibility, and effectiveness of e-OIT. Combined with immune mechanistic studies, this should inform the implementation of e-OIT.
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Affiliation(s)
- Lieke J C Barten
- Pediatric Allergy Treatment Center, Deventer Hospital, Deventer, The Netherlands
- Utrecht Institute for Pharmaceutical Sciences, Division Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Marit Zuurveld
- Utrecht Institute for Pharmaceutical Sciences, Division Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Joyce Faber
- Pediatric Allergy Treatment Center, Deventer Hospital, Deventer, The Netherlands
| | - Johan Garssen
- Utrecht Institute for Pharmaceutical Sciences, Division Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - Ted Klok
- Pediatric Allergy Treatment Center, Deventer Hospital, Deventer, The Netherlands
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O'Sullivan MD, Bear N, Metcalfe J. Early Peanut Immunotherapy in Children (EPIC) trial: protocol for a pragmatic randomised controlled trial of peanut oral immunotherapy in children under 5 years of age. BMJ Paediatr Open 2023; 7:e002294. [PMID: 37963680 PMCID: PMC10649730 DOI: 10.1136/bmjpo-2023-002294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/12/2023] [Indexed: 11/16/2023] Open
Abstract
INTRODUCTION Food allergy is a major public health challenge in Australia. Despite widespread uptake of infant feeding and allergy prevention guidelines the incidence of peanut allergy in infants has not fallen, and prevalence of peanut allergy in school-aged children continues to rise. Therefore, effective and accessible treatments for peanut allergy are required. There is high-quality evidence for efficacy of oral immunotherapy in children aged 4-17 years old; however, few randomised trials have investigated peanut oral immunotherapy (OIT) in young children. Furthermore, the use of food products for OIT with doses prepared and administered by parents without requiring pharmacy compounding has the potential to reduce costs associated with the OIT product. METHODS AND ANALYSIS Early Peanut Immunotherapy in Children is an open-label randomised controlled trial of peanut OIT compared with standard care (avoidance) to induce desensitisation in children aged 1-4 years old with peanut allergy. n=50 participants will be randomised 1:1 to intervention (daily peanut OIT for 12 months) or control (peanut avoidance). The primary outcome is the proportion of children in each group with a peanut eliciting dose >600 mg peanut protein as assessed by open peanut challenge after 12 months, analysed by intention to treat. Secondary outcomes include safety as assessed by frequency and severity of treatment-related adverse events, quality of life measured using age-appropriate food allergy-specific questionnaires and immunological changes during OIT. ETHICS The trial is approved by the Child and Adolescent Health Service Human Research Ethics Committee and prospectively registered with the Australia and New Zealand Clinical Trials Registry. DISSEMINATION Trial outcomes will be published in a peer-review journal and presented and local and national scientific meetings. TRIAL REGISTRATION NUMBER ACTRN12621001001886.
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Affiliation(s)
- Michael David O'Sullivan
- Immunology Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
- The University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Natasha Bear
- Immunology Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Jessica Metcalfe
- Immunology Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Telethon Kids Institute, Nedlands, Western Australia, Australia
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Wanniang N, Boehm TM, Codreanu-Morel F, Divaret-Chauveau A, Assugeni I, Hilger C, Kuehn A. Immune signatures predicting the clinical outcome of peanut oral immunotherapy: where we stand. FRONTIERS IN ALLERGY 2023; 4:1270344. [PMID: 37849958 PMCID: PMC10577271 DOI: 10.3389/falgy.2023.1270344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/11/2023] [Indexed: 10/19/2023] Open
Abstract
Peanut allergy is a growing health concern that can cause mild to severe anaphylaxis as well as reduced quality of life in patients and their families. Oral immunotherapy is an important therapeutic intervention that aims to reshape the immune system toward a higher threshold dose reactivity and sustained unresponsiveness in some patients. From an immunological point of view, young patients, especially those under 3 years old, seem to have the best chance for therapy success. To date, surrogate markers for therapy duration and response are evasive. We provide a comprehensive overview of the current literature state regarding immune signatures evolving over the course of oral immunotherapy as well as baseline immune conditions prior to the initiation of treatment. Although research comparing clinical and immune traits in the first years of life vs. later stages across different age groups is limited, promising insights are available on immunological endotypes among peanut-allergic patients. The available data call for continued research to fill in gaps in knowledge, possibly in an integrated manner, to design novel precision health approaches for advanced therapeutic interventions in peanut allergy.
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Affiliation(s)
- Naphisabet Wanniang
- 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
| | - Theresa-Maria Boehm
- 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
| | - Amandine Divaret-Chauveau
- Pediatric Allergy Department, Children’s Hospital, University of Nancy, Vandœuvre-lès-Nancy, France
- EA3450 DevAH, Faculty of Medecine, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Isabela Assugeni
- 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
| | - Christiane Hilger
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
| | - Annette Kuehn
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
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Bastin M, Carr WW, Davis CM, Fleischer DM, Lieberman JA, Mustafa SS, Helleputte T, Bois T, Campbell DE, Green TD, Greenhawt M. Immune response evolution in peanut epicutaneous immunotherapy for peanut-allergic children. Allergy 2023; 78:2467-2476. [PMID: 36916639 DOI: 10.1111/all.15709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 02/07/2023] [Accepted: 02/17/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND Epicutaneous immunotherapy with investigational Viaskin™ Peanut 250 μg (DBV712) has demonstrated statistically superior desensitization versus placebo in peanut-allergic children in clinical trials. It is unclear whether serologic biomarkers predict response. METHODS Serum-specific IgG4 and IgE (whole peanut and components) from subjects enrolled in the phase 3 Efficacy and Safety of Viaskin Peanut in Children With IgE-Mediated Peanut Allergy study were examined by exploratory univariate and multivariate analyses to determine trajectories and predictors of treatment response, based upon peanut protein eliciting dose (ED) at Month (M) 12 double-blind placebo-controlled food challenge. RESULTS Among Viaskin Peanut-treated subjects, peanut sIgG4 significantly increased from baseline through M12 and peanut sIgE peaked at M3 and fell below baseline by M12, with sIgG4 and sIgE peanut components mirroring these trajectories. Placebo subjects had no significant changes. By univariate analysis, M12 peanut sIgG4/sIgE was higher in treatment responders (p < 0.001) and had highest area under the curve (AUC) for predicting ED ≥300 mg and ≥1000 mg (AUC 69.5% and 69.9%, respectively). M12 peanut sIgG4/sIgE >20.1 predicted M12 ED ≥300 mg (80% positive predictive value). The best performing component was Ara h 1 sIgE <15.7 kUA /L (AUC 66.5%). A multivariate model combining Ara h 1 and peanut sIgG4/sIgE had an AUC of 68.2% (ED ≥300 mg) and 67.8% (ED ≥1000 mg). CONCLUSIONS Peanut sIgG4 rise most clearly differentiated Viaskin Peanut versus placebo subjects. sIgG4/sIgE ratios >20.1 and the combination of Ara h 1 and peanut sIgG4/sIgE had moderate ability to predict treatment response and could potentially be useful for clinical monitoring. Additional data are needed to confirm these relationships.
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Affiliation(s)
| | - Warner W Carr
- Allergy and Asthma Associates of Southern California, Southern California Research, California, Mission Viejo, USA
| | - Carla M Davis
- Department of Pediatrics, Immunology, Allergy, and Retrovirology Division, Baylor College of Medicine, Houston, Texas, USA
| | - David M Fleischer
- Children's Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Jay A Lieberman
- The University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - S Shahzad Mustafa
- Rochester Regional Health, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | | | | | | | - Todd D Green
- DBV Technologies SA, Montrouge, France
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Matthew Greenhawt
- Children's Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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Chua GT, Greenhawt M, Shaker M, Soller L, Abrams EM, Cameron SB, Cook VE, Erdle SC, Fleischer DM, Mak R, Vander Leek TK, Chan ES. Real-world data are critical for the implementation of preschool food allergen immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2624-2625. [PMID: 37558366 DOI: 10.1016/j.jaip.2023.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/23/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Gilbert T Chua
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China; Allergy Centre, Union Hospital, Hong Kong SAR, China.
| | - Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Marcus Shaker
- Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Lianne Soller
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Elissa M Abrams
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Man, Canada
| | - Scott B Cameron
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | - Victoria E Cook
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; Community Allergy Clinic, Victoria, BC, Canada
| | - Stephanie C Erdle
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - David M Fleischer
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Raymond Mak
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Timothy K Vander Leek
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alta, Canada
| | - Edmond S Chan
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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13
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Bjelac J, Shaker M, Greenhawt M, Kodish E. Viewing Pediatric Food Oral Immunotherapy Through an Ethical Lens-A Narrative Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1914-1925. [PMID: 36965706 DOI: 10.1016/j.jaip.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/31/2023] [Accepted: 03/11/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Food allergy remains a common problem and a lifelong condition for many children. In recent years, food allergy management has increasingly involved conversations about food oral immunotherapy (OIT). Although ethical considerations of autonomy, beneficence, nonmaleficence, and justice implicitly inform these conversations, applying these principles can be complex, particularly in young children. Families of young children assume a role of surrogate decision-maker and must balance immediate risks with the hope of longer-term benefits. OBJECTIVE To explore implementation of OIT in children through an ethical lens. METHODS To evaluate OIT through an ethical lens, we conducted a literature search to explore currently published frameworks in this area. RESULTS Evaluation of the harm principle, the basic interest principle, and the best interest principle of parental decision-making can be informative. Shared decision-making continues to be central to the process of engaging with patient-family units to individualize the best care, at the right time, and minimize decisional discord. Although OIT is well-positioned to promote health and well-being, challenges to equity, sustainability, and organizational support must be considered to improve access for appropriate patients. CONCLUSIONS Whereas approaches to food OIT may be tailored to the individual context of each patient-family unit, ethical principles must guide decisions to initiate and continue therapy. Traditional ethical principles of autonomy, beneficence, nonmaleficence, and justice remain cornerstones when considering the ethical context of OIT.
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Affiliation(s)
- Jaclyn Bjelac
- Food Allergy Center of Excellence, Center for Pediatric Allergy and Immunology, Cleveland Clinic, Cleveland, Ohio.
| | - Marcus Shaker
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Eric Kodish
- Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic Children's and Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
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Abstract
Background Across the practice of allergy and clinical immunology, disruptive innovations have accelerated the adoption of shared decision-making (SDM) to improve the health of patients and populations, particularly with regard to food allergy prevention and management of food allergy and anaphylaxis. Methods A narrative review was performed to describe recent innovations in shared decision-making, risk communication, and food allergy. Results Several challenges, primarily related to the coronavirus disease 2019 (COVID-19) pandemic and misinformation campaigns, have catalyzed adaptations to evolve clinical care. Recent pressures have facilitated the rapid adoption of telemedicine. In 2023, many allergist/immunologists routinely incorporate both in-person and virtual visits to contextually deliver value-based care to each patient. SDM may occur in a hybrid model that incorporates both in-person and virtual encounters, with many patients experiencing benefit from a combination approach. This may be facilitated by leveraging previsit web-based SDM tools. Whether in person or by telemedicine, effective risk communication to avoid cognitive overload while appreciating population variation in numeracy is key to competent implementation of SDM. Misinformation continues to disproportionately harm patients who belong to groups that encourage denial of evidence-based medical recommendations and COVID-19 vaccination intent correlating with sociopolitical factors. Still, strategies to address misinformation that leverage empathy, respect, and expertise can help to mitigate these effects. Physician wellness is a key component to realization of the Quadruple Aim of health care, and the use of positive framing and appreciative inquiry can help to optimize outcomes and improve value in health care. Conclusion SDM is an important component to consider when incorporating recent innovations in allergy and clinical immunology care, particularly in the setting of contextual and conditional medical recommendations. Effective risk communication is critical to SDM that is truly reflective of patient goals and preferences, and can be facilitated through in-person encounters, telemedicine, and hybrid models. It is important to foster physician wellness as a component of the Quadruple Aim, particularly in the recent pandemic climate of misinformation and denial of evidence-based medicine within large groups of society.
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Affiliation(s)
- Marcus Shaker
- From the Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, and
- Department of Medicine and Pediatrics, Dartmouth Geisel School of Medicine, Hanover, New Hampshire
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15
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Karunakaran D, Chan ES, Zhang Q, Bone JN, Carr S, Kapur S, Rex GA, McHenry M, Cameron SB, Cook VE, Leo S, Wong T, Gerstner TV, Yeung J, Abrams EM, Mak R, Erdle SC, Soller L. Risk factors associated with safety of preschool peanut oral immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100094. [PMID: 37780798 PMCID: PMC10510002 DOI: 10.1016/j.jacig.2023.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/25/2023] [Accepted: 02/07/2023] [Indexed: 10/03/2023]
Abstract
Background An understanding of how patient characteristics such as age, baseline peanut-specific IgE, and atopic comorbidities may influence potential safety outcomes during peanut oral immunotherapy (P-OIT) could aid in shared decision making between clinicians and patient families. Objective This study explored the relationship between baseline patient characteristics and reactions during P-OIT using a large sample size to better understand potential risk factors influencing P-OIT safety. Methods Data were obtained from the Food Allergy Immunotherapy (FAIT) registry, which collects real-world OIT data from community and academic allergy clinics across Canada. Multivariable logistic regression modeling was performed to examine the relationship between baseline patient characteristics and reactions during P-OIT. Multiple imputation was applied to reduce potential bias caused by missingness and to maximize the use of available information to preserve statistical power. Results Between April 2017 and June 2021, a total of 653 eligible patients initiated P-OIT. Multivariable regression analysis showed pre-OIT grade 2+ initial reaction (odds ratio [OR] = 1.33, 95% confidence interval [CI] 1.10, 1.61), allergic rhinitis (OR = 1.60, 95% CI 1.08, 2.38), older age (OR = 1.01, 95% CI 1.00, 1.02), and higher baseline peanut-specific IgE (OR = 1.02, 95% CI 1.02, 1.03) were associated with grade 2+ reaction during P-OIT after adjusting for potential risk factors. Conclusion Our study identified several clinically important risk factors for grade 2+ reactions during P-OIT: pre-OIT grade 2+ initial reaction, allergic rhinitis, older age, and higher baseline peanut-specific IgE. These results highlight the need for individualized risk stratification for OIT.
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Affiliation(s)
- Duva Karunakaran
- British Columbia Children’s Hospital, Vancouver, British Columbia
- Department of Medicine, Queen’s University, Kingston, Ontario
| | - Edmond S. Chan
- British Columbia Children’s Hospital, Vancouver, British Columbia
- Department of Pediatrics, Division of Allergy, University of British Columbia, Vancouver, British Columbia
| | - Qian Zhang
- British Columbia Children’s Hospital, Vancouver, British Columbia
| | - Jeffrey N. Bone
- British Columbia Children’s Hospital, Vancouver, British Columbia
| | - Stuart Carr
- Snö Asthma & Allergy Clinic, Abu Dhabi, United Arab Emirates
| | - Sandeep Kapur
- Department of Pediatrics, Division of Allergy, Dalhousie University/IWK Health Centre, Halifax
- Halifax Allergy & Asthma Associates, Halifax, Nova Scotia
| | - Gregory A. Rex
- Department of Pediatrics, Division of Allergy, Dalhousie University/IWK Health Centre, Halifax
- Halifax Allergy & Asthma Associates, Halifax, Nova Scotia
| | - Mary McHenry
- Department of Pediatrics, Division of Allergy, Dalhousie University/IWK Health Centre, Halifax
- Halifax Allergy & Asthma Associates, Halifax, Nova Scotia
| | - Scott B. Cameron
- Department of Pediatrics, Division of Allergy, University of British Columbia, Vancouver, British Columbia
- Community Allergy Clinic, Victoria, British Columbia
| | - Victoria E. Cook
- Department of Pediatrics, Division of Allergy, University of British Columbia, Vancouver, British Columbia
- Community Allergy Clinic, Victoria, British Columbia
| | - Sara Leo
- Department of Pediatrics, Division of Allergy, University of British Columbia, Vancouver, British Columbia
- West Coast Allergy and Immunology Clinic, Vancouver, British Columbia
| | - Tiffany Wong
- British Columbia Children’s Hospital, Vancouver, British Columbia
- Department of Pediatrics, Division of Allergy, University of British Columbia, Vancouver, British Columbia
| | - Thomas V. Gerstner
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba
- Meadowood Medical Center, Winnipeg, Manitoba
| | - Joanne Yeung
- Department of Pediatrics, Division of Allergy, University of British Columbia, Vancouver, British Columbia
- Meadowood Medical Center, Winnipeg, Manitoba
- Vancouver Kids Allergy, Vancouver, British Columbia
| | - Elissa M. Abrams
- Department of Pediatrics, Division of Allergy, University of British Columbia, Vancouver, British Columbia
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba
- Meadowood Medical Center, Winnipeg, Manitoba
| | - Raymond Mak
- British Columbia Children’s Hospital, Vancouver, British Columbia
- Department of Pediatrics, Division of Allergy, University of British Columbia, Vancouver, British Columbia
| | - Stephanie C. Erdle
- British Columbia Children’s Hospital, Vancouver, British Columbia
- Department of Pediatrics, Division of Allergy, University of British Columbia, Vancouver, British Columbia
| | - Lianne Soller
- British Columbia Children’s Hospital, Vancouver, British Columbia
- Department of Pediatrics, Division of Allergy, University of British Columbia, Vancouver, British Columbia
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16
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Loke P, Vickery BP, Jones SM, Peters RL, Roberts G, Koplin JJ. Food Allergen Immunotherapy in Preschool Children: Do We Have the Evidence? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1028-1035. [PMID: 36649799 DOI: 10.1016/j.jaip.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/26/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
Standard care for the management of food allergies previously centered on allergen avoidance and the treatment of adverse reactions after allergen exposure. An increase in the development of immunotherapy treatments for food allergy has occurred over the past 2 decades, with many centers now offering immunotherapy. Previous studies mainly focused on school-age children in whom food allergies are likely to be persistent. However, there is increasing evidence that delivering immunotherapy for food allergy to preschool-age children may deliver higher rates of success, and that peanut allergen immunotherapy leads the way. Conversely, the natural resolution of food allergies occurs primarily in these younger age groups, resulting in challenges to selecting patients who will ultimately benefit from these treatments. Both immunotherapy and natural history studies reveal the inherent plasticity of the immune system in early life, which may be more amenable to intervention, but this raises a delicate yet unknown balance between the optimal timing of intervention versus waiting for natural resolution of the food allergy. Here we review the evidence for early food allergen immunotherapy in preschoolers, and present the pros and cons of this approach while acknowledging important research gaps in this age group.
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Affiliation(s)
- Paxton Loke
- Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Monash Children's Hospital, Melbourne, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Australia.
| | - Brian P Vickery
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Ga
| | - Stacie M Jones
- Department of Pediatrics, Allergy, and Immunology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Rachel L Peters
- Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Graham Roberts
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; David Hide Asthma and Allergy Centre, St Mary's Hospital, Isle of Wight, United Kingdom
| | - Jennifer J Koplin
- Murdoch Children's Research Institute, Melbourne, Australia; Child Health Research Centre, University of Queensland, Brisbane, Australia
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ITO chez le jeune enfant de moins de 4 ans : pourquoi, comment, résultats ? REVUE FRANÇAISE D'ALLERGOLOGIE 2023. [DOI: 10.1016/j.reval.2023.103290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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18
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Erdle SC, Cook VE, Cameron SB, Yeung J, Kapur S, McHenry M, Chan ES, Mak R, Rex GA, Wong T, Soller L. Real-World Safety Analysis of Preschool Tree Nut Oral Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1177-1183. [PMID: 36736958 DOI: 10.1016/j.jaip.2023.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Our group previously described preschool peanut oral immunotherapy (OIT) in a real-world, multicenter setting, suggesting that this therapy is safe for most preschoolers. OBJECTIVE To examine the safety and tolerability of tree nut (TN) OIT in preschoolers in the real world. METHODS As part of a Canada-wide quality improvement project, TN-OIT (cashew/pistachio, walnut/pecan, hazelnut, almond, and macadamia nut) was performed in preschoolers who had (1) a skin prick test wheal diameter greater than or equal to 3 mm or a specific IgE level greater than or equal to 0.35 kU/L and a convincing objective IgE-mediated reaction or (2) no ingestion history and a specific IgE level greater than or equal to 5 kU/L. Dose escalations were performed every 2 to 4 weeks till a maintenance dose of 300 mg of TN protein was reached. Symptoms were recorded and classified using the modified World Allergy Organization Subcutaneous Immunotherapy Reaction Grading System (1, mildest; 5, fatal). RESULTS Of the 92 patients who started TN-OIT from 2018 to 2021, 79 (85.9%) underwent single-food TN-OIT and 13 (14.1%) underwent multifood TN-OIT to 2 (10.8%) or 3 (3.3%) TNs. Eighty-nine (96.7%) patients reached maintenance, and 4 (4.3%) dropped out. Sixty-five (70.7%) patients experienced reactions during buildup: 35 (38.0%) grade 1 reactions, 30 (32.6%) grade 2 reactions, no grade 3 or 4 reactions, and 2 (2.17%) received epinephrine. CONCLUSIONS Preschool TN-OIT in a real-world, multicenter setting appears safe and tolerable, with results comparable with our previously reported peanut OIT findings.
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Affiliation(s)
- Stephanie C Erdle
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada.
| | - Victoria E Cook
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada; Community Allergy Clinic, Victoria, British Columbia, Canada
| | - Scott B Cameron
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada; Community Allergy Clinic, Victoria, British Columbia, Canada
| | - Joanne Yeung
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada; Vancouver Kids Allergy, Vancouver, British Columbia, Canada
| | - Sandeep Kapur
- Division of Allergy, Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada; Halifax Allergy and Asthma Associates, Halifax, Nova Scotia, Canada
| | - Mary McHenry
- Division of Allergy, Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada; Halifax Allergy and Asthma Associates, Halifax, Nova Scotia, Canada
| | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Raymond Mak
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Gregory A Rex
- Division of Allergy, Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada; Halifax Allergy and Asthma Associates, Halifax, Nova Scotia, Canada
| | - Tiffany Wong
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Lianne Soller
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada
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Management of Anaphylaxis During Peanut Oral Immunotherapy. Curr Allergy Asthma Rep 2023; 23:21-27. [PMID: 36445653 DOI: 10.1007/s11882-022-01054-x] [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: 10/03/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Peanut oral immunotherapy (POIT) has emerged as an active management option for peanut allergy, with an FDA-approved product now available for therapy. Allergic reactions, including anaphylaxis, can occur during therapy and their management is key in optimizing this treatment and patient outcomes. PURPOSE OF REVIEW In this manuscript, we will review the rates of allergic reactions and anaphylaxis in seminal peanut oral immunotherapy research studies. We will examine factors that can alter the risk of anaphylaxis and describe various strategies, including adjunct therapies, that have the potential to mitigate anaphylaxis risk based on published evidence. RECENT FINDINGS Rates of anaphylaxis and epinephrine administration vary in different research studies, but there is consensus that most POIT-related allergic reactions are mild or moderate and not severe. Certain external factors (for example, tiredness, exercise, viral illness) as well as uncontrolled allergic co-morbidities (asthma, allergic rhinitis) have been shown to increase the risk of anaphylaxis during OIT. The search of biomarkers who may predict who is at risk for severe allergic reactions is ongoing. Adjunct therapies have shown promise, but further studies are required to optimize their use alongside POIT. Our understanding of anaphylaxis during POIT has increased in recent years, resulting in better management strategies. However, future plans will need to involve all stakeholders, including physicians, patients and families, researchers, public health authorities, and the food, hospitality, and catering industries.
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20
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Lee T, Edwards-Salmon S, Vickery BP. Current and future treatments for peanut allergy. Clin Exp Allergy 2023; 53:10-24. [PMID: 36222329 DOI: 10.1111/cea.14244] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 01/24/2023]
Abstract
Peanut allergy (PA) is a common, burdensome childhood disease that in most patients continues into adulthood and has historically been untreatable. However, peanut oral immunotherapy (POIT) is increasingly being incorporated into allergy practices, using both the first FDA-approved product, PTAH (previously AR101; Palforzia™, Aimmune Therapeutics), as well as store-bought peanut products. POIT in preschoolers continues to gain more acceptance as evidence accrues that it is a safe and feasible approach that may have distinct advantages. There are many new therapeutic interventions currently under study with a variety of different approaches and potential mechanisms. With respect to other forms of immunotherapy, none are currently approved, but the epicutaneous approach is the most well-studied and others are being actively investigated, including sublingual, subcutaneous, and intralymphatic. Biologics are gaining evidence both as adjunctive treatments to POIT and as monotherapy. Omalizumab is the most widely studied biologic for PA but others also have potential. Looking ahead to a future therapeutic landscape of choice, allergists will need to understand each patient's goal of treatment through shared decision-making and fully evaluate the risks, benefits, and alternatives of each new therapy.
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Affiliation(s)
- Tricia Lee
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Brian P Vickery
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Emory University School of Medicine, Atlanta, Georgia, USA
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Shaker M, Mauger D, Fuhlbrigge AL. Value-Based, Cost-Effective Care: The Role of the Allergist-Immunologist. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:132-139. [PMID: 35944893 DOI: 10.1016/j.jaip.2022.07.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 01/11/2023]
Abstract
Asthma and allergic disease impact millions of patients and are associated with high costs. Up to 30% of all medical care involves wasted spending. Across the spectrum of care provided by the allergist-immunologist, there are opportunities to improve value and reduce medical waste. Several examples highlight this reality. Evidence suggests that most patients may receive cost-effective care in the management of chronic spontaneous urticaria without the need for laboratory testing. For patients with asthma, although a single maintenance and reliever therapy approach may be cost-effective, insurance-mandated therapy changes are not, and may harm patients. Biologics may be very effective in improving asthma control but are too expensive for this indication-as demonstrated by cost-effectiveness analyses and highlighted by the Institute of Clinical and Economic Review, which concluded that the value-based price for asthma biologics ranges between $6500 and 14,3000 per year. Early introduction may prevent food allergy, but screening before first introduction is neither necessary nor cost-effective, although early salvage food oral immunotherapy may result in improved quality of life and cost savings. Evidence does not support the presence of allergic disease as a risk factor for anaphylaxis to coronavirus disease 2019 vaccination, and risk-stratified vaccination approaches do not appear cost-effective. Allergen immunotherapy is a very cost-effective treatment option. The practice of allergy-immunology has continued to evolve in recent years and can provide a leading example of high-value practice.
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Affiliation(s)
- Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - David Mauger
- Department of Public Health Sciences, Division of Biostatistics and Bioinformatics, The Pennsylvania State University, State College, Pa
| | - Anne L Fuhlbrigge
- Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo
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22
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Vers une prise en charge globale et personnalisée de l’allergie alimentaire. REVUE FRANÇAISE D'ALLERGOLOGIE 2022. [DOI: 10.1016/s1877-0320(22)00489-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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23
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Mack DP, Greenhawt M, Turner PJ, Wasserman RL, Hanna MA, Shaker M, Hughes SW, Del Río PR. Information needs of patients considering oral immunotherapy for food allergy. Clin Exp Allergy 2022; 52:1391-1402. [PMID: 36083693 DOI: 10.1111/cea.14225] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/24/2022] [Accepted: 09/06/2022] [Indexed: 01/26/2023]
Abstract
While the historic management of food allergy includes avoidance strategies and allergic reaction treatment, oral immunotherapy (OIT) approaches have become more commonly integrated into therapeutic approaches. International guidelines, phase 3 trials and real-world experience have supported the implementation of this procedure. However, OIT is an elective, rarely curative procedure with inherent risks that necessitates an increased degree of health literacy for the patients and families. Families assume the responsibility of amateur healthcare providers to ensure the daily safe administration of the allergenic food. As such, it is incumbent upon physicians to ensure that families are prepared for this role. A thorough educational and shared decision-making approach is necessary during the counselling and consent process to adequately inform the families. Educated discussion about the efficacy and patient-centred effectiveness, therapeutic alternatives and family goals is required to align physician and patient expectations. A frank discussion about the struggles, practical challenges, risks and contraindications can help to develop an understanding of the risk mitigation strategies employed to maintain safety. Physicians should develop a proactive approach to educate families about this, at times, burdensome procedure. This educational approach should encourage ongoing support starting prior to consent through the maintenance visits. By preparing families for their unique management role, physicians can help ensure the safe and successful integration of OIT into the therapeutic offering for the management of food allergies.
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Affiliation(s)
- Douglas Paul Mack
- Halton Pediatric Allergy, McMaster University, Hamilton, Ontario, Canada
| | - Matthew Greenhawt
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, UK
| | | | - Mariam A Hanna
- Halton Pediatric Allergy, McMaster University, Hamilton, Ontario, Canada
| | - Marcus Shaker
- Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Sarah W Hughes
- Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Dartmouth, New Hampshire, USA
| | - Pablo Rodríguez Del Río
- Adjunto Especialista en Alergología, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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24
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Agache I, Zemelka-Wiącek M, Shamji MH, Jutel M. Immunotherapy: State-of-the-art review of therapies and theratypes. J Allergy Clin Immunol 2022; 150:1279-1288. [PMID: 36328808 DOI: 10.1016/j.jaci.2022.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/02/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
Through its disease-modifying potential, immunotherapy is the keystone to curing allergic diseases. Allergen immunotherapy, applied for more than a century, is currently supported by novel modalities such as mAb-based therapies or small molecules targeting the key nodes of the allergic inflammation network. In this review, a summary of the most significant advances in immunotherapy is presented, addressing not only novel approaches to stratifying patients but also major controlled clinical trials and real-world evidence that strengthen the role of immunotherapy in the treatment of allergies.
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Affiliation(s)
- Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania.
| | | | - Mohamed H Shamji
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; NIHR Imperial Biomedical Research Centre, London, United Kingdom
| | - Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland; ALL-MED Medical Research Institute, Wroclaw, Poland
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25
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Muraro A, de Silva D, Halken S, Worm M, Khaleva E, Arasi S, Dunn-Galvin A, Nwaru BI, De Jong NW, Rodríguez Del Río P, Turner PJ, Smith P, Begin P, Angier E, Arshad H, Ballmer-Weber B, Beyer K, Bindslev-Jensen C, Cianferoni A, Demoulin C, Deschildre A, Ebisawa M, Fernandez-Rivas MM, Fiocchi A, Flokstra-de Blok B, Gerdts J, Gradman J, Grimshaw K, Jones C, Lau S, Loh R, Alvaro Lozano M, Makela M, Marchisotto MJ, Meyer R, Mills C, Nilsson C, Nowak-Wegrzyn A, Nurmatov U, Pajno G, Podestà M, Poulsen LK, Sampson HA, Sanchez A, Schnadt S, Szajewska H, Van Ree R, Venter C, Vlieg-Boerstra B, Warner A, Wong G, Wood R, Zuberbier T, Roberts G. Managing food allergy: GA 2LEN guideline 2022. World Allergy Organ J 2022; 15:100687. [PMID: 36119657 PMCID: PMC9467869 DOI: 10.1016/j.waojou.2022.100687] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/27/2022] [Accepted: 08/01/2022] [Indexed: 12/29/2022] Open
Abstract
Food allergy affects approximately 2-4% of children and adults. This guideline provides recommendations for managing food allergy from the Global Allergy and Asthma European Network (GA2LEN). A multidisciplinary international Task Force developed the guideline using the Appraisal of Guidelines for Research and Evaluation (AGREE) II framework and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We reviewed the latest available evidence as of April 2021 (161 studies) and created recommendations by balancing benefits, harms, feasibility, and patient and clinician experiences. We suggest that people diagnosed with food allergy avoid triggering allergens (low certainty evidence). We suggest that infants with cow's milk allergy who need a breastmilk alternative use either hypoallergenic extensively hydrolyzed cow's milk formula or an amino acid-based formula (moderate certainty). For selected children with peanut allergy, we recommend oral immunotherapy (high certainty), though epicutaneous immunotherapy might be considered depending on individual preferences and availability (moderate certainty). We suggest considering oral immunotherapy for children with persistent severe hen's egg or cow's milk allergy (moderate certainty). There are significant gaps in evidence about safety and effectiveness of the various strategies. Research is needed to determine the best approaches to education, how to predict the risk of severe reactions, whether immunotherapy is cost-effective and whether biological therapies are effective alone or combined with allergen immunotherapy.
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Affiliation(s)
| | | | - Susanne Halken
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Denmark
| | | | | | | | | | | | - Nicolette W. De Jong
- Internal Medicine, Allergology & Clinical Immunology, Pediatric Allergology, University Medical Centre, Rotterdam, the Netherlands
| | | | | | - Pete Smith
- Griffith University School of Medicine, Australia
| | | | | | - Hasan Arshad
- Faculty of Medicine, University of Southampton, UK
| | - Barbara Ballmer-Weber
- Department of Dermatology, University Hospital Zürich and Clinic for Dermatology and Allergology, Kantonsspital St. Gallen, Switzerland
| | | | | | - Antonella Cianferoni
- University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Céline Demoulin
- Association Francaise pour la Prevention des Allergies, France
| | - Antoine Deschildre
- CHU Lille, Univ.Lille, Pediatric Pulmonology and Allergy Unit, Hôpital Jeanne de Flandre, Lille, France
| | | | | | | | - Bertine Flokstra-de Blok
- General Practitioners Research Institute, Groningen, the Netherlands
- University of Groningen, University Medical Center Groningen, Groningen Research Institute Asthma and COPD (GRIAC), Groningen, the Netherlands
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Department of Pediatric Pulmonology and Pediatric Allergology, Groningen, the Netherlands
| | | | - Josefine Gradman
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Denmark
| | - Kate Grimshaw
- Dietetic Department, Salford Care Organisation, Northern Care Alliance NHS Group, UK
| | | | - Susanne Lau
- Charité - Universitätsmedizin Berlin, Germany
| | | | | | | | | | - Rosan Meyer
- Imperial College London, London, United Kingdom
| | - Clare Mills
- School of Biological Sciences, Manchester Institute of Biotechnology, University of Manchester, Manchester, M17DN, UK
| | - Caroline Nilsson
- Karolinska Institutet, Dept. of Clinical Science and Education, Södersjukhuset and Sachs’ Children and Youth Hospital, Sweden
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | | | | | | | | | | | - Angel Sanchez
- AEPNAA Spanish Association for People with Food and Latex Allergy, Spain
| | | | - Hania Szajewska
- Department of Paediatrics, Medical University of Warsaw, Poland
| | | | - Carina Venter
- Children's Hospital Colorado, University of Colorado, USA
| | | | | | - Gary Wong
- Chinese University of Hong Kong, Hong Kong
| | - Robert Wood
- Department of Pediatrics, John Hopkins University School of Medicine, USA
| | | | - Graham Roberts
- University of Southampton, UK
- Southampton NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- David Hide Asthma and Allergy Centre, St Mary’s Hospital, Isle of Wight, UK
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26
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Chua GT, Chan ES. A practical focus on legume oral immunotherapy. JOURNAL OF FOOD ALLERGY 2022; 4:144-147. [PMID: 39021847 PMCID: PMC11250432 DOI: 10.2500/jfa.2022.4.220006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Legumes other than peanut are an important source of protein and consist of a wide variety of species, such as soy, peas, chickpeas, lentils, and lupin. Due to their health benefits and the rising popularity of veganism, legume consumption has increased. Legume allergy, cross-sensitization, and cross-reactivity between different species have been reported in the literature and are increasingly recognized. Unlike peanut, oral immunotherapy (OIT) for nonpeanut legumes has not been well studied and published protocols are lacking. Future studies are needed to provide real-world data on the safety and effectiveness of nonpeanut legume OIT, and whether desensitization to one legume leads to desensitization to other legumes in patients with multiple legume allergy. Nevertheless, due to the abundance of clinical trial and real-world data for peanut OIT, it is reasonable to use protocols that substitute peanut protein with other legume protein when desensitizing individuals with nonpeanut legume allergy. Clinicians who are starting to offer legume OIT in their practices may consider starting with preschoolers, an age group for whom real-world data has shown the greatest safety and effectiveness.
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Affiliation(s)
- Gilbert T. Chua
- From the Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Edmond S. Chan
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; and
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
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27
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Abstract
Tree nut (TN) allergy is common, with a global prevalence of up to 4.9%. TN allergy is persistent in most patients, and accidental reactions are common. There is considerable clinical cross-reactivity between cashew and pistachio, and between walnut and pecan. A diagnosis of TN allergy is based on a history of clinical reaction on ingestion, along with confirmed sensitization through either skin-prick or serum immunoglobulin E (IgE) testing. Component testing and food challenges may be required in patients with birch pollinosis to distinguish between IgE-mediated allergy to a heat-stable protein and pollen food allergy syndrome. There is available evidence that TN oral immunotherapy (OIT) is reasonably safe and effective. There are numerous nonpharmaceutical food products to facilitate TN-OIT dosing. TN OIT should be offered as a treatment option for patients with TN allergy.
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Affiliation(s)
- Stephanie Erdle
- From the Division of Clinical Immunology and Allergy, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Victoria E. Cook
- From the Division of Clinical Immunology and Allergy, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; and
- Allergy Victoria, Victoria, British Columbia, Canada
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28
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Upton JE. Efficacy, effectiveness and other patient-centered outcomes of oral immunotherapy. JOURNAL OF FOOD ALLERGY 2022; 4:28-33. [PMID: 39021849 PMCID: PMC11250439 DOI: 10.2500/jfa.2022.4.220017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Oral immunotherapy (OIT) is the medically supervised ingestion of a food allergen. Understanding of the expected outcomes of OIT allow for risk-benefit assessments for patient-centered decisions. The efficacy of OIT to achieve desensitization in children has been confirmed in multiple meta-analyses, even with vastly disparate study populations and methodologies. Most children initiated on OIT will achieve the ability to eat more allergen before experiencing an allergic reaction than if they continue to avoid their allergen. This effect is diminished without regular ingestion. Previous meta-analyses showed increased allergic reactions on OIT versus avoidance or placebo due to the dosing itself; however, a recent meta-analysis showed that peanut OIT in children did not lead to an increase in allergic reactions. Analysis of emerging data suggests that OIT may reduce reactions to accidental exposures over time. Important patient-centered outcomes, including reaction avoidance or amelioration, and psychosocial impacts and/or quality of life, and studies of more demographically representative populations are also necessary.
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Affiliation(s)
- Julia E.M. Upton
- From the Division of Immunology and Allergy, The Hospital for Sick Children, Toronto, Ontario, Canada; and
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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29
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Chua GT, Chan ES, Yeung J, Cameron SB, Soller L, Williams BA, Chomyn A, Vander Leek TK, Abrams EM, Mak R, Wong T. Patient selection for milk and egg ladders using a food ladder safety checklist. Allergy Asthma Clin Immunol 2022; 18:51. [PMID: 35692059 PMCID: PMC9188637 DOI: 10.1186/s13223-022-00696-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022] Open
Abstract
A food ladder is a form of home-based dietary advancement therapy that gradually increases exposure to an allergenic food through the gradual introduction of egg or milk containing food with increasing quantity and allergenicity from extensively heated forms, such as baked goods, to less processed products. While widely considered safe, the food ladder is not risk-free and most of the egg and milk ladder studies only included preschoolers with mild egg and milk allergies, and with no or well-controlled asthma. We propose a Food Ladder Safety Checklist to assist with patient selection using “4 A's” based on available evidence for food ladders, including Age, active or poorly controlled Asthma, history of Anaphylaxis, and Adherence.
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Affiliation(s)
- Gilbert T Chua
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 1/F, New Clinical Building, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong,, SAR, China. .,Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Hong Kong, SAR, China. .,Department of Paediatrics, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
| | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Joanne Yeung
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Scott B Cameron
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,Community Allergy Clinic, Victoria, BC, Canada
| | - Lianne Soller
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Brock A Williams
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,Food, Nutrition, and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, Canada
| | - Alanna Chomyn
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Timothy K Vander Leek
- Department of Pediatrics, Pediatric Allergy & Asthma, University of Alberta, Edmonton, AB, Canada
| | - Elissa M Abrams
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Canada
| | - Raymond Mak
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Tiffany Wong
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
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30
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Fong AT, Ahlstedt S, Golding MA, Protudjer JLP. The Economic Burden of Food Allergy: What We Know and What We Need to Learn. CURRENT TREATMENT OPTIONS IN ALLERGY 2022; 9:169-186. [PMID: 35502316 PMCID: PMC9046535 DOI: 10.1007/s40521-022-00306-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 02/04/2023]
Abstract
Purpose of Review Food allergy management and treatment require dietary modification, are associated with significant burdens, and affect food choices and behaviours. Emerging therapies, such as oral immunotherapy (OIT), provide a glimmer of hope for those living with the condition. Some burdens have received substantial focus, whereas many knowledge gaps on the significance of other impacts, including economic burden, remain. Recent Findings Evidence from many countries, but disproportionately from the United States, supports that food allergy carries significant healthcare and societal costs. Early introduction for the prevention of food allergies is theoretically cost-effective, but remains largely undescribed. Unique considerations, such as those to cow’s milk protein allergy, which affects a substantial proportion of infants, and adrenaline autoinjectors, which have a high cost-per-use, require a balance between cost-effectiveness to the healthcare system and adverse outcomes. Household costs have largely been explored in two countries, but owing to different healthcare structures and costs of living, comparisons are difficult, as are generalisations to other countries. Stock epinephrine in schools may present a cost-effective strategy, particularly in economically disadvantaged areas. Costs relating to OIT must be examined within both immediate benefits, such as protection from anaphylaxis, and long-term benefits, such as sustained unresponsiveness. Summary Although the absolute costs differ by region/country and type of food allergy, a consistent pattern persists: food allergy is a costly condition, to those who live with it, and the multiple stakeholders with which they interact. Supplementary Information The online version contains supplementary material available at 10.1007/s40521-022-00306-5.
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Affiliation(s)
| | - Staffan Ahlstedt
- Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Michael A. Golding
- The Children’s Hospital Research Institute of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- Department of Pediatrics and Child Health, The University of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
| | - Jennifer L. P. Protudjer
- Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
- The Children’s Hospital Research Institute of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- Department of Pediatrics and Child Health, The University of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- George and Fay Yee Centre for Healthcare Innovation, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- Food and Human Nutritional Sciences, The University of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
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31
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Soller L, Carr S, Kapur S, Rex GA, McHenry M, Cook VE, Leo S, Wong T, Vander Leek TK, Gerstner TV, Yeung J, Abrams EM, Mak R, Hildebrand KJ, Erdle SC, Cameron SB, Chan ES. Real-world peanut OIT in infants may be safer than non-infant preschool OIT and equally effective. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1113-1116.e1. [PMID: 34954121 DOI: 10.1016/j.jaip.2021.12.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Lianne Soller
- Allergy Clinic, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Stuart Carr
- Snö Asthma and Allergy Clinic, Abu Dhabi, United Arab Emirates
| | - Sandeep Kapur
- Division of Allergy, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, Nova Scotia, Canada; Halifax Allergy and Asthma Associates, Halifax, Nova Scotia, Canada
| | - Gregory A Rex
- Division of Allergy, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, Nova Scotia, Canada; Halifax Allergy and Asthma Associates, Halifax, Nova Scotia, Canada
| | - Mary McHenry
- Division of Allergy, Department of Pediatrics, Dalhousie University/IWK Health Centre, Halifax, Nova Scotia, Canada; Halifax Allergy and Asthma Associates, Halifax, Nova Scotia, Canada
| | - Victoria E Cook
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Community Allergy Clinic, Victoria, British Columbia, Canada
| | - Sara Leo
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; West Coast Allergy and Immunology Clinic, Vancouver, British Columbia, Canada
| | - Tiffany Wong
- Allergy Clinic, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Thomas V Gerstner
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Meadowood Medical Center, Winnipeg, Manitoba, Canada
| | - Joanne Yeung
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver Kids Allergy, Vancouver, British Columbia, Canada
| | - Elissa M Abrams
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Meadowood Medical Center, Winnipeg, Manitoba, Canada
| | - Raymond Mak
- Allergy Clinic, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kyla J Hildebrand
- Allergy Clinic, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie C Erdle
- Allergy Clinic, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Scott B Cameron
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Community Allergy Clinic, Victoria, British Columbia, Canada
| | - Edmond S Chan
- Allergy Clinic, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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32
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Tedner SG, Asarnoj A, Thulin H, Westman M, Konradsen JR, Nilsson C. Food allergy and hypersensitivity reactions in children and adults-A review. J Intern Med 2022; 291:283-302. [PMID: 34875122 DOI: 10.1111/joim.13422] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Adverse reactions after food intake are commonly reported and a cause of concern and anxiety that can lead to a very strict diet. The severity of the reaction can vary depending on the type of food and mechanism, and it is not always easy to disentangle different hypersensitivity diagnoses, which sometimes can exist simultaneously. After a carefully taken medical history, hypersensitivity to food can often be ruled out or suspected. The most common type of allergic reaction is immunoglobulin E (IgE)-mediated food allergy (prevalence 5-10%). Symptoms vary from mild itching, stomach pain, and rash to severe anaphylaxis. The definition of IgE-mediated food allergy is allergic symptoms combined with specific IgE-antibodies, and therefore only IgE-antibodies to suspected allergens should be analyzed. Nowadays, methods of molecular allergology can help with the diagnostic process. The most common allergens are milk and egg in infants, peanut and tree nuts in children, and fish and shellfish in adults. In young children, milk/egg allergy has a good chance to remit, making it important to follow up and reintroduce the food when possible. Other diseases triggered by food are non-IgE-mediated food allergy, for example, eosinophilic esophagitis, celiac disease, food protein-induced enterocolitis syndrome, and hypersensitivity to milk and biogenic amines. Some of the food hypersensitivities dominate in childhood, others are more common in adults. Interesting studies are ongoing regarding the possibilities of treating food hypersensitivity, such as through oral immunotherapy. The purpose of this review was to provide an overview of the most common types of food hypersensitivity reactions.
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Affiliation(s)
- Sandra G Tedner
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Asarnoj
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Thulin
- Allergy and Lung Department, Sachs' Children and Youth Hospital, Stockholm, Sweden.,Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Marit Westman
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Asthma and Allergy Clinic S:t Göran, Stockholm, Sweden
| | - Jon R Konradsen
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Nilsson
- Allergy and Lung Department, Sachs' Children and Youth Hospital, Stockholm, Sweden.,Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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33
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Greenhawt M, Shaker M, Abrams EM. Peanut oral immunotherapy in very young children. Lancet 2022; 399:336-337. [PMID: 35065770 DOI: 10.1016/s0140-6736(22)00088-5] [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: 12/13/2021] [Accepted: 01/10/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA.
| | - Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH, USA
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34
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The Role of Diet Modification in Atopic Dermatitis: Navigating the Complexity. Am J Clin Dermatol 2022; 23:27-36. [PMID: 34687433 DOI: 10.1007/s40257-021-00647-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 02/06/2023]
Abstract
Diet has long been understood to have an intricate association with atopic dermatitis, although much remains unelucidated. Skin barrier dysfunction with dysbiosis and consequent impairment of immune tolerance likely underly the pathogenesis of coincident atopic dermatitis and food allergy. There is a wide range of possible skin reactions to food, complicating the diagnosis and understanding of food allergies. Many patients, parents, and providers incorrectly suspect diet as causative of atopic dermatitis symptoms and many have tried elimination diets. This frequently leads to inaccurate labeling of food allergies, contributing to a dangerous spiral of inappropriate testing, referrals, and dietary changes, while neglecting established atopic dermatitis treatment essentials. Alternatively, certain dietary supplements or the introduction of certain foods may be beneficial for atopic dermatitis management or prevention. Greater consensus on the role of diet among providers of patients with atopic dermatitis is strongly encouraged to improve the management of atopic dermatitis.
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Wu Y, Chai X. Effects of maternal sugar intake during pregnancy on allergies in offspring: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27447. [PMID: 34678875 PMCID: PMC8542120 DOI: 10.1097/md.0000000000027447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 09/20/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND To our knowledge, there is no comprehensive evidence quantifying the plausibility of the association between maternal free sugar intake during pregnancy and the development of offspring's allergic diseases. Thus, this systematic review examines the weight of evidence for causality from cohort studies on the association between maternal free sugar intake during pregnancy and the development of allergies in offspring. METHODS The present meta-analysis is prepared and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. We search PUBMED, Scopus, EMBASE, and Cochrane Library databases through October, 2021. All clinical trials to assess the efficacy of maternal sugar intake during pregnancy on allergies in offspring are considered eligible for analysis. The Comprehensive Meta-Analysis Software 2 program is used for statistical analyses of the pooled data. A P value < .05 is considered statistically significant. The outcome measure is development of allergic disease among offspring assessed by any method (parental history, doctor diagnosed, or questionnaire based). RESULTS It is hypothesized that high free sugar consumption during pregnancy may be associated with the development of allergies in offspring.
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Affiliation(s)
- Yijun Wu
- Department of Obstetrics, Huanggang Central Hospital, Huanggang, Hubei, China
| | - Xiaoli Chai
- Department of Obstetrics and Gynecology, Xishui County People's Hospital, Hubei University of Science and Technology, Huanggang, Hubei, China
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Chua GT, Chan ES, Soller L, Cook VE, Vander Leek TK, Mak R. Home-Based Peanut Oral Immunotherapy for Low-Risk Peanut-Allergic Preschoolers During the COVID-19 Pandemic and Beyond. FRONTIERS IN ALLERGY 2021; 2:725165. [PMID: 35387028 PMCID: PMC8974914 DOI: 10.3389/falgy.2021.725165] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/23/2021] [Indexed: 12/03/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has led to the deprioritization of non-emergency services, such as oral food challenges and the initiation of oral immunotherapy (OIT) for food-allergic children. Recent studies have suggested that home-based peanut OIT could be a safe and effective option for low-risk peanut-allergic children. In the period between September 1, 2020, and January 31, 2021, nine preschoolers with a history of mild allergic reactions to peanut underwent home-based peanut OIT. Eight of them (88.9%) completed the build-up phase at home in 11–28 weeks, tolerating a daily maintenance dose of 320 mg peanut protein. During the build-up, six patients (75.0%) reported urticaria, three (33.3%) reported gastrointestinal tract symptoms, and one (14.3%) reported oral pruritis. None of the patients developed anaphylaxis, required epinephrine, or attended emergency services related to OIT. One or two virtual follow-up visits were completed per patient during the build-up phase. Our case series shows that home-based OIT could be offered to the low-risk preschoolers during the COVID-19 pandemic when non-emergency services are limited and could be considered beyond the pandemic, especially for the families living in the rural or remote areas that may otherwise be unable to access OIT.
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Affiliation(s)
- Gilbert T. Chua
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong, SAR China
- *Correspondence: Gilbert T. Chua
| | - Edmond S. Chan
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Lianne Soller
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Victoria E. Cook
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
- Community Allergy Clinic, Victoria, BC, Canada
| | - Timothy K. Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Raymond Mak
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Chomyn A, Chan ES, Yeung J, Vander Leek TK, Williams BA, Soller L, Abrams EM, Mak R, Wong T. Canadian food ladders for dietary advancement in children with IgE-mediated allergy to milk and/or egg. Allergy Asthma Clin Immunol 2021; 17:83. [PMID: 34353372 PMCID: PMC8340453 DOI: 10.1186/s13223-021-00583-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/15/2021] [Indexed: 12/16/2022] Open
Abstract
Food ladders are clinical tools already widely used in Europe for food reintroduction in milk- and egg-allergic children. Previously developed milk and egg ladders have limited applicability to Canadian children due to dietary differences and product availability. Herein we propose a Canadian version of cow’s milk and egg food ladders and discuss the potential role that food ladders may have in the care of children with IgE-mediated allergies to cow’s milk and/or egg, as either a method of accelerating the acquisition of tolerance in those who would outgrow on their own, or as a form of modified oral immunotherapy in those with otherwise persistent allergy.
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Affiliation(s)
- Alanna Chomyn
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada.
| | - Edmond S Chan
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada
| | - Joanne Yeung
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada
| | - Timothy K Vander Leek
- Pediatric Allergy & Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Brock A Williams
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada.,Food, Nutrition, and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, Canada
| | - Lianne Soller
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada
| | - Elissa M Abrams
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada.,Department of Pediatrics and Child Health, Section of Allergy and Immunology, University of Manitoba, Winnipeg, Canada
| | - Raymond Mak
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada
| | - Tiffany Wong
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B, 4480 Oak Street, Vancouver, BC, V5Z 4H4, Canada.
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Worm M, Reese I, Ballmer-Weber B, Beyer K, Bischoff SC, Bohle B, Brockow K, Claßen M, Fischer PJ, Hamelmann E, Jappe U, Kleine-Tebbe J, Klimek L, Koletzko B, Lange L, Lau S, Lepp U, Mahler V, Nemat K, Raithel M, Saloga J, Schäfer C, Schnadt S, Schreiber J, Szépfalusi Z, Treudler R, Wagenmann M, Werfel T, Zuberbier T. Update of the S2k guideline on the management of IgE-mediated food allergies. Allergol Select 2021; 5:195-243. [PMID: 34263109 PMCID: PMC8276640 DOI: 10.5414/alx02257e] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/21/2021] [Indexed: 01/02/2023] Open
Abstract
Not available.
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Affiliation(s)
- Margitta Worm
- Allergology and Immunology, Department of Dermatology, Venereology, and Allergology, Charité – Universitätsmedizin Berlin, Germany
| | - Imke Reese
- Nutritional Counseling and Therapy, Focus on Allergology, Munich, Germany
| | - Barbara Ballmer-Weber
- University Hospital Zurich, Department of Dermatology, Zurich, Switzerland, and Cantonal Hospital St. Gallen, Department of Dermatology and Allergology, St. Gallen, Switzerland
| | - Kirsten Beyer
- Clinic of Pediatrics m. S. Pneumology, Immunology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Germany
| | - Stephan C. Bischoff
- Institute of Nutritional Medicine and Prevention, University of Hohenheim, Stuttgart, Germany
| | - Barbara Bohle
- Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Austria
| | - Knut Brockow
- Department of Dermatology and Allergology, Biederstein, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Martin Claßen
- Klinik für Kinder und Jugendmedizin/Päd. Intensivmedizin, Eltern-Kind-Zentrum Prof. Hess Klinikum Bremen-Mitte
| | - Peter J. Fischer
- Practice for Pediatric and Adolescent Medicine m. S. Allergology and Pediatric Pneumology, Schwäbisch Gmünd
| | - Eckard Hamelmann
- University Clinic for Pediatric and Adolescent Medicine, Evangelisches Klinikum Bethel gGmbH, Bielefeld
| | - Uta Jappe
- Research Group Clinical and Molecular Allergology, Research Center Borstel, Airway Research Center North (ARCN), member of the German Center for Lung Research (DZL), Borstel
- Interdisciplinary Allergy Outpatient Clinic, Medical Clinic III, University Hospital Schleswig-Holstein, Lübeck
| | | | | | - Berthold Koletzko
- Pediatric Clinic and Pediatric Polyclinic, Dr. von Haunersches Kinderspital, Department of Metabolic and Nutritional Medicine, Ludwig-Maximilians-University, Munich
| | - Lars Lange
- Pediatric and Adolescent Medicine, St.- Marien-Hospital, Bonn
| | - Susanne Lau
- Clinic of Pediatrics m. S. Pneumology, Immunology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Germany
| | - Ute Lepp
- Practice for Pulmonary Medicine and Allergology, Buxtehude
| | | | - Katja Nemat
- Practice for Pediatric Pneumology/Allergology at the Children’s Center Dresden (Kid), Dresen
| | | | - Joachim Saloga
- Department of Dermatology, University Medical Center, Johannes Gutenberg-University Mainz
| | - Christiane Schäfer
- Nutritional Therapy, Focus on Allergology and Gastroenterology, Schwarzenbek, Germany
| | - Sabine Schnadt
- German Allergy and Asthma Association, Mönchengladbach, Germany
| | - Jens Schreiber
- Pneumology, University Hospital of Otto von Guericke University, Magdeburg, Germany
| | - Zsolt Szépfalusi
- University Hospital for Pediatrics and Adolescent Medicine, Medical University of Vienna, Austria
| | - Regina Treudler
- Clinic of Dermatology, Venereology and Allergology, University Medical Center Leipzig, Germany
| | | | - Thomas Werfel
- Clinic of Dermatology, Allergology and Venerology, Hannover Medical School, Germany, and
| | - Torsten Zuberbier
- Department of Dermatology, Venerology and Allergology, Charité – Universitätsmedizin Berlin
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Chua GT, Chan ES, Soller L, Cameron SB. Grass pollen allergy as an anaphylaxis cofactor during peanut oral immunotherapy. Ann Allergy Asthma Immunol 2021; 127:263-264. [PMID: 33971356 DOI: 10.1016/j.anai.2021.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/08/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Gilbert T Chua
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Edmond S Chan
- BC Children's Hospital, Vancouver, Canada; Division of Allergy & Immunology, Department of Pediatrics, The University of British Columbia, Vancouver, Canada
| | - Lianne Soller
- BC Children's Hospital, Vancouver, Canada; Division of Allergy & Immunology, Department of Pediatrics, The University of British Columbia, Vancouver, Canada
| | - Scott B Cameron
- Division of Allergy & Immunology, Department of Pediatrics, The University of British Columbia, Vancouver, Canada; Community Allergy Clinic, Victoria, Canada.
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The Cost-Effectiveness of Preschool Peanut Oral Immunotherapy in the Real-World Setting. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2876-2884.e4. [PMID: 33744474 DOI: 10.1016/j.jaip.2021.02.058] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/13/2021] [Accepted: 02/03/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Across North America, 1.4% to 4.5% of children and families live with peanut allergy (PA). Preschool peanut oral immunotherapy (POIT) has been shown to be safe and effective in the real-world setting. OBJECTIVE Evaluate the cost effectiveness of preschool POIT in North America. METHODS Markov cohort analyses and microsimulation was used to evaluate simulated preschool children with PA over an 80-year time horizon. Models incorporated the natural history of PA, comparing children treated with preschool POIT with those not receiving immunotherapy. Costs were expressed in U.S. and Canadian dollars. RESULTS A preschool POIT strategy was associated with cost savings while improving quality-adjusted life-years (QALY), dominating a nonimmunotherapy approach. Over the model horizon, when all costs (and effectiveness) of PA were included from a societal perspective, a POIT versus a non-POIT approach cost $82,514 (18.51 QALY) versus $84,367 (17.75 QALY) in the United States, and $40,111 (18.83 QALY) versus $53,848 (18.26 QALY) in Canada. In microsimulations, systemic reactions to POIT were less frequent than anaphylaxis from accidental exposure without POIT (United States: 3.59, SD 3.49 vs 19.53, SD 11.71; Canada: 3.63, SD 3.54 vs 4.56, SD 3.30), epinephrine use was reduced with POIT (United States: 5.85, SD 5.73 vs 9.76, SD 5.85; Canada: 0.34, SD 0.36 vs 0.53, SD 0.38), and fatalities were rare but lower in the POIT strategy (United States: 0.00005, SD 0.0071 vs 0.00015, SD 0.012; Canada: 0.00005, SD 0.0071 vs 0.00009, SD 0.0095). CONCLUSIONS Preschool POIT in a real-world setting improved health and economic outcomes in the United States and Canada.
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41
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Burris AD, Lomas JM, Järvinen KM. Is It Time to Offer Peanut Oral Immunotherapy to Toddlers? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:1357-1358. [PMID: 33685612 DOI: 10.1016/j.jaip.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Amy D Burris
- Division of Allergy and Immunology and Center for Food Allergy, Department of Pediatrics, University of Rochester School of Medicine and Dentistry and Golisano Children's Hospital, Rochester, NY
| | - Jeanne M Lomas
- Division of Allergy and Immunology and Center for Food Allergy, Department of Pediatrics, University of Rochester School of Medicine and Dentistry and Golisano Children's Hospital, Rochester, NY
| | - Kirsi M Järvinen
- Division of Allergy and Immunology and Center for Food Allergy, Department of Pediatrics, University of Rochester School of Medicine and Dentistry and Golisano Children's Hospital, Rochester, NY.
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Kidon MI, Yahia SH, Machnes-Maayan D, Levy Y, Frizinsky S, Maoz-Segal R, Offenganden I, Kenett RS, Agmon-Levin N, Hovav R. Diagnosis of Peanut Allergy in Preschool Children: The Impact of Skin Testing With a Novel Composition of Peanuts. Front Pediatr 2021; 9:739224. [PMID: 34917557 PMCID: PMC8670606 DOI: 10.3389/fped.2021.739224] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/31/2021] [Indexed: 11/17/2022] Open
Abstract
Peanut allergy is an increasing concern in younger children. Available bedside diagnostic tools, i.e., prick tests with commercial extracts or peanut-containing foods have only limited predictive values. In a cohort of preschoolers with both a history of allergic reactions and sensitization to peanut proteins, we aimed to characterize the impact of skin tests with a novel composition of peanuts LPP-MH. Almost one quarter (27/110) of preschool children, with a history of allergic reactions to peanuts and positive standard IgE-mediated tests for peanut allergy, can tolerate the reintroduction of peanut proteins into their diet after resolving their allergy and, thus, can avoid adverse health outcomes associated with the false diagnosis. In the younger age group, a quarter of peanut allergic children, display a relatively high threshold, potentially enabling an easier and safer oral immunotherapy protocol in this window of opportunity in childhood. The use of the novel diagnostic skin test, LPP-MH, significantly improves the predictive value of outpatient evaluation for the outcomes of peanut challenge as well as the expected threshold at which the PA child will react, thus, making for a better informed decision of how, when, and where to challenge.
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Affiliation(s)
- Mona I Kidon
- Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Allergy Clinic, Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Soad Haj Yahia
- Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Diti Machnes-Maayan
- Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Allergy Clinic, Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Yael Levy
- Volcani Center, Plant Sciences Institute, Ministry of Agriculture, Beit Dagan, Israel
| | - Shirli Frizinsky
- Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Allergy Clinic, Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Ramit Maoz-Segal
- Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - Irena Offenganden
- Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - Ron S Kenett
- KPA Group and Institute for Drug Research, School of Pharmacy, Hebrew University, Jerusalem, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Unit, Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Allergy Clinic, Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Ran Hovav
- Volcani Center, Plant Sciences Institute, Ministry of Agriculture, Beit Dagan, Israel
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