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Abstract
Die Allergenimmuntherapie (AIT) ist – neben der oft nicht suffizient durchzuführenden Allergenmeidung – die einzige kausale Therapie Ig(Immunglobulin)E-vermittelter Allergien gegen Aeroallergene und Hymenopterengifte. Sie kann je nach Allergen als subkutane Injektion (subkutane Immuntherapie [SCIT]) oder über eine sublinguale Applikation (sublinguale Immuntherapie [SLIT]) erfolgen, kürzlich wurde zudem auch ein Verfahren zur oralen Immuntherapie zur Behandlung der Nahrungsmittelallergie zugelassen. Neben der korrekten Indikationsstellung (positive Anamnese und Diagnostik einer IgE-vermittelten Allergie, Allergenkarenz nicht ausreichend möglich) sind mögliche Kontraindikationen und Risikofaktoren zu beachten. Zudem kann es unter einer AIT zu – potenziell auch lebensgefährlichen – Nebenwirkungen kommen. Im Folgenden sollen häufig gestellte Fragen und Fakten zur Entscheidungsfindung für die Durchführung und zum Risikomanagement der AIT beleuchtet und unter Berücksichtigung der aktuellen Datenlage diskutiert werden.
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Benefits and limitations of sting challenge in hymenoptera venom allergy. Allergol Select 2021; 5:45-50. [PMID: 33490858 PMCID: PMC7814776 DOI: 10.5414/alx02148e] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 01/13/2021] [Indexed: 11/29/2022] Open
Abstract
The prevalence of systemic reactions to hymenoptera stings is up to 7.5%. Venom-specific immunotherapy (VIT) is an established treatment for insect venom allergy. In order to monitor the allergic status and thus the success of the therapy, controlled sting challenge under VIT continues to be the gold standard. This review deals not only with useful indications and therapeutic consequences but also with critical aspects that should be considered when performing sting challenge.
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3
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Blank S, Grosch J, Ollert M, Bilò MB. Precision Medicine in Hymenoptera Venom Allergy: Diagnostics, Biomarkers, and Therapy of Different Endotypes and Phenotypes. Front Immunol 2020; 11:579409. [PMID: 33193378 PMCID: PMC7643016 DOI: 10.3389/fimmu.2020.579409] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022] Open
Abstract
Allergic reactions to stings of Hymenoptera species may be severe and are potentially fatal deviations of the immunological response observed in healthy individuals. However, venom-specific immunotherapy (VIT) is an immunomodulatory approach able to cure venom allergy in the majority of affected patients. An appropriate therapeutic intervention and the efficacy of VIT not only depend on a conclusive diagnosis, but might also be influenced by the patient-specific manifestation of the disease. As with other diseases, it should be borne in mind that there are different endotypes and phenotypes of venom allergy, each of which require a patient-tailored disease management and treatment scheme. Reviewed here are different endotypes of sting reactions such as IgE-mediated allergy, asymptomatic sensitization or a simultaneous presence of venom allergy and mast cell disorders including particular considerations for diagnosis and therapy. Additionally, phenotypical manifestations of venom allergy, as e.g. differences in age of onset and disease severity, multiple sensitization or patients unsusceptible to therapy, are described. Moreover, biomarkers and diagnostic strategies that might reflect the immunological status of the patient and their value for therapeutic guidance are discussed. Taken together, the increasing knowledge of different disease manifestations in venom hypersensitivity and the growing availability of diagnostic tools open new options for the classification of venom allergy and, hence, for personalized medical approaches and precision medicine in Hymenoptera venom allergy.
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Affiliation(s)
- Simon Blank
- Center of Allergy and Environment (ZAUM), Technical University of Munich, School of Medicine and Helmholtz Center Munich, German Research Center for Environmental Health, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Johannes Grosch
- Center of Allergy and Environment (ZAUM), Technical University of Munich, School of Medicine and Helmholtz Center Munich, German Research Center for Environmental Health, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Markus Ollert
- Department of Infection and Immunity, Luxembourg Institute of Health (LIH), Esch-sur-Alzette, Luxembourg.,Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense, Denmark
| | - Maria Beatrice Bilò
- Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy.,Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Ancona, Italy
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4
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Abstract
PURPOSE OF REVIEW Component-resolved diagnostics (CRD) is a new tool aiming at detecting IgE-mediated sensitizations against individual, relevant allergens. Here, we discuss recent literature on molecular diagnosis in the field of Hymenoptera venom allergy (HVA) as well as CRD strengths and weaknesses. RECENT FINDINGS CRD, using single molecules or panels of allergens, may discriminate between primary sensitization and cross-reactivity in patients with double/multiple positivity in diagnostic tests with whole extracts, allowing the specialist to choose the most suitable venom for specific immunotherapy (VIT), avoiding unnecessary VIT and reducing the risk of side effects. Future availability of the cross-reactive recombinant pairs of allergens of different species may further increase the diagnostic performance. CRD may be useful in patients with negative allergy tests and a proven history of a previous systemic reaction, including those with mast cell disorders, who could benefit from VIT. In honeybee venom allergy, different sensitization profiles have been identified, which could be associated with a greater risk of VIT failure or treatment side effects. SUMMARY CRD is undoubtedly an innovative diagnostic method that leads to a more precise definition of the sensitization profile of the HVA patient. Together with a better knowledge of the molecular composition of different venom extracts, CRD may contribute to optimize patient-tailored therapy.
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Martini M, Corsi A, Agolini S, Marchionni A, Antonicelli L, Bilò MB. High long-term efficacy of venom immunotherapy after discontinuation. Allergy 2020; 75:1793-1796. [PMID: 32043579 DOI: 10.1111/all.14224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/02/2020] [Accepted: 02/06/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Matteo Martini
- Allergy and Clinical Immunology School Università Politecnica delle Marche Ancona Italy
| | - Alice Corsi
- Allergy and Clinical Immunology School Università Politecnica delle Marche Ancona Italy
| | - Stefano Agolini
- Allergy and Clinical Immunology School Università Politecnica delle Marche Ancona Italy
| | - Aureliano Marchionni
- Allergy and Clinical Immunology School Università Politecnica delle Marche Ancona Italy
| | | | - Maria Beatrice Bilò
- Allergy Unit Department of Internal Medicine AOU Ospedali Riuniti Ancona Italy
- Department of Clinical and Molecular Sciences Università Politecnica delle Marche Ancona Italy
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Jarkvist J, Salehi C, Akin C, Gülen T. Venom immunotherapy in patients with clonal mast cell disorders: IgG4 correlates with protection. Allergy 2020; 75:169-177. [PMID: 31306487 DOI: 10.1111/all.13980] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/09/2019] [Accepted: 05/26/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with clonal mast cell disorders (cMCD), systemic mastocytosis (SM) and monoclonal mast cell activation syndrome (MMAS), represent an increased risk for Hymenoptera venom anaphylaxis (HVA). Lifelong venom immunotherapy (VIT) is recommended; however, its efficacy and safety are controversial. Hence, we sought to evaluate the efficacy and safety of VIT in HVA patients with cMCD. METHODS A retrospective study was conducted among 46 patients with Vespula venom allergy who had experienced severe HVA, 32 cMCD (22 with SM and 10 with MMAS) and 14 controls. There were no differences between cMCD patients and controls in age (58 vs 66) and duration of VIT (47 vs 48 months), respectively. RESULTS During VIT, 11 (34%) cMCD patients experienced adverse reactions (ARs) (7% in controls), including 1 anaphylaxis. There were 23 re-stings in 17 (53%) patients during VIT. Of episodes, four (17%) presented with anaphylaxis, 14 (60%) presented with local reaction, and five (23%) were asymptomatic. In 11 episodes (48%), the patient did not take epinephrine, of these 8 (73%) presented with local reaction, and 3 (27%) were asymptomatic. Patient-based protection from anaphylaxis was 76% (4/17) in cMCD vs. 100% in controls during VIT. The venom-specific IgG4 concentrations increased during VIT (P < .001) although tryptase and IgE were unaltered. CONCLUSION Both safety and efficacy of VIT in cMCD patients were slightly reduced than controls. Severe ARs were rare. The elevated IgG4 levels may be a biomarker for efficacy of VIT in cMCD patients, as it correlates with protection from re-stings.
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Affiliation(s)
- Jesper Jarkvist
- Department of Respiratory Medicine and Allergy Karolinska University Hospital Huddinge Stockholm Sweden
- Immunology and Allergy Unit, Department of Medicine Solna Karolinska Institutet, and Karolinska University Hospital Stockholm Sweden
| | - Clara Salehi
- Department of Respiratory Medicine and Allergy Karolinska University Hospital Huddinge Stockholm Sweden
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Internal Medicine University of Michigan Health System Ann Arbor MI USA
| | - Theo Gülen
- Department of Respiratory Medicine and Allergy Karolinska University Hospital Huddinge Stockholm Sweden
- Immunology and Allergy Unit, Department of Medicine Solna Karolinska Institutet, and Karolinska University Hospital Stockholm Sweden
- Mastocytosis Center Karolinska Karolinska Institutet and Karolinska University Hospital Stockholm Sweden
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Sahiner UM, Durham SR. Hymenoptera Venom Allergy: How Does Venom Immunotherapy Prevent Anaphylaxis From Bee and Wasp Stings? Front Immunol 2019; 10:1959. [PMID: 31497015 PMCID: PMC6712168 DOI: 10.3389/fimmu.2019.01959] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 08/02/2019] [Indexed: 01/12/2023] Open
Abstract
Hymenoptera stings may cause both local and systemic allergic reactions and even life threatening anaphylaxis. Along with pharmaceutical drugs and foods, hymenoptera venom is one of the most common causes of anaphylaxis in humans. To date, no parameter has been identified that may predict which sensitized people will have a future systemic sting reaction (SSR), however some risk factors, such as mastocytosis and age >40 years are known. Venom immunotherapy (VIT) is the most effective method of treatment for people who had SSR, which is shown to be effective even after discontinuation of the therapy. Development of peripheral tolerance is the main mechanism during immunotherapy. It is mediated by the production of blocking IgG/IgG4 antibodies that may inhibit IgE dependent reactions through both high affinity (FcεRI) and low affinity (FcεRII) IgE receptors on mast cells, basophils and B cells. The generation of antigen specific regulatory T cells produces IL-10 and suppresses Th2 immunity and the immune responses shift toward a Th1-type response. B regulatory cells are also involved in the production of IL-10 and the development of long term immune tolerance. During VIT the number of effector cells in target organs also decreases, such as mast cells, basophils, innate type 2 lymphocytes and eosinophils. Several meta-analyses and randomized controlled studies have proved that VIT is effective for preventing SSR to a sting and improves the quality of life. In this review, the risk of SSR in venom allergy and how VIT changed this risk are discussed.
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Affiliation(s)
- Umit Murat Sahiner
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom.,Pediatric Allergy Department, Hacettepe University School of Medicine, Ankara, Turkey
| | - Stephen R Durham
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom.,MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
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Heddle R, Smith A, Woodman R, Hissaria P, Petrovsky N. Randomized controlled trial demonstrating the benefits of delta inulin adjuvanted immunotherapy in patients with bee venom allergy. J Allergy Clin Immunol 2019; 144:504-513.e16. [PMID: 31300280 PMCID: PMC7112352 DOI: 10.1016/j.jaci.2019.03.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/11/2019] [Accepted: 03/22/2019] [Indexed: 12/29/2022]
Abstract
Background Allergic reactions to Hymenoptera insect stings remain a major global clinical problem. Although effective, parenteral desensitization regimens require use of costly venom extracts and require frequent visits over extended periods of time. Objective Adjuvants are commonly used to enhance the efficacy of infectious disease vaccines, and this study asked whether Advax (Vaxine Pty Ltd, Adelaide, Australia), a novel noninflammatory polysaccharide adjuvant, might provide similar benefits for allergy desensitization. Methods A randomized, controlled phase 1/2 trial was undertaken in 27 adults with a history of rapid-onset systemic allergic reactions to honeybee stings and positive specific IgE levels to evaluate the safety and efficacy of honeybee venom immunotherapy (HBVIT) combined with Advax adjuvant. Venom immunotherapy (VIT) was administered monthly for 30 months after achievement of maintenance doses. Results Advax-adjuvanted HBVIT was well tolerated. Around week 14 of VIT, specific IgG4 responses peaked in both groups but increased earlier, peaked higher, and were better maintained through the end of the study in the Advax-adjuvanted arm. Several different patterns of serologic response to VIT were seen; some subjects had a dominant IgG4 response, some had a combined IgG4 and IgG1 response, and some had an exclusively IgG1 response. In some subjects specific IgE levels increased during the induction phase and then decreased, whereas in others specific IgE levels progressively decreased from the start of VIT. Conclusion Advax adjuvant favorably enhanced the immunogenicity of HBVIT, with an early and prolonged switch to specific IgG4 production. The ability of Advax adjuvant to enhance VIT efficacy warrants further study.
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Affiliation(s)
- Robert Heddle
- University of Adelaide, North Terrace, Adelaide, Australia; Royal Adelaide Hospital, North Terrace, Adelaide, Australia; Flinders University, Bedford Park, Australia
| | - Anthony Smith
- Allergy and Clinical Immunology Department, Flinders Medical Centre, Bedford Park, Australia
| | - Richard Woodman
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, Bedford Park, Australia
| | | | - Nikolai Petrovsky
- Flinders University, Bedford Park, Australia; Vaxine, Bedford Park, Australia.
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Incorvaia C, Martignago I, Ridolo E. Use of a Combination of Allergen Immunotherapy and Omalizumab for Prevention of Anaphylaxis. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0170-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Sturm GJ, Varga EM, Roberts G, Mosbech H, Bilò MB, Akdis CA, Antolín-Amérigo D, Cichocka-Jarosz E, Gawlik R, Jakob T, Kosnik M, Lange J, Mingomataj E, Mitsias DI, Ollert M, Oude Elberink JNG, Pfaar O, Pitsios C, Pravettoni V, Ruëff F, Sin BA, Agache I, Angier E, Arasi S, Calderón MA, Fernandez-Rivas M, Halken S, Jutel M, Lau S, Pajno GB, van Ree R, Ryan D, Spranger O, van Wijk RG, Dhami S, Zaman H, Sheikh A, Muraro A. EAACI guidelines on allergen immunotherapy: Hymenoptera venom allergy. Allergy 2018; 73:744-764. [PMID: 28748641 DOI: 10.1111/all.13262] [Citation(s) in RCA: 236] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2017] [Indexed: 01/27/2023]
Abstract
Hymenoptera venom allergy is a potentially life-threatening allergic reaction following a honeybee, vespid, or ant sting. Systemic-allergic sting reactions have been reported in up to 7.5% of adults and up to 3.4% of children. They can be mild and restricted to the skin or moderate to severe with a risk of life-threatening anaphylaxis. Patients should carry an emergency kit containing an adrenaline autoinjector, H1 -antihistamines, and corticosteroids depending on the severity of their previous sting reaction(s). The only treatment to prevent further systemic sting reactions is venom immunotherapy. This guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on Venom Immunotherapy as part of the EAACI Guidelines on Allergen Immunotherapy initiative. The guideline aims to provide evidence-based recommendations for the use of venom immunotherapy, has been informed by a formal systematic review and meta-analysis and produced using the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included representation from a range of stakeholders. Venom immunotherapy is indicated in venom-allergic children and adults to prevent further moderate-to-severe systemic sting reactions. Venom immunotherapy is also recommended in adults with only generalized skin reactions as it results in significant improvements in quality of life compared to carrying an adrenaline autoinjector. This guideline aims to give practical advice on performing venom immunotherapy. Key sections cover general considerations before initiating venom immunotherapy, evidence-based clinical recommendations, risk factors for adverse events and for relapse of systemic sting reaction, and a summary of gaps in the evidence.
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Manmohan M, Müller S, Rauber MM, Koberne F, Reisch H, Koster J, Böhm R, Messelken M, Fischer M, Jakob T. Current state of follow-up care for patients with Hymenoptera venom anaphylaxis in southwest Germany. ALLERGO JOURNAL 2018. [DOI: 10.1007/s15007-018-1523-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Manmohan M, Müller S, Myriam Rauber M, Koberne F, Reisch H, Koster J, Böhm R, Messelken M, Fischer M, Jakob T. Current state of follow-up care for patients with Hymenoptera venom anaphylaxis in southwest Germany: Major impact of early information. ACTA ACUST UNITED AC 2018; 27:4-14. [PMID: 29399436 PMCID: PMC5785614 DOI: 10.1007/s40629-017-0046-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 11/21/2017] [Indexed: 11/17/2022]
Abstract
Background Up to 3.5% of the population experience anaphylactic reactions in response to Hymenoptera stings. Current guidelines are in place for the diagnostic workup and follow-up care of patients with Hymenoptera venom anaphylaxis (HVA). However, little is known about the degree of implementation of the recommendations and patient attitudes toward the recommendations in the general patient population. Methods For the analysis of the follow-up care in real life, a retrospective questionnaire-based study was conducted in unselected patients who had received treatment from an emergency medical response team for HVA, as documented in records of three regional Medical Emergency Response Centers. Results From over 125,000 cases, a filtered list of 1895 patients that coded for anaphylaxis was generated and examination of paper records identified 548 patients with a documented insect sting anaphylaxis. Patients were sent a standardized questionnaire addressing different aspects of diagnostics and follow-up care. Almost 40% of the patients did not receive a referral to an allergist at the emergency center, over 50% did not consult an allergy specialist at any time after the index sting, 25% did not receive any form of diagnostic workup, over 30% did not receive any information about venom immunotherapy (VIT) as treatment option, and only 50% were eventually started on VIT. Emergency medication was prescribed in 90% of the cases, 77% including an adrenalin auto injector, of which 47% were expired at the time of the survey. Patients who were informed about diagnostic and treatment options early during the index event, i. e., during the stay in the emergency department, displayed a higher rate of referral to an allergist (70% vs. 17%), higher rate of diagnostic workup (88% vs. 59%), and a higher rate of initiation of VIT (89% vs. 64%), as compared to patients who did not. Conclusion Our results demonstrate that there are missed opportunities for secondary and tertiary prevention of anaphylaxis due to insect venom allergy and that early information on required diagnostics and treatment options has a major impact on the degree of proper follow-up care in line with current guideline recommendations.
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Affiliation(s)
- Manisha Manmohan
- 1Department of Dermatology, Allergy Research Group, Medical Center, University of Freiburg, Freiburg, Germany.,2Department of Dermatology and Allergology, University Medical Center Giessen, Justus Liebig University, Gaffkystraße 14, 35392 Giessen, Germany.,3Dermatology and Plastic Surgery Institute, Cleveland Clinic, 9500 Euclid Ave., 44195 Cleveland, OH USA
| | - Sabine Müller
- 1Department of Dermatology, Allergy Research Group, Medical Center, University of Freiburg, Freiburg, Germany
| | - Michèle Myriam Rauber
- 2Department of Dermatology and Allergology, University Medical Center Giessen, Justus Liebig University, Gaffkystraße 14, 35392 Giessen, Germany
| | - Frank Koberne
- Emergency Medical Response Center Freiburg, St. Joseph's Hospital, Freiburg, Germany
| | - H Reisch
- Emergency Medical Response Center Freiburg, St. Joseph's Hospital, Freiburg, Germany
| | - Joachim Koster
- 5Emergency Medical Response Center Bad Krozingen, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Richard Böhm
- Department of Anesthesia, Intensive Care and Emergency Medicine, Alb Fils Kliniken GmbH, Klinik am Eichert, Göppingen, Germany
| | - Martin Messelken
- Department of Anesthesia, Intensive Care and Emergency Medicine, Alb Fils Kliniken GmbH, Klinik am Eichert, Göppingen, Germany
| | - Matthias Fischer
- Department of Anesthesia, Intensive Care and Emergency Medicine, Alb Fils Kliniken GmbH, Klinik am Eichert, Göppingen, Germany
| | - Thilo Jakob
- 1Department of Dermatology, Allergy Research Group, Medical Center, University of Freiburg, Freiburg, Germany.,2Department of Dermatology and Allergology, University Medical Center Giessen, Justus Liebig University, Gaffkystraße 14, 35392 Giessen, Germany
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Schiener M, Graessel A, Ollert M, Schmidt-Weber CB, Blank S. Allergen-specific immunotherapy of Hymenoptera venom allergy - also a matter of diagnosis. Hum Vaccin Immunother 2017; 13:2467-2481. [PMID: 28604163 PMCID: PMC5647953 DOI: 10.1080/21645515.2017.1334745] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/03/2017] [Accepted: 05/21/2017] [Indexed: 12/16/2022] Open
Abstract
Stings of hymenoptera can induce IgE-mediated hypersensitivity reactions in venom-allergic patients, ranging from local up to severe systemic reactions and even fatal anaphylaxis. Allergic patients' quality of life can be mainly improved by altering their immune response to tolerate the venoms by injecting increasing venom doses over years. This venom-specific immunotherapy is highly effective and well tolerated. However, component-resolved information about the venoms has increased in the last years. This knowledge is not only able to improve diagnostics as basis for an accurate therapy, but was additionally used to create tools which enable the analysis of therapeutic venom extracts on a molecular level. Therefore, during the last decade the detailed knowledge of the allergen composition of hymenoptera venoms has substantially improved diagnosis and therapy of venom allergy. This review focuses on state of the art diagnostic and therapeutic options as well as on novel directions trying to improve therapy.
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Affiliation(s)
- Maximilian Schiener
- Center of Allergy and Environment (ZAUM), Technical University of Munich and Helmholtz Center Munich, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Anke Graessel
- Center of Allergy and Environment (ZAUM), Technical University of Munich and Helmholtz Center Munich, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Markus Ollert
- Department of Infection and Immunity, Luxembourg Institute of Health (LIH), Esch-sur-Alzette, Luxembourg
- Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense C, Denmark
| | - Carsten B. Schmidt-Weber
- Center of Allergy and Environment (ZAUM), Technical University of Munich and Helmholtz Center Munich, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Simon Blank
- Center of Allergy and Environment (ZAUM), Technical University of Munich and Helmholtz Center Munich, Member of the German Center of Lung Research (DZL), Munich, Germany
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Fiedler C, Miehe U, Treudler R, Kiess W, Prenzel F. Long-Term Follow-Up of Children after Venom Immunotherapy: Low Adherence to Anaphylaxis Guidelines. Int Arch Allergy Immunol 2017; 172:167-172. [DOI: 10.1159/000458707] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 01/30/2017] [Indexed: 11/19/2022] Open
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Abstract
Allergies affect a large proportion of the population. Allergies can adversely affect productivity, sleep, and quality of life and can lead to life-threatening reactions. Allergies can spread to affect multiple organ systems. Allergen immunotherapy is the only therapy that can change the natural history of allergic disease.
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Affiliation(s)
- Efren Rael
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University, Box 18885, Stanford, CA 94309, USA.
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When can immunotherapy for insect sting allergy be stopped? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 3:324-8; quiz 329-30. [PMID: 25956311 DOI: 10.1016/j.jaip.2014.11.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 11/14/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Stings by Hymenoptera (honey bees, vespids, ants) can cause systemic allergic reactions (SARs). Venom immunotherapy (VIT) is highly effective and reduces an allergic patient's risk of a recurrent SAR to less than 5-20%. The risk of a recurrent SAR to a re-sting decreases the longer VIT is continued. The recommended duration of VIT is at least 3 to 5 years. RISK FACTORS Risk factors for recurrent SARs to a sting after stopping VIT have been identified and discussed: Recommendations concerning stopping VIT: For patients without any of the identified risk factors, VIT should be continued for 5 rather than 3 years. In patients with definite risk factors, a longer duration of VIT has to be discussed before stopping it. In mast cell disorders, VIT for life is recommended. Because of the residual risk of SARs after VIT, all patients are advised to carry an epinephrine autoinjector indefinitely and to continue to take measures to avoid Hymenoptera stings.
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Insektengiftallergie. ALLERGOLOGIE 2016. [DOI: 10.1007/978-3-642-37203-2_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Möbs C, Müller J, Rudzio A, Pickert J, Blank S, Jakob T, Spillner E, Pfützner W. Decline of Ves v 5-specific blocking capacity in wasp venom-allergic patients after stopping allergen immunotherapy. Allergy 2015; 70:715-9. [PMID: 25753563 DOI: 10.1111/all.12606] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2015] [Indexed: 11/26/2022]
Abstract
While allergen-specific immunotherapy (AIT) is very efficient in hymenoptera venom (HV)-allergic patients, long-term outcome after finishing AIT is not well investigated, especially regarding mechanisms that are suggested to contribute to allergen-specific tolerance. Here, we analyse the Ves v 5-inhibitory activity of sera from wasp venom-allergic patients using the novel cell-free enzyme-linked immunosorbent facilitated antigen binding (ELIFAB) assay. Compared to pre-AIT, sera from patients undergoing AIT displayed an increased ability to inhibit Ves v 5 binding by IgE antibodies. In contrast, this inhibitory activity was reduced in patients having finished AIT 5-12 years ago. Allergen-blocking capacity correlated with serum concentrations of Ves v 5-specific IgG4 which rose during AIT but almost reached pretreatment levels in patients who had stopped AIT more than 5 years ago. These data raise questions about how long allergen tolerance is maintained in AIT-treated HV-allergic patients and suggest that the ELIFAB assay might be an easy-to-use tool assessing long-term tolerance in patients treated with HV-AIT.
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Affiliation(s)
- C. Möbs
- Clinical & Experimental Allergology; Department of Dermatology and Allergology; Philipps University Marburg; Marburg Germany
| | - J. Müller
- Clinical & Experimental Allergology; Department of Dermatology and Allergology; Philipps University Marburg; Marburg Germany
| | - A. Rudzio
- Clinical & Experimental Allergology; Department of Dermatology and Allergology; Philipps University Marburg; Marburg Germany
| | - J. Pickert
- Clinical & Experimental Allergology; Department of Dermatology and Allergology; Philipps University Marburg; Marburg Germany
| | - S. Blank
- Center of Allergy and Environment (ZAUM); Helmholtz Center Munich; Technical University Munich; Munich Germany
| | - T. Jakob
- Allergy Research Group; Department of Dermatology; Medical Center; University of Freiburg; Freiburg Germany
| | - E. Spillner
- Immunological Engineering; Department of Engineering; Aarhus University; Aarhus Denmark
| | - W. Pfützner
- Clinical & Experimental Allergology; Department of Dermatology and Allergology; Philipps University Marburg; Marburg Germany
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Díez Zuluaga LS, Cardona Villa R, Restrepo Colorado MN, Sánchez Caraballo JM. Inmunoterapia con alérgenos, ¿cuándo y por qué? IATREIA 2014. [DOI: 10.17533/udea.iatreia.17755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
La inmunoterapia específica con alérgenos es el único tratamiento que modifica el curso natural de algunas enfermedades alérgicas como asma, rinitis, conjuntivitis, dermatitis atópica y alergia al veneno de himenópteros. Sin embargo, aún existe cierta controversia respecto a su seguridad y su utilidad clínica. En el presente artículo se presenta una revisión de los mecanismos moleculares, las indicaciones y contraindicaciones de dicha inmunoterapia, y se evalúan su seguridad y eficacia en cada una de estas enfermedades mediante casos ilustrativos y una breve revisión del tema.
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Antolín-Amérigo D, Moreno Aguilar C, Vega A, Alvarez-Mon M. Venom immunotherapy: an updated review. Curr Allergy Asthma Rep 2014; 14:449. [PMID: 24934908 DOI: 10.1007/s11882-014-0449-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Venom immunotherapy (VIT) is the most effective form of specific immunotherapy to date. Hitherto, several relevant queries remain unanswered, namely optimal doses, duration, and means of assessment. Important progress has been lately made in terms of diagnosis by means of component-resolved diagnosis. Moreover, basophil activation test results in patients with negative serum immunoglobulin E (IgE) and skin prick test confer this technique a promising future, although these outcomes shall be considered with caution. This review aims to unravel the important advances made on diagnosis, management, and prognosis and also focuses on several undetermined aspects of VIT.
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Affiliation(s)
- Darío Antolín-Amérigo
- Servicio de Enfermedades del Sistema Inmune-Alergia, Hospital Universitario Príncipe de Asturias, Departamento de Medicina, Universidad de Alcalá, Carretera Alcalá-Meco S/N, 28805, Alcalá de Henares, Madrid, Spain,
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Bidad K, Nawijn MC, van Oosterhout AJM, van der Heide S, Elberink JNGO. Basophil activation test in the diagnosis and monitoring of mastocytosis patients with wasp venom allergy on immunotherapy. CYTOMETRY PART B-CLINICAL CYTOMETRY 2014; 86:183-90. [PMID: 24478037 DOI: 10.1002/cyto.b.21148] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 11/27/2013] [Accepted: 12/03/2013] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is need for an accurate diagnostic test in mastocytosis patients with wasp venom allergy (WVA) and monitoring of these patients during immunotherapy (IT). In this study, we aimed to evaluate sensitivity and specificity of the Basophil Activation Test (BAT) as a diagnostic and monitoring test in patients with mastocytosis and WVA. METHODS Seventeen patients with mastocytosis and WVA and six mastocytosis patients without WVA were included. BAT was performed before the start of IT (first visit) and at 6 weeks (second visit) and 1 year (third visit), after reaching the maintenance dose. Of 17 patients included, 11 completed the third visit. In mastocytosis patients with WVA, dose-dependent wasp-venom induced upregulation of CD63 and CD203c expression on basophils was observed compared with mastocytosis patients without WVA. Serum specific IgE, IgG4, and tryptase levels were measured in all patients. RESULTS BAT had a sensitivity of 87% and specificity of 100% in diagnosing WVA in mastocytosis patients. Basophil allergen threshold sensitivity with respect to CD63 and CD203c was significantly decreased in the second visit compared with the first visit and increased significantly in the third visit compared with the second visit. Specific IgE levels increased significantly in the second visit compared with first and decreased significantly in the third visit compared with the second. Specific IgG4 levels rose significantly in the second visit compared with the first and on the third visit compared with the second. Tryptase levels did not change significantly during the study. CONCLUSIONS BAT represents a diagnostic test with 100% specificity in allergic patients with mastocytosis and these patients are better to be monitored for a longer period during IT.
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Affiliation(s)
- Katayoon Bidad
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Pathology and Medical Biology, Laboratory of Allergology and Pulmonary Diseases, University Medical Center of Groningen, University of Groningen, Groningen, The Netherlands
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Stoevesandt J, Hofmann B, Hain J, Kerstan A, Trautmann A. Single venom-based immunotherapy effectively protects patients with double positive tests to honey bee and Vespula venom. Allergy Asthma Clin Immunol 2013; 9:33. [PMID: 24004607 PMCID: PMC3846485 DOI: 10.1186/1710-1492-9-33] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 08/10/2013] [Indexed: 11/29/2022] Open
Abstract
Background Referring to individuals with reactivity to honey bee and Vespula venom in diagnostic tests, the umbrella terms “double sensitization” or “double positivity” cover patients with true clinical double allergy and those allergic to a single venom with asymptomatic sensitization to the other. There is no international consensus on whether immunotherapy regimens should generally include both venoms in double sensitized patients. Objective We investigated the long-term outcome of single venom-based immunotherapy with regard to potential risk factors for treatment failure and specifically compared the risk of relapse in mono sensitized and double sensitized patients. Methods Re-sting data were obtained from 635 patients who had completed at least 3 years of immunotherapy between 1988 and 2008. The adequate venom for immunotherapy was selected using an algorithm based on clinical details and the results of diagnostic tests. Results Of 635 patients, 351 (55.3%) were double sensitized to both venoms. The overall re-exposure rate to Hymenoptera stings during and after immunotherapy was 62.4%; the relapse rate was 7.1% (6.0% in mono sensitized, 7.8% in double sensitized patients). Recurring anaphylaxis was statistically less severe than the index sting reaction (P = 0.004). Double sensitization was not significantly related to relapsing anaphylaxis (P = 0.56), but there was a tendency towards an increased risk of relapse in a subgroup of patients with equal reactivity to both venoms in diagnostic tests (P = 0.15). Conclusions Single venom-based immunotherapy over 3 to 5 years effectively and long-lastingly protects the vast majority of both mono sensitized and double sensitized Hymenoptera venom allergic patients. Double venom immunotherapy is indicated in clinically double allergic patients reporting systemic reactions to stings of both Hymenoptera and in those with equal reactivity to both venoms in diagnostic tests who have not reliably identified the culprit stinging insect.
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Affiliation(s)
- Johanna Stoevesandt
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany.
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Longitudinal study of 954 patients with stinging insect anaphylaxis. Ann Allergy Asthma Immunol 2013; 111:199-204.e1. [PMID: 23987196 DOI: 10.1016/j.anai.2013.06.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 05/23/2013] [Accepted: 06/14/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Stinging insect anaphylaxis (SIA) is a common cause of anaphylaxis and is potentially life-threatening. OBJECTIVES To examine US patients with an emergency department (ED) visit or hospitalization for SIA to evaluate postdischarge follow-up care. METHODS We identified all patients with an ED visit or hospitalization for SIA during 2002-2008 in the MarketScan Database using International Classification of Diseases, Ninth Revision, Clinical Modification codes (index date was the initial ED visit or hospitalization). Patients were required to have continuous full insurance coverage for 1 year or more before and after index. We examined patient factors during the preindex period, characteristics of the index event, and outcomes during the postindex period. Multivariable logistic regression was used to identify independent predictors of receiving preventive anaphylaxis care. RESULTS We identified 954 patients with an ED visit or hospitalization for SIA (mean [SD] age, 46 [19] years; 41% female). A total of 85% of patients were discharged directly from the ED. For those hospitalized, the mean hospital stay was 1 day, and 50% spent time in the intensive care unit. Cardiorespiratory failure occurred in 27% of those hospitalized. During the postindex period, 69% filled 1 or more epinephrine autoinjector prescription, but only 14% had 1 or more allergist/immunologist visit. Independent factors associated with receiving preventive anaphylaxis care during the postindex period were higher household income, no ED visit (for any reason) in the preindex period, and no cardiorespiratory arrest or failure during the index event. CONCLUSION Although two-thirds of patients filled a prescription for an epinephrine autoinjector after an ED visit or hospitalization for SIA, only 14% of patients received follow-up care by an allergist/immunologist. This missed opportunity to provide venom immunotherapy, an essentially curative therapy, unnecessarily places patients at risk for recurrent anaphylaxis.
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Bilò MB, Antonicelli L, Bonifazi F. Honeybee venom immunotherapy: certainties and pitfalls. Immunotherapy 2013. [PMID: 23194365 DOI: 10.2217/imt.12.113] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The honeybee is an interesting insect because of the fundamental agricultural role it plays, together with the composition of its venom, which presents new diagnostic and immunotherapeutic challenges. This article examines various aspects of honeybee venom allergy from epidemiology to diagnosis and treatment, with special emphasis on venom immunotherapy (VIT). Honeybee venom allergy represents a risk factor for severe systemic reaction in challenged allergic patients, for the diminished effectiveness of VIT, for more frequent side effects during VIT and relapse after cessation of treatment. Some strategies are available for reducing the risk of honeybee VIT-induced side effects; however, there is considerable room for further improvement in these all-important areas. At the same time, sensitized and allergic beekeepers represent unique populations for epidemiological, venom allergy immunopathogenesis and VIT mechanism studies.
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Affiliation(s)
- M Beatrice Bilò
- Allergy Unit, Department of Immunology, Allergy & Respiratory Diseases, University Hospital Ospedali Riuniti di Ancona, Ancona, Italy.
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Can we produce true tolerance in patients with food allergy? J Allergy Clin Immunol 2013; 131:14-22. [PMID: 23265693 DOI: 10.1016/j.jaci.2012.10.058] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 10/05/2012] [Accepted: 10/05/2012] [Indexed: 11/23/2022]
Abstract
Immune tolerance is defined as nonresponsiveness of the adaptive immune system to antigens. Immune mechanisms preventing inappropriate immune reactivity to innocuous antigens include deletion of reactive lymphocytes and generation of regulatory T (Treg) cells. The normal response to food antigens is the generation of antigen-specific Treg cells. In patients with food allergy, the dominant immune response is a T(H)2-skewed T-cell response and the generation of food-specific IgE antibodies from B cells. It is not known whether a failure of the Treg cell response is behind this inappropriate immune response, but interventions that boost the Treg cell response, such as mucosal immunotherapy, might lead to a restoration of immune tolerance to foods. Tolerance has been notoriously difficult to restore in animal disease models, but limited data from human trials suggest that tolerance (sustained nonresponsiveness) can be re-established in a subset of patients. Furthermore, studies on the natural history of food allergy indicate that spontaneous development of tolerance to foods over time is not uncommon. The current challenge is to understand the mechanisms responsible for restoration of natural or induced tolerance so that interventions can be developed to more successfully induce tolerance in the majority of patients with food allergy.
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Simioni L, Vianello A, Bonadonna P, Marcer G, Severino M, Pagani M, Morlin L, Crivellaro M, Passalacqua G. Efficacy of venom immunotherapy given every 3 or 4 months: a prospective comparison with the conventional regimen. Ann Allergy Asthma Immunol 2012; 110:51-4. [PMID: 23244659 DOI: 10.1016/j.anai.2012.09.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 09/02/2012] [Accepted: 09/18/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Standard venom immunotherapy involves the administration of the maintenance dose every 4 to 6 weeks. This regimen may have adherence problems, especially in the long term; thus, extended intervals have been proposed. OBJECTIVE We prospectively compared the efficacy of 3- or 4-month extended maintenance dose vs the conventional regimen. METHODS Patients receiving immunotherapy with a single venom were offered the extended maintenance dose (EMD) and were then followed up for field re-stings. Only the re-stings by the insect for which the patients received immunotherapy were considered. A comparable group of patients receiving the conventional maintenance dose (CMD) was used for comparison by logistic regression analysis. RESULTS Seventy-six patients (60 male; mean age, 48 years) receiving the EMD were re-stung on 247 occasions by the insect for which they were receiving immunotherapy. The group receiving CMD included 110 patients (82 male; mean age, 44 years) certainly re-stung on 167 occasions by the specific insect. The percentage of re-sting without reaction was 93.5% in the EMD group and 81.5% in the CMD group, with a significant difference in favor of the former (P=.001). At logistic regression analysis, only age, but not maintenance dose protocol, was predictive of subsequent systemic reactions. CONCLUSION The EMD is as effective and safe as the CMD. An increased maintenance seems to be the best option in term of convenience and economic savings.
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Affiliation(s)
- Livio Simioni
- Allergy and Clin. Immunology, Internal Medicine Department, S. Maria del Prato Feltre Hospital, Italy
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Abstract
INTRODUCTION Omalizumab has been demonstrated to be a successful therapy in the management of asthma through reduction of patient's symptoms and use of inhaled corticosteroids. The effect of omalizumab is achieved by immunoglobulin E (IgE) blockage and other secondary mechanisms resulting from this blockage. Because other diseases have an important IgE mediation in their physiopathology, the question arises as to if omalizumab would be useful in the treatment of other IgE-mediated diseases. OBJECTIVE We present an overview of the experimental studies and clinical reports evaluating the use of omalizumab in diseases different to asthma including atopic dermatitis, urticaria, eosinophilic gastrointestinal disorders, idiopathic anaphylaxis, latex allergy, hymenoptera venom allergy, and other IgE diseases. METHODS We reviewed the literature using PUBMED, EMBASE, and LILACS for publications which used omalizumab in the treatment of patients with allergic diseases or any other diseases. Complete articles published in English, Spanish or Portuguese were included. CONCLUSION There is not enough evidence to support the regular use of omalizumab in IgE diseases other than asthma. However, some experimental and clinical investigations indicate that omalizumab could be a therapeutic option in several allergic diseases like atopic dermatitis, urticaria, and eosinophilic gastrointestinal disorders. More control studies are needed in each IgE disease to evaluate the efficacy and safety of omalizumab in IgE mediated diseases.
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Eržen R, Košnik M, Šilar M, Korošec P. Basophil response and the induction of a tolerance in venom immunotherapy: a long-term sting challenge study. Allergy 2012; 67:822-30. [PMID: 22469017 DOI: 10.1111/j.1398-9995.2012.02817.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is no in vitro test to predict the induction of long-term tolerance in patients treated with venom immunotherapy (VIT). The aim of this study was to investigate whether immunotherapy-induced changes in basophil responsiveness reflect a state of protection and the induction of a tolerance. METHODS Twenty-three patients with allergic reaction after Hymenoptera sting (11 wasp and 12 honeybee) were treated with VIT. In all patients, a CD63 basophil activation test was performed before the beginning of immunotherapy, after 1 year and after completing 4-6.5 years of immunotherapy (approximately 1 year after stopping). The tolerance was then evaluated by a sting challenge test. The basophil activation test was repeated 3-6 months after the challenge. RESULTS Twenty-two subjects showed a negative sting challenge, and one subject, a positive sting challenge. Allergen-specific basophil response remained unchanged after 1 year of immunotherapy. However, after immunotherapy, a significant and approximately fourfold decrease was demonstrated in all tolerant subjects mainly in response to submaximal 0.1 μg/ml allergen concentration. This depression was sustained and did not change with the sting challenge test. In a nontolerant patient with a positive sting challenge, basophil response did not change. CONCLUSIONS Our results suggest that the depression of allergen-specific basophil response seems to be associated with the induction of a tolerance after completing a course of VIT.
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Affiliation(s)
- R. Eržen
- University Clinic of Respiratory and Allergic Diseases; Golnik; Slovenia
| | - M. Košnik
- University Clinic of Respiratory and Allergic Diseases; Golnik; Slovenia
| | - M. Šilar
- University Clinic of Respiratory and Allergic Diseases; Golnik; Slovenia
| | - P. Korošec
- University Clinic of Respiratory and Allergic Diseases; Golnik; Slovenia
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González-de-Olano D, Alvarez-Twose I, Vega A, Orfao A, Escribano L. Venom immunotherapy in patients with mastocytosis and hymenoptera venom anaphylaxis. Immunotherapy 2011; 3:637-51. [PMID: 21554093 DOI: 10.2217/imt.11.44] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Systemic mastocytosis (SM) is typically suspected in patients with cutaneous mastocytosis (CM). In recent years, the presence of clonal mast cells (MCs) in a subset of patients with systemic symptoms associated with MC activation in the absence of CM has been reported and termed monoclonal MC activation syndromes or clonal systemic MC activation syndromes. In these cases, bone marrow (BM) MC numbers are usually lower than in SM with CM, there are no detectable BM MC aggregates, and serum baseline tryptase is often <20 µg/l; thus, diagnosis of SM in these patients should be based on careful evaluation of other minor WHO criteria for SM in reference centers, where highly sensitive techniques for immunophenotypic analysis and investigation of KIT mutations on fluorescence-activated cell sorter-purified BM MCs are routinely performed. The prevalence of hymenoptera venom anaphylaxis (HVA) among SM patients is higher than among the normal population and it has been reported to be approximately 5%. In SM patients with IgE-mediated HVA, venom immunotherapy is safe and effective and it should be prescribed lifelong. Severe adverse reactions to hymenoptera stings or venom immunotherapy have been associated with increased serum baseline tryptase; however, presence of clonal MC has not been ruled out in most reports and thus both SM and clonal MC activation syndrome might be underdiagnosed in such patients. In fact, clonal BM MC appears to be a relevant risk factor for both HVA and severe reactions to venom immunotherapy, while the increase in serum baseline tryptase by itself should be considered as a powerful surrogate marker for anaphylaxis. The Spanish Network on Mastocytosis has developed a scoring system based on patient gender, the clinical symptoms observed during anaphylaxis and serum baseline tryptase to predict for the presence of both MC clonality and SM among individuals who suffer from anaphylaxis.
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Scadding G, Durham SR. Mechanisms of Sublingual Immunotherapy. Immunol Allergy Clin North Am 2011; 31:191-209, viii. [DOI: 10.1016/j.iac.2011.02.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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