3
|
Wilson BE, Sacta MA, Wright BL, Spergel J, Wolfset N. The Relationship Between Eosinophilic Esophagitis and Immunotherapy. Immunol Allergy Clin North Am 2024; 44:281-291. [PMID: 38575223 PMCID: PMC11008775 DOI: 10.1016/j.iac.2024.01.001] [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] [Indexed: 04/06/2024]
Abstract
Immunotherapy is a treatment approach based on the principle of incremental allergen exposure to achieve desensitization. Recently, oral immunotherapy has been introduced as a treatment of IgE-mediated food allergy. Some patients receiving oral immunotherapy for food allergy may develop eosinophilic esophagitis. Here, we summarize the literature examining this association, its treatment, and outcomes and discuss possible explanations for this clinical phenomenon. We further identify potential associations with aeroallergen sensitivity and other forms of immunotherapy including subcutaneous immunotherapy and sublingual immunotherapy. Finally, we discuss management of immunotherapy-induced eosinophilic esophagitis. Epicutaneous immunotherapy is highlighted as an area of therapeutic investigation.
Collapse
Affiliation(s)
- Bridget E Wilson
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, 13400 E. Shea Boulevard Scottsdale, AZ 85259, USA; Division of Allergy/Immunology, Phoenix Children's, 1919 E. Thomas Road, Phoenix, AZ 85054, USA.
| | - Maria A Sacta
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Benjamin L Wright
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, 13400 E. Shea Boulevard Scottsdale, AZ 85259, USA; Division of Allergy/Immunology, Phoenix Children's, 1919 E. Thomas Road, Phoenix, AZ 85054, USA
| | - Jonathan Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Nicole Wolfset
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| |
Collapse
|
4
|
Bognanni A, Fiocchi A, Arasi S, Chu DK, Ansotegui I, Assa'ad AH, Bahna SL, Berni Canani R, Bozzola M, Dahdah L, Dupont C, Dziechciarz P, Ebisawa M, Firmino RT, Chu A, Galli E, Horvath A, Kamenwa R, Lack G, Li H, Martelli A, Nowak-Węgrzyn A, Papadopoulos NG, Pawankar R, Roldan Y, Said M, Sánchez-Borges M, Shamir R, Spergel JM, Szajewska H, Terracciano L, Vandenplas Y, Venter C, Waffenschmidt S, Waserman S, Warner A, Wong GW, Schünemann HJ, Brozek JL. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guideline update - XII - Recommendations on milk formula supplements with and without probiotics for infants and toddlers with CMA. World Allergy Organ J 2024; 17:100888. [PMID: 38706757 PMCID: PMC11068951 DOI: 10.1016/j.waojou.2024.100888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 02/13/2024] [Accepted: 02/21/2024] [Indexed: 05/07/2024] Open
Abstract
Background Cow's milk allergy (CMA) is the most common food allergy in infants. The replacement with specialized formulas is an established clinical approach to ensure adequate growth and minimize the risk of severe allergic reactions when breastfeeding is not possible. Still, given the availability of multiple options, such as extensively hydrolyzed cow's milk protein formula (eHF-CM), amino acid formula (AAF), hydrolyzed rice formula (HRF) and soy formulas (SF), there is some uncertainty as to the most suitable choice with respect to health outcomes. Furthermore, the addition of probiotics to a formula has been proposed as a potential approach to maximize benefit. Objective These evidence-based guidelines from the World Allergy Organization (WAO) intend to support patients, clinicians, and others in decisions about the use of milk specialized formulas, with and without probiotics, for individuals with CMA. Methods WAO formed a multidisciplinary guideline panel balanced to include the views of all stakeholders and to minimize potential biases from competing interests. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to review by stakeholders. Results After reviewing the summarized evidence and thoroughly discussing the different management options, the WAO guideline panel suggests: a) using an extensively hydrolyzed (cow's milk) formula or a hydrolyzed rice formula as the first option for managing infants with immunoglobulin E (IgE) and non-IgE-mediated CMA who are not being breastfed. An amino-acid formula or a soy formula could be regarded as second and third options respectively; b) using either a formula without a probiotic or a casein-based extensively hydrolyzed formula containing Lacticaseibacillus rhamnosus GG (LGG) for infants with either IgE or non-IgE-mediated CMA.The issued recommendations are labeled as "conditional" following the GRADE approach due to the very low certainty about the health effects based on the available evidence. Conclusions If breastfeeding is not available, clinicians, patients, and their family members might want to discuss all the potential desirable and undesirable consequences of each formula in infants with CMA, integrating them with the patients' and caregivers' values and preferences, local availability, and cost, before deciding on a treatment option. We also suggest what research is needed to determine with greater certainty which formulas are likely to be the most beneficial, cost-effective, and equitable.
Collapse
Affiliation(s)
- Antonio Bognanni
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Alessandro Fiocchi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome 00165, Italy
| | - Stefania Arasi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome 00165, Italy
| | - Derek K. Chu
- Department of Medicine, Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
| | | | - Amal H. Assa'ad
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sami L. Bahna
- Allergy and Immunology Section, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Roberto Berni Canani
- Pediatric Allergy Program at the Department of Translational Medical Science, and ImmunoNutritionLab at Ceinge Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Martin Bozzola
- Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, British Hospital-Perdriel, Buenos Aires, Argentina
| | - Lamia Dahdah
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome 00165, Italy
| | - Christophe Dupont
- Paris Descartes University, Pediatric Gastroenterology, Necker Hospital, Paris, France
- Clinique Marcel Sembat, Boulogne-Billancourt, France
| | - Piotr Dziechciarz
- Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
| | - Ramon T. Firmino
- Faculty of Medical Sciences of Campina Grande, UNIFACISA University Centre, Campina Grande, Paraiba, Brazil
| | - Alexandro Chu
- Department of Medicine, Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
| | - Elena Galli
- Pediatric Allergy Unit, San Pietro Hospital - Fatebenefratelli, Rome, Italy
| | - Andrea Horvath
- Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Rose Kamenwa
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya
| | - Gideon Lack
- King's College London, Asthma-UK Centre in Allergic Mechanisms of Asthma, Department of Pediatric Allergy, St Thomas' Hospital, London, UK
| | - Haiqi Li
- Department of Primary Child Care, Children's Hospital, Chongqing Medical University, China
| | - Alberto Martelli
- Member of Italian Society of Allergy and Pediatric Immunology (SIAIP), Italy
| | - Anna Nowak-Węgrzyn
- 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
| | - Nikolaos G. Papadopoulos
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
- Allergy Department, 2nd Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Ruby Pawankar
- Division of Allergy, Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Yetiani Roldan
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maria Said
- Allergy & Anaphylaxis Australia, Castle Hill, New South Wales, Australia
| | - Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico Docente La Trinidad and Clínica El Avila, Caracas, Venezuela
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan M. Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Hania Szajewska
- Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Luigi Terracciano
- Pediatric Primary Care, National Pediatric Health Care System, Milan, Italy
| | - Yvan Vandenplas
- Department of Pediatric Gastroenterology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Carina Venter
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Siw Waffenschmidt
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | - Susan Waserman
- Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
| | | | - Gary W.K. Wong
- Department of Paediatrics, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Holger J. Schünemann
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Medicine, Division of Internal Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jan L. Brozek
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
8
|
Lodge CJ, Waidyatillake N, Peters RL, Netting M, Dai X, Burgess J, Hornung CJ, Perrett KP, Tang MLK, Koplin JJ, Dharmage SC. Efficacy and safety of oral immunotherapy for peanut, cow's milk, and hen's egg allergy: A systematic review of randomized controlled trials. Clin Transl Allergy 2023; 13:e12268. [PMID: 37488726 PMCID: PMC10314278 DOI: 10.1002/clt2.12268] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 04/18/2023] [Accepted: 05/17/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Oral immunotherapy (OIT) is a promising treatment for food allergies; however, safety is a concern. We synthesized evidence from the best randomized controlled trials (RCTs) on efficacy/safety of OIT for desensitization (DS) and remission (sustained unresponsiveness (SU)) in IgE mediated allergy to peanut, hen's eggs, and cow's milk. BODY: We searched Pubmed, EMBASE, and Cochrane databases (Until Oct 22) identifying 16 eligible RCTs published in English measuring food allergy by food challenge at the beginning and at the end of the study. The Cochrane Risk of Bias tool was used to assess study quality. We found 18 eligible studies. There was evidence of efficacy for DS for all allergens: peanut (RR 11.32; 95% CI 5.93, 21.60, I2 49%, 8 studies); hen's egg (RR 4.67; 2.66, 8.21, I2 0%, 5 studies); cow's milk (RR 13.98; 3.51, 55.65, I2 0%, 4 studies) and evidence for SU for peanut (RR 7.74; 2.90, 20.69, I2 0%, 3 studies) and hen's egg (RR 6.91; 1.67, 28.57, I2 0%, 2 studies). Allergic events were increased with intervention, and risk of adrenaline use increased for peanut RR 2.96; 1.63, 5.35, I2 0%, 8 studies; egg RR 1.71; 0.42, 6.92, I2 0%, 6 studies; and milk RR 8.45; 2.02, 35.27, I2 0%, 4 studies. CONCLUSION We found strong evidence that peanut, hen's egg, and cow's milk OIT can induce DS and some evidence for remission. There was a high risk of allergic reactions. Generalizability to the entire food allergic population is not known.
Collapse
Affiliation(s)
- Caroline J Lodge
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Nilakshi Waidyatillake
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
| | - Rachel L Peters
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Merryn Netting
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Women and Kids Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
- Discipline of Paediatrics, University of Adelaide, Adelaide, South Australia, Australia
| | - Xin Dai
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
| | - John Burgess
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Catherine J Hornung
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Kirsten P Perrett
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Mimi L K Tang
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Allergy Immunology, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Jennifer J Koplin
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Child Research Centre, University of Queensland, South Brisbane, Queensland, Australia
| | - Shyamali C Dharmage
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| |
Collapse
|