1
|
Underwood B, Mills C, Devonshire AL, Andorf S, Assa'ad AH, Ramsey R, Schwartz JT. OIT-BRAVE questionnaire: Development and clinical implementation of a screening instrument for patient-reported difficulties during oral immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00579-8. [PMID: 38851488 DOI: 10.1016/j.jaip.2024.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/17/2024] [Accepted: 05/29/2024] [Indexed: 06/10/2024]
Affiliation(s)
- Brynne Underwood
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christa Mills
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ashley L Devonshire
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sandra Andorf
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amal H Assa'ad
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rachelle Ramsey
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Justin T Schwartz
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| |
Collapse
|
2
|
Winslow A, Mills C, Schwartz JT, Assa'ad A. Implementing Food Oral Immunotherapy Into Clinical Practice: Quality and Safety Perspectives From a US Academic Center. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1159-1169. [PMID: 38423284 DOI: 10.1016/j.jaip.2024.02.032] [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: 09/11/2023] [Revised: 02/03/2024] [Accepted: 02/22/2024] [Indexed: 03/02/2024]
Abstract
Oral immunotherapy (OIT) is an accessible procedure for practicing allergy/immunology providers, yet rigorous safety standards are limited in the clinical setting. By exploring the transition from research to clinical practice OIT, we review relevant safety considerations necessary for the clinical provider. We offer a perspective on clinical benefits and considerations at the individual, collaboration, and policy levels from the vantage of a large academic OIT program, and we propose several practical start-up checklists and clerical considerations for practicing providers. Awareness of the local population and front-end planning is necessary to improve the accessibility of this procedure in clinical practice among racial and socioeconomic minority populations. Sharing and merging OIT protocols, procedural methods, and electronic medical record order sets may increase harmonization among OIT-providing institutions and further our abilities to pool safety and outcomes data, ultimately enhancing the safety and efficacy of clinical OIT.
Collapse
Affiliation(s)
- Andrew Winslow
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Christa Mills
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Justin T Schwartz
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amal Assa'ad
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
3
|
Mack DP, Upton J, Patel N, Turner PJ. Flex-IT! Applying "Platform Trials" Methodology to Immunotherapy for Food Allergy in Research and Clinical Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:554-561. [PMID: 38218449 DOI: 10.1016/j.jaip.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/27/2023] [Accepted: 01/09/2024] [Indexed: 01/15/2024]
Abstract
There is an increasing trend in the management of food allergy toward active treatment using allergen immunotherapy (AIT). Although AIT is efficacious, treatment-related adverse events are common, particularly with oral immunotherapy in those with high levels of allergen-specific IgE sensitization. In clinical practice, these adverse events inevitably create challenges: clinicians and patients routinely face decisions whether to alter the dose itself, the frequency of dosing, and the pace of escalation, or indeed discontinue AIT altogether. Flexibility is therefore needed to adapt treatment, particularly in clinical practice, so that participants are "treated-to-target." For example, this may entail a significant change in the dosing protocol or even switching from one route of administration to another in response to frequent adverse events. We refer to this approach as flexible immunotherapy. However, there is little evidence to inform clinicians as to what changes to treatment are most likely to result in treatment success. Classical clinical trials rely, by necessity, on relatively rigid updosing protocols. To provide an evidence base to optimize AIT, the food allergy community should adopt adaptive platform trials, where a "master protocol" facilitates more efficient evaluation, including longer-term outcomes of multiple interventions. Within a single clinical trial, participants are able to switch between different treatment arms; interventions can be added or dropped without compromising the integrity of the trial. Developing platform trials for food AIT may initially be costly, but they represent a significant opportunity to grow the evidence base (with respect to both treatment outcomes and biomarker discovery) at scale. In addition, they could help understand longitudinal disease trajectories that are difficult to study in clinical trials for food allergy due to the time needed to demonstrate changes in efficacy. Finally, their adoption would achieve greater collaboration and consistency in approaches to proactive management of food allergy in routine clinical practice. As a community, we need to actively pursue this with funders and established research collaborations to deliver the very best outcomes for our patients and their families.
Collapse
Affiliation(s)
- Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Julia Upton
- SickKids Food Allergy and Anaphylaxis Programme, Division of Immunology and Allergy, Department of Pediatrics, the Hospital for Sick Children, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nandinee Patel
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, United Kingdom.
| |
Collapse
|
4
|
Chong AC, Diwakar L, Kaplan CM, Fox AT, Abrams EM, Greenhawt M, Oppenheimer JJ, Shaker MS. Provision of Food Allergy Care in the United Kingdom and United States: Current Issues and Future Directions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2054-2066. [PMID: 36990429 DOI: 10.1016/j.jaip.2023.03.029] [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: 02/05/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023]
Abstract
Food allergy (FA) is a growing issue worldwide. The United Kingdom and United States are high-income, industrialized countries with reported increases in FA prevalence over the past few decades. This review compares delivery of FA care in the United Kingdom and United States and each country's response to the heightened demand and disparities for FA services. In the United Kingdom, allergy specialists are scarce and general practitioners (GPs) provide most allergy care. Whereas the United States has more allergists per capita than the United Kingdom, there is still a shortage of allergy services owing to the greater reliance on specialist care for FA in America and wide geographic variation in access to allergist services. Currently, generalists in these countries lack the specialty training and equipment to diagnose and manage FA optimally. Moving forward, the United Kingdom aims to enhance training for GPs so they may provide better quality frontline allergy care. In addition, the United Kingdom is implementing a new tier of semi-specialized GPs and increasing cross-center collaboration through clinical networks. The United Kingdom and United States aim to increase the number of FA specialists, which is critical at a time of rapidly expanding management options for allergic and immunologic diseases requiring clinical expertise and shared decision-making to select appropriate therapies. While these countries aim to grow their supply of quality FA services actively, further efforts to build clinical networks and perhaps recruit international medical graduates and expand telehealth services are necessary to reduce disparities in access to care. For the United Kingdom in particular, increasing quality services will require additional support from the leadership of the centralized National Health Service, which remains challenging.
Collapse
Affiliation(s)
- Albert C Chong
- Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Lavanya Diwakar
- Department of Immunology, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom; Department of Health Economics, University of Birmingham, Birmingham, United Kingdom
| | - Cameron M Kaplan
- Gehr Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, Los Angeles, Los Angeles, Calif
| | - Adam T Fox
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Elissa M Abrams
- Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada; Division of Allergy and Immunology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - John J Oppenheimer
- Department of Internal Medicine, Pulmonary and Allergy, UMDJ Rutgers University School of Medicine, Newark, NJ
| | - Marcus S Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Pediatrics, Dartmouth Geisel School of Medicine, Hanover, NH; Department of Medicine, Dartmouth Geisel School of Medicine, Hanover, NH.
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Lloyd M, Loke P, Mack DP, Sicherer SH, Perkin MR, Boyle R, Yin Leung AS, Lee BW, Levin M, Blumchen K, Fiocchi A, Ebisawa M, Oliveira LCLD, Tang MLK. Varying Approaches to Management of IgE-Mediated Food Allergy in Children Around the World. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1010-1027.e6. [PMID: 36805346 DOI: 10.1016/j.jaip.2023.01.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 02/17/2023]
Abstract
Food allergy is a chronic disease that affects individuals of all ages and is a significant public health problem globally. This narrative overview examines clinical management strategies for IgE-mediated food allergy in children around the world to understand variations in practice. Information was drawn from clinical practice guidelines, recent research, the websites of professional and governmental bodies with expertise in food allergy, and clinical experts from a broad cross-section of geographical regions. The structure and delivery of clinical services, allergen avoidance and food labeling, and resources to support the management of allergic reactions in the community are discussed in detail. The adoption of emerging food immunotherapies is also explored. Wide variations in clinical management of food allergy were apparent across the different countries. Common themes were continuing issues with access to specialist care and recognition of the need to balance risk reduction with dietary and social restrictions to avoid unnecessary detrimental impacts on the quality of life of food allergy sufferers. Findings highlight the need for standardized presentation of practice and priorities, and may assist clinicians and researchers when engaging with government and funding agencies to address gaps.
Collapse
Affiliation(s)
- Melanie Lloyd
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - Paxton Loke
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, Monash University, Clayton, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Scott H Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael R Perkin
- Population Health Research Institute, St. George's, University of London, London, United Kingdom
| | - Robert Boyle
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Agnes Sze Yin Leung
- Department of Paediatrics, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong; Hong Kong Hub of Paediatric Excellence, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Bee Wah Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Michael Levin
- Division of Paediatric Allergology, University of Cape Town, Cape Town, South Africa
| | - Katharina Blumchen
- Department of Children and Adolescent Medicine, Division of Pneumology, Allergology and Cystic Fibrosis, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Alessandro Fiocchi
- Translational Research in Paediatric Specialities Area, Allergy Division, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Sagamihara, Japan
| | - Lucila Camargo Lopes de Oliveira
- Department of Paediatrics, Division of Allergy, Clinical Immunology and Rheumatology, Federal University of São Paulo, São Paulo, Brazil
| | - Mimi L K Tang
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, VIC, Australia.
| |
Collapse
|