Pharmacokinetics and effects of cetirizine in horses with insect bite hypersensitivity

Pruritic Horse: Approach to Allergic Skin Diseases in Horses

Allergy to insects is the most common skin allergy in horses. Pruritus in affected patients can be extreme. Face, ears, mane, and tail area are commonly affected areas. Diagnosis of insect bite hypersensitivity (IBH) is clinical and is based on history, clinical signs, and response to repellents. Allergy tests are not to be used for diagnostic purposes. Currently, there is no specific treatment for IBH other than insect avoidance, treatment of secondary infections, and symptomatic relief of pruritus. Many allergic horses become also sensitized to pollens. For these patients, allergen specific immunotherapy is beneficial.

Efficacy and Safety of Subcutaneous Allergen-Specific Immuno-Therapy in Horses with Allergic Cutaneous and Respiratory Diseases-A Systematic Review

Allergen-specific immunotherapy (AIT) is the only current intervention that has the ability to modify the immune response toward a tolerogenic state. This study aimed to assess the efficacy and safety of AIT in horses with allergic diseases in a systematic manner. Three databases were searched to identify articles reporting clinical outcomes and adverse events associated with AIT. The articles were evaluated for beneficial responses to AIT, defined as a ≥50% reduction in clinical signs, and clinical remission. Horses with respiratory diseases, urticaria, and pruritic dermatitis receiving insect monotherapy or multi-allergen AIT were included. All adverse events were graded, and analytical and confounding biases were assessed. The results showed that multi-allergen AIT had a beneficial response in 75% of horses with respiratory diseases, 88% with urticaria, and 56% with pruritic dermatitis. However, horses treated solely with insect AIT for pruritic dermatitis had a lower response rate (36%). Self-limiting local reactions were the most common adverse events, with systemic reactions grade II accounting for 11% of reported events. Analytical and confounding biases were identified as major limitations in the available studies. Further research is needed to address these biases and provide stronger evidence on the efficacy and safety of AIT in horses with allergic diseases.

Insect Bite Hypersensitivity in Horses: Causes, Diagnosis, Scoring and New Therapies

Insect Bite Hypersensitivity (IBH, Queensland itch, sweet itch, equine summer eczema) is the most common pruritic disease of horses. It is most often caused by sensitivity to the saliva of Culicoides spp. of biting midges; however, it can also be caused by hypersensitivity to other insect species. The prevalence of IBH in horses is reported to be as high as 60% in some parts of the world. Due to the severe pruritus and effects of secondary self-trauma, IBH has animal welfare concerns, and there is currently no cure. Management of this condition is life-long, time consuming and costly. New grading systems to document disease severity are being validated, which will allow the comparison of clinical trial results of new and existing therapies. Management involves the minimisation of insect bites by use of stabling, fans, rugs and repellents. Symptomatic therapy involves the administration of systemic or topical corticosteroids, systemic antihistamines, and creams and sprays to promote skin healing and decrease inflammation. New immune-mediated therapeutics including vaccines, in addition to desensitisation procedures, show promise at controlling hypersensitivity reactions. This article will review aetiologic agents, pathophysiology, scoring systems and current and new therapies.

Equine allergic skin diseases: Clinical consensus guidelines of the World Association for Veterinary Dermatology

BACKGROUND

Allergic skin diseases are common in horses worldwide. The most common causes are insect bites and environmental allergens.

OBJECTIVES

To review the current literature and provide consensus on pathogenesis, diagnosis, treatment and prevention.

MATERIALS AND METHODS

The authors reviewed the literature up to November 2022. Results were presented at North America Veterinary Dermatology Forum (2021) and European Veterinary Dermatology Congress (2021). The report was available to member organisations of the World Association for Veterinary Dermatology for feedback.

CONCLUSIONS AND CLINICAL RELEVANCE

Insect bite hypersensitivity (IBH) is the best characterised allergic skin disease. An immunoglobulin (Ig)E response against Culicoides salivary antigens is widely documented. Genetics and environmental factors play important roles. Tests with high sensitivity and specificity are lacking, and diagnosis of IBH is based on clinical signs, seasonality and response to insect control. Eosinophils, interleukin (IL)-5 and IL-31 are explored as therapeutic targets. Presently, the most effective treatment is insect avoidance. Existing evidence does not support allergen-specific immunotherapy (ASIT) using commercially available extracts of Culicoides. Hypersensitivity to environmental allergens (atopic dermatitis) is the next most common allergy. A role for IgE is supported by serological investigation, skin test studies and positive response to ASIT. Prospective, controlled, randomised studies are limited, and treatment relies largely on glucocorticoids, antihistamines and ASIT based on retrospective studies. Foods are known triggers for urticaria, yet their role in pruritic dermatitis is unknown. Recurrent urticaria is common in horses, yet our understanding is limited and focussed on IgE and T-helper 2 cell response. Prospective, controlled studies on treatments for urticaria are lacking. Glucocorticoids and antihistamines are primary reported treatments.

The Effect of Insect Bite Hypersensitivity on Movement Activity and Behaviour of the Horse

Insect bite hypersensitivity (IBH) associated with Culicoides biting midges is a common allergic skin disease in horses, reducing the welfare of affected horses. This study investigated the effect of IBH on animal welfare and behaviour and assessed a new prophylactic insect repellent. In total, 30 horses were recruited for a prospective cross-over and case-control study. Clinical signs of IBH, inflammatory markers in skin biopsies and behavioural data (direct observations, motion index) were scored longitudinally during two consecutive summers. No differences were observed in the total number of itching behaviours or motion index between IBH-affected horses and controls, but higher numbers of itching behaviours were observed in the evening. IBH-affected horses showed both clinical and histopathological signs of inflammatory skin lesions, with even short periods of scratching being associated with moderate/severe inflammatory skin lesions. In order to improve the welfare of the IBH-affected horses, they should be stabled/given extra protection in the evening and even short-term exposure to Culicoides should be avoided. Preliminary results showed that the repellent tested can be used as a safe and non-toxic prophylactic to potentially reduce allergen exposure in horses with IBH, but further studies are needed to determine its efficacy.

Development of an inhibiting antibody against equine interleukin 5 to treat insect bite hypersensitivity of horses

Insect bite hypersensitivity (IBH) is the most common allergic skin disease of horses. It is caused by insect bites of the Culicoides spp. which mediate a type I/IVb allergy with strong involvement of eosinophil cells. No specific treatment option is available so far. One concept could be the use of a therapeutic antibody targeting equine interleukin 5, the main activator and regulator of eosinophils. Therefore, antibodies were selected by phage display using the naïve human antibody gene libraries HAL9/10, tested in a cellular in vitro inhibition assay and subjected to an in vitro affinity maturation. In total, 28 antibodies were selected by phage display out of which eleven have been found to be inhibiting in the final format as chimeric immunoglobulin G with equine constant domains. The two most promising candidates were further improved by in vitro affinity maturation up to factor 2.5 regarding their binding activity and up to factor 2.0 regarding their inhibition effect. The final antibody named NOL226-2-D10 showed a strong inhibition of the interleukin 5 binding to its receptor (IC₅₀ = 4 nM). Furthermore, a nanomolar binding activity (EC₅₀ = 8.8 nM), stable behavior and satisfactory producibility were demonstrated. This antibody is an excellent candidate for in vivo studies for the treatment of equine IBH.

Pharmacokinetics of diphenhydramine following single-dose intravenous and oral administration in non-fasted adult horses

Diphenhydramine is an H1 receptor antagonist used to control urticaria and other allergic signs caused by type I hypersensitivity reactions in horses (Equus caballus). Limited studies have been conducted on pharmacokinetics of this drug in horses, with no studies involving oral formulations. Our study investigated pharmacokinetics of an oral diphenhydramine formulation compared to intravenous administration in non-fasted adult horses. Six healthy horses underwent a single administration of three different doses of diphenhydramine (1 mg/kg intravenously, 1 mg/kg intragastrically, and 5 mg/kg intragastrically) with a two-week washout period between doses. Bioavailability of intragastric diphenhydramine was less than one percent and six percent for 1 mg/kg and 5 mg/kg intragastric doses, respectively. This poor bioavailability is similar to what is reported in dogs. Two of six horses experienced transient side effects after intravenous diphenhydramine administration, emphasizing the need for determining therapeutic plasma levels in efforts to determine the lowest effective dose minimizing risk of adverse effects. The main conclusion of our study was that oral diphenhydramine at doses up to 5 mg/kg are unlikely to achieve therapeutic plasma levels in adult horses.

Molecular mechanisms and treatment modalities in equine Culicoides hypersensitivity

Equine Culicoides hypersensitivity (CH) is the most common allergic condition in horses affecting the skin. This review focuses on immunopathology and molecular mechanisms of equine CH. The role of eosinophils is emphasized, as well as disease severity and the influence of long-term chronic allergen exposure on T helper (Th) 2 cells. Using current knowledge from human allergic disorders, similar effects are hypothesized in equine patients. Key aspects of CH diagnosis and treatment are discussed, focusing on allergen specific immunotherapy and allergen-independent approaches, such as targeting hypereosinophilia through interleukin-5 and allergic non-histaminic pruritus though interleukin-31.

Interleukin 31 in insect bite hypersensitivity-Alleviating clinical symptoms by active vaccination against itch

BACKGROUND

Insect bite hypersensitivity (IBH) is the most common seasonal pruritic allergic dermatitis of horses occurring upon insect bites. In recent years, a major role for IL-31 in allergic pruritus of humans, monkeys, dogs, and mice was acknowledged. Here, we investigate the role of IL-31 in IBH of horses and developed a therapeutic vaccine against equine IL-31 (eIL-31).

METHODS

IL-31 levels were quantified in allergen-stimulated peripheral blood mononuclear cells (PBMCs) and skin punch biopsies of IBH lesions and healthy skin from IBH-affected and healthy horses. The vaccine consisted of eIL-31 covalently coupled to a virus-like particle (VLP) derived from cucumber mosaic virus containing a tetanus toxoid universal T-cell epitope (CuMVTT). Eighteen IBH-affected horses were recruited and immunized with 300 μg of eIL-31-CuMVTT vaccine or placebo and IBH severity score was recorded.

RESULTS

IL-31 was increased in PBMCs and exclusively detectable in skin lesions of IBH-affected horses. Vaccination against eIL-31 reduced delta clinical scores when compared to previous untreated IBH season of the same horses and to placebo-treated horses in the same year. The vaccine was well tolerated without safety concerns throughout the study.

CONCLUSION

TH2-derived IL-31 is involved in IBH pathology and accordingly the immunotherapeutic vaccination approach targeting IL-31 alleviated clinical scores in affected horses.

New Strategies for Prevention and Treatment of Insect Bite Hypersensitivity in Horses

Purpose of Review

Treatment of equine insect bite hypersensitivity (IBH) needs to be improved. Allergen-specific immunotherapy (ASIT), the only curative treatment of allergy, currently has only a limited efficacy for treatment of IBH. This review highlights the latest findings in prophylactic and therapeutic strategies.

Recent Findings

Prophylactic vaccination against IBH using recombinant Culicoides allergen has been developed in unexposed Icelandic horses and is ready to be tested. Therapeutic virus-like particle (VLP)–based vaccines targeting equine interleukin- (IL-) 5 or IL-31 improved clinical signs of IBH by induction of anti-cytokine antibodies thus reducing eosinophil counts or allergic pruritus, respectively.

Summary

First studies for development of ASIT using pure r-Culicoides allergens have yielded promising results and need now to be tested in clinical studies for both prevention and treatment of IBH. Therapeutic vaccines inducing neutralizing antibodies against IL-5 or IL-31 will be valuable future treatments for reduction of clinical signs of IBH.

Comparison of three clinical scoring systems for Culicoides hypersensitivity in a herd of Icelandic horses

BACKGROUND

Culicoides hypersensitivity (CH), an intensely pruritic and seasonal allergic dermatitis, is a common allergic disease affecting horses worldwide. Currently, there is no validated clinical scoring system for the quantification of clinical signs associated with CH.

OBJECTIVES

To (i) determine the best cut-off point of three scoring systems, (ii) test the accuracy of each system when compared to the clinical diagnosis of an experienced veterinarian and (iii) assess agreement between systems.

ANIMALS

Icelandic horses (n = 20); eight with CH and 12 unaffected, from a research herd receiving no treatments for allergic dermatitis.

METHODS AND MATERIALS

Lesion scores were recorded biweekly from April until September with three clinical scoring systems (A, B and C) by a single observer initially blinded to CH status. Separate logistic regression analyses for each time point were used to determine appropriate cut-offs for CH classification. Spearman's rho and Cohen's kappa were calculated to analyze correlation of scores and agreement of CH categorization between systems, respectively.

RESULTS

The best allergic cut-off scores for system A, B and C were determined to be three, eight and 12, respectively. For each system median areas under the curve (>0.85) were excellent and discriminatory ability for correctly classifying CH status was strong. Excellent correlation between scores for each system (Spearman's rho > 0.96) and excellent intersystem agreement for CH categorization (kappa ≥ 0.73) were found across scoring time points.

CONCLUSION AND CLINICAL IMPORTANCE

Results support the use of these scoring systems as templates for the future standardization of a CH clinical scoring system.

Phospholipid analysis in sera of horses with allergic dermatitis and in matched healthy controls

Background

Lipids have become an important target for searching new biomarkers typical of different autoimmune and allergic diseases. The most common allergic dermatitis of the horse is related to stings of insects and is known as insect bite hypersensitivity (IBH) or summer eczema, referring to its recurrence during the summer months. This intense pruritus has certain similarities with atopic dermatitis of humans. The treatment of IBH is difficult and therefore new strategies for therapy are needed. Autoserum therapy based on the use of serum phospholipids has recently been introduced for horses. So far, serum lipids relating to these allergic disorders have been poorly determined. The main aim of this study was to analyse phospholipid profiles in the sera of horses with allergic dermatitis and in their healthy controls and to further assess whether these lipid profiles change according to the clinical status after therapy.

Methods

Sera were collected from 10 horses with allergic dermatitis and from 10 matched healthy controls both before and 4 weeks after the therapy of the affected horses. Eczema horses were treated with an autogenous preparation made from a horse’s own serum and used for oral medication. Samples were analysed for their phospholipid content by liquid chromatography coupled to a triple-quadrupole mass spectrometer (LC-MS). Data of phospholipid concentrations between the groups and over the time were analysed by using the Friedman test. Correlations between the change of concentrations and the clinical status were assessed by Spearman’s rank correlation test.

Results

The major phospholipid classes detected were phosphatidylcholine (PC), sphingomyelin (SM), phosphatidylinositol (PI) and phosphatidylethanolamine (PE). Eczema horses had significantly lower total concentrations of PC (p < 0.0001) and SM (p = 0.0115) than their healthy controls. After a 4-week therapy, no significant differences were found between the groups. Changes in SM concentrations correlated significantly with alterations in clinical signs (p = 0.0047).

Conclusions

Horses with allergic dermatitis have an altered phospholipid profile in their sera as compared with healthy horses and these profiles seem to change according to their clinical status. Sphingomyelin seems to have an active role in the course of equine insect bite hypersensitivity.

Equine allergy therapy: update on the treatment of environmental, insect bite hypersensitivity, and food allergies

Allergies are common in horses. It is important to identify and correct as many factors as possible to control pruritus and make the patient comfortable. Culicoides hypersensitivity is a common component in allergic horses. The main treatment continues to be rigorous fly control and avoidance of insect bites. Environmental allergies are best addressed by early identification of the offending allergens and formulation of allergen-specific immunotherapy to decrease the need for rescue medications. Food allergy is best managed with food avoidance. Urticaria is one of the manifestations of allergic disease wherein detection of the triggering cause is essential for management.

Cloning and expression of candidate allergens from Culicoides obsoletus for diagnosis of insect bite hypersensitivity in horses

Insect bite hypersensitivity (IBH) is an IgE-mediated (Type I) hypersensitivity reaction induced by allergens from biting midges of the Culicoides spp. The aim of the present study was to identify, clone and express recombinant allergens from C. obsoletus, the main species found feeding on horses in the Netherlands, by sequence homology searches on the C. obsoletus specific RNA database, with previously described allergens from C. nubeculosus and C. sonorensis. BLAST searches with these described allergens resulted in similarity hits with 7 genes coding for C. obsoletus allergens. These allergens were expressed as hexahistidine tagged recombinant proteins in E. coli. Allergens were termed Cul o 1-Cul o 7. A maltase (Cul o 1) plus Cul s 1 (maltase of C. sonorensis) were additionally expressed in insect cells using the baculovirus expression system to compare homologous allergens from different species produced with different expression systems in diagnostic in vitro and in vivo tests. We demonstrate that IBH affected horses in the Netherlands show higher IgE levels to Cul o 1 than to Cul s 1, as determined by an IgE ELISA. Furthermore, we show that Cul o 1 produced in E. coli is at least as suitable for in vitro diagnosis of IBH affected horses as Cul o 1 produced in the baculovirus/insect cell expression system. The resulting proteins were evaluated for their ability to discriminate IBH affected and healthy horses by ELISA and intradermal testing. The frequency of positive test results by ELISA within IBH affected horses ranged from 38% to 67% for the different allergens. When results of IgE-binding to Cul o 1-Cul o 7 were combined the test had a sensitivity of 92% and specificity of 85%. The capability of the allergens to induce Type I hypersensitivity reaction in IBH affected horses was demonstrated by an intradermal test. The results show that E. coli expressed recombinant allergens from C. obsoletus are valuable tools to determine the allergen specific sensitisation profile (component resolved diagnosis) in horses with IBH in countries were C. obsoletus is the most abundant species and may facilitate in the development of future immunotherapy.

Equine insect bite hypersensitivity: what do we know?

Insect bite hypersensitivity (IBH) is an allergic dermatitis of the horse caused by bites of insects of the genus Culicoides and is currently the best characterized allergic disease of horses. This article reviews knowledge of the immunopathogenesis of IBH, with a particular focus on the causative allergens. Whereas so far hardly any research has been done on the role of antigen presenting cells in the pathogenesis of IBH, recent studies suggest that IBH is characterized by an imbalance between a T helper 2 (Th2) and regulatory T cell (T(reg)) immune response, as shown both locally in the skin and with stimulated peripheral blood mononuclear cells. Various studies have shown IBH to be associated with IgE-mediated reactions against salivary antigens from Culicoides spp. However, until recently, the causative allergens had not been characterized at the molecular level. A major advance has now been made, as 11 Culicoides salivary gland proteins have been identified as relevant allergens for IBH. Currently, there is no satisfactory treatment of IBH. Characterization of the main allergens for IBH and understanding what mechanisms induce a healthy or allergic immune response towards these allergens may help to develop new treatment strategies, such as immunotherapy.