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Plessis AA, Cameron SB, Invik R, Hanna M, Mack DP, Cook VE. Real-world experience: a retrospective pediatric chart review to determine why patients and caregivers discontinue oral immunotherapy. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2024; 20:54. [PMID: 39407324 PMCID: PMC11481366 DOI: 10.1186/s13223-024-00912-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Accepted: 09/08/2024] [Indexed: 10/19/2024]
Abstract
BACKGROUND Oral immunotherapy (OIT) is an increasingly utilized management strategy for IgE-mediated food allergy. Despite promising efficacy and effectiveness, there is still a lack of data surrounding the reasons for discontinuation of OIT. The primary reason stated in the literature for discontinuation is adverse gastrointestinal effects. Social factors contributing to OIT discontinuation have not been well reported. We hypothesize that social considerations are significant contributors to treatment discontinuation. METHODS We completed a retrospective chart review of 50 patients treated in community pediatric allergy practices who discontinued OIT out of 507 patients who were started on OIT between October 1, 2017-October 27, 2022. Reasons for discontinuation were identified and classified into five main categories: unsafe care decisions, anxiety, adverse effects of OIT, uncontrolled comorbidity and social factors. Categories were not exclusive. RESULTS 507 patients were started on OIT, with data available for 50 patients who discontinued OIT, aged 10 months to 18 years and 2 months. The overall discontinuation rate was 9.8%, of which 40 patients (80%) discontinued during buildup, 9 patients (18%) discontinued during maintenance and one patient on two food OIT discontinued one food during buildup and one during maintenance (2%). Thirty-four patients (68%) had multiple reasons for discontinuing OIT. Social factors were the most common reason for discontinuation and were identified in 32 patients (64%). Twenty-four patients (48%) discontinued OIT due to adverse effects. Gastrointestinal symptoms were the most prevalent, while anaphylaxis contributed to discontinuation in 15 patients (30%). Anxiety led to discontinuation in 17 patients (34%). CONCLUSIONS Our data highlights the importance of social factors and anxiety in the success of OIT completion. Our results support the need to consider not only the patient's medical history, but also their social history and support networks when selecting patients who are good candidates for OIT to optimize the successful completion of OIT.
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Affiliation(s)
- Amy A Plessis
- Department of Pediatrics, Faculty of Medicine, University of British Columbia Island Medical Program, Victoria, BC, Canada
| | - Scott B Cameron
- Division of Allergy, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Division of Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Community Allergy Clinic, Victoria, BC, Canada
| | | | - Mariam Hanna
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Victoria E Cook
- Division of Allergy, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
- Division of Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
- Community Allergy Clinic, Victoria, BC, Canada.
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2
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Zheng W, Wai CYY, Sit JKC, Cheng NS, Leung CWM, Leung TF. Routinely Used and Emerging Diagnostic and Immunotherapeutic Approaches for Wheat Allergy. Biomedicines 2024; 12:1549. [PMID: 39062122 PMCID: PMC11275021 DOI: 10.3390/biomedicines12071549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 07/06/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
Wheat, a component of the staple diet globally, is a common food allergen in children. The symptoms of wheat allergy (WA) range from skin rash to shortness of breath, significantly impairing quality of life. Following initial clinical suspicion, individuals may undergo routinely used allergy tests such as a wheat allergen-specific skin prick test (SPT), a blood test for specific immunoglobulin E (sIgE) levels, or oral food challenge. Conventional management of WA lies in wheat avoidance, yet accidental consumption may be inevitable owing to the ubiquity of wheat in various food products. This article aims to provide an overview of the immunologic pathway of WA, followed by its emerging diagnostic methods, namely alcohol-soluble SPT extracts, component-resolved diagnosis, and the basophil activation test (BAT). The mechanisms underlying wheat allergen-specific oral immunotherapy (OIT) as well as a summary of the efficacy, tolerability, and safety of related clinical trials will then be discussed.
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Affiliation(s)
- Wanqi Zheng
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong; (W.Z.); (C.Y.Y.W.); (J.K.C.S.); (N.S.C.)
| | - Christine Yee Yan Wai
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong; (W.Z.); (C.Y.Y.W.); (J.K.C.S.); (N.S.C.)
- Hong Kong Hub of Paediatric Excellence, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jason Ka Chun Sit
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong; (W.Z.); (C.Y.Y.W.); (J.K.C.S.); (N.S.C.)
| | - Nam Sze Cheng
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong; (W.Z.); (C.Y.Y.W.); (J.K.C.S.); (N.S.C.)
| | | | - Ting Fan Leung
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong; (W.Z.); (C.Y.Y.W.); (J.K.C.S.); (N.S.C.)
- Hong Kong Hub of Paediatric Excellence, The Chinese University of Hong Kong, Shatin, Hong Kong
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3
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Itonaga T, Yanagida N, Nagakura KI, Asaumi T, Tokunaga M, Nishino M, Takahashi K, Ogura K, Sato S, Ebisawa M. Three-year prognosis after low-dose oral food challenge for children with wheat allergy. Allergol Int 2024; 73:416-421. [PMID: 38296769 DOI: 10.1016/j.alit.2024.01.004] [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] [Received: 08/18/2023] [Revised: 12/21/2023] [Accepted: 01/10/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Low-dose oral food challenge (LD-OFC) is an approach to avoid complete elimination in high-risk patients with wheat allergy (WA). We examined the 3-year prognosis after LD-OFC among patients who passed and failed LD-OFC. METHODS Children with immediate-type WA aged ≤6 years with a history of reaction to ≤390 mg of wheat protein underwent their first LD-OFC with 52 mg (baseline LD-OFC). After passing the LD-OFC, children stepped up to 390, 1300, and 5200 mg step-by-step every 3-6 months. After failing LD-OFC, children repeated LD-OFC every 6-12 months. We assessed wheat tolerance defined as consuming 5200 mg without symptoms for 3 years after baseline LD-OFC. RESULTS The median age of 124 children was 2.4 years, and the wheat- and ω-5-gliadin-specific immunoglobulin E (IgE) levels (kUA/L) were 23.6 and 2.1, respectively. Upon baseline LD-OFC, 57% passed (LD-tolerant), whereas 43% failed (LD-reactive). Within 3 years, 38% of the LD-reactive group passed re-administered LD-OFC, and 70% of all participants avoided complete elimination. The percentage of the participants who became capable of consuming 390 mg (87% vs. 18%), 1300 mg (78% vs. 13%), and acquired tolerance (70% vs. 13%) was significantly higher in the LD-tolerant group than in the LD-reactive group (p < 0.001). Predictors of persistent WA in the LD-tolerant group were older age (adjusted odds ratio, 1.63), ω-5-gliadin-specific IgE level (1.62 per 10-fold increase), and other food allergies (1.94). CONCLUSIONS LD-tolerant patients frequently acquired wheat tolerance within 3 years. Even if once positive, one-third could pass the re-administered LD-OFC within 3 years.
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Affiliation(s)
- Takaaki Itonaga
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Kanagawa, Japan; Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Noriyuki Yanagida
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Kanagawa, Japan.
| | - Ken-Ichi Nagakura
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Kanagawa, Japan
| | - Tomoyuki Asaumi
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Kanagawa, Japan
| | - Mai Tokunaga
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Kanagawa, Japan
| | - Makoto Nishino
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Kanagawa, Japan
| | - Kyohei Takahashi
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Kanagawa, Japan
| | - Kiyotake Ogura
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Kanagawa, Japan
| | - Sakura Sato
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Kanagawa, Japan
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Kanagawa, Japan; Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
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4
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Özdemir PG, Sato S, Yanagida N, Ebisawa M. Oral Immunotherapy in Food Allergy: Where Are We Now? ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2023; 15:125-144. [PMID: 37021501 PMCID: PMC10079524 DOI: 10.4168/aair.2023.15.2.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/01/2023] [Accepted: 03/14/2023] [Indexed: 04/07/2023]
Abstract
Food allergy (FA) has become more prevalent and problematic in the last 2 decades, and it poses important individual, social, and economic burdens. Besides treating reactions induced by accidental exposure and periodic evaluation for acquiring natural tolerance, the primary management approach is still allergen avoidance as a global standard. However, an active therapeutic approach that can raise the reaction threshold or accelerate tolerance is needed. This review aimed to provide an overview and the latest evidence of oral immunotherapy (OIT), which has recently been used in the active treatment of FA. FA immunotherapy, particularly OIT, is gaining considerable interest, and substantial effort has been made to integrate this active treatment into clinical practice. Consequently, growing evidence has been obtained regarding the efficacy and safety of OIT, particularly for allergens such as peanuts, eggs, and milk. However, several issues need to be addressed regarding the availability, safety, and long-term effects of this intervention. In this review, we summarize currently available information regarding tolerance-inducing immune mechanisms of OIT, data on efficacy and safety, gaps in current evidence, and ongoing research to develop new therapeutic molecules in order to enhance safety.
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Affiliation(s)
- Pınar Gökmirza Özdemir
- Department of Pediatric Allergy and Immunology, Trakya University School of Medicine, Edirne, Turkey
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | - Sakura Sato
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | - Noriyuki Yanagida
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan.
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5
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Leeds S, Belmont A, Winfield H, Nowak-Wegrzyn A. A practical focus on wheat oral immunotherapy. JOURNAL OF FOOD ALLERGY 2022; 4:136-143. [PMID: 39021844 PMCID: PMC11250616 DOI: 10.2500/jfa.2022.4.220029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Wheat is a dietary staple in many cultures as well as a common food allergen. Although not as extensively studied as other forms of oral immunotherapy, the current literature suggests that wheat oral immunotherapy (WOIT) can result in successful desensitization. There has only been one multicenter, double-blind, randomized controlled trial of WOIT, along with several open-label nonrandomized trials. The trials were limited by several factors, including small sample sizes; demographic skew; and heterogeneity in dosing, duration, and outcomes. The majority of WOIT regimens results in desensitization, with literature that indicates that a longer duration and higher dosing may lead to more clinical success. WOIT has been associated with adverse events, including allergic reactions, but these events seem to decrease over time. Study on WOIT is underway, but evidence from trials suggests it can be successful and safe. Further studies will need to optimize dosing protocols to improve efficacy and safety.
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Affiliation(s)
- Stephanie Leeds
- From the Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Ami Belmont
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Holly Winfield
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children’s Hospital, New York, New York; and
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children’s Hospital, New York, New York; and
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
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6
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Haahtela T, Jantunen J, Saarinen K, Tommila E, Valovirta E, Vasankari T, Mäkelä MJ. Managing the allergy and asthma epidemic in 2020s-Lessons from the Finnish experience. Allergy 2022; 77:2367-2380. [PMID: 35202479 PMCID: PMC9546028 DOI: 10.1111/all.15266] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 12/13/2022]
Abstract
In Finland, a systematic public health programme was implemented from 2008 to 2018 to mitigate the burden of allergic disorders by revisiting the prevention strategy. Allergy health and contacts with natural environment were emphasized to promote immunological and psychological resilience instead of poorly justified avoidance. Allergy management practices were improved and low‐valued recommendations for care, for example for food allergy, were revised. Patients and families were empowered to use guided self‐management to proactively stop symptom exacerbations. A professional non‐governmental organization implemented the nationwide education for healthcare and patient NGOs for patients, families and lay public. In healthcare, the work supporting allergic patients and families was organized towards common goals and integrated into everyday work without extra costs. Reaching the predefined goals was followed by employing the national healthcare registers and questionnaire surveys. Governmental bodies contributed with kick‐off funding, which was supplemented by private funding. International collaboration, for example with the European patient organization (EFA), increased awareness of the Finnish action and predisposed it for peer review. The 10‐year results are favourable, patients are less disabled, practices and attitudes in healthcare have changed, and major cost savings have been obtained. Views of the lay public and patients are slow to move, however. Local multidisciplinary allergy teams were set up to continue the activities also after the Programme. Changes in environment and lifestyle in the last 50 years are the main reasons for the allergy rise. The Finnish experience may help to manage allergic diseases, improve nature relatedness in the fast‐urbanizing world, combat nature loss and reduce the disease burden.
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Affiliation(s)
- Tari Haahtela
- Skin and Allergy Hospital Helsinki University Hospital University of Helsinki Helsinki Finland
| | - Juha Jantunen
- Allergy, Skin and Asthma Federation Helsinki Finland
| | | | - Erja Tommila
- Finnish Lung Health Association (FILHA) Helsinki Finland
| | - Erkka Valovirta
- Department of Lung Diseases and Clinical Allergology University of Turku, and Allergy ClinicTerveystalo Turku Finland
| | | | - Mika J. Mäkelä
- Skin and Allergy Hospital Helsinki University Hospital University of Helsinki Helsinki Finland
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7
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Perrett KP, Sindher SB, Begin P, Shanks J, Elizur A. Advances, Practical Implementation, and Unmet Needs Regarding Oral Immunotherapy for Food Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:19-33. [PMID: 34785391 DOI: 10.1016/j.jaip.2021.10.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/07/2021] [Accepted: 10/25/2021] [Indexed: 06/13/2023]
Abstract
Treatment of food allergy is a rapidly changing landscape, with arguably, the most significant advancement in recent years, the transition of oral immunotherapy (OIT) to clinical practice. As an innovation, OIT is a phase of rapidly increasing demand, particularly for some allergens such as peanut, egg, and milk, which have substantial evidence of efficacy. However, significant questions remain about how to best treat multiple food allergies and less common food allergies and how to optimize long-term safety and efficacy. This review summarizes the currently available resources for integrating food allergy OIT into clinical practice and focuses on the multiple remaining unmet needs such as providing an approach for OIT to food allergens for which there is no or limited evidence; practical issues related to food allergy treatment particularly when it is not going well; long-term outcomes and follow-up after OIT; and strategies to help meet the impending increase in demand.
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Affiliation(s)
- Kirsten P Perrett
- Population Allergy, Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia.
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, California; Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford, California
| | - Philippe Begin
- Division of Allergy, Immunology and Rheumatology, CHU Sainte-Justine, Montréal, Canada
| | - Josiah Shanks
- Population Allergy, Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Be'er Ya'akov, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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8
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Mori F, Giovannini M, Barni S, Jiménez-Saiz R, Munblit D, Biagioni B, Liccioli G, Sarti L, Liotti L, Ricci S, Novembre E, Sahiner U, Baldo E, Caimmi D. Oral Immunotherapy for Food-Allergic Children: A Pro-Con Debate. Front Immunol 2021; 12:636612. [PMID: 34650547 PMCID: PMC8507468 DOI: 10.3389/fimmu.2021.636612] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 09/03/2021] [Indexed: 11/13/2022] Open
Abstract
The prevalence of food allergy has increased in recent years, especially in children. Allergen avoidance, and drugs in case of an allergic reaction, remains the standard of care in food allergy. Nevertheless, increasing attention has been given to the possibility to treat food allergy, through immunotherapy, particularly oral immunotherapy (OIT). Several OIT protocols and clinical trials have been published. Most of them focus on children allergic to milk, egg, or peanut, although recent studies developed protocols for other foods, such as wheat and different nuts. OIT efficacy in randomized controlled trials is usually evaluated as the possibility for patients to achieve desensitization through the consumption of an increasing amount of a food allergen, while the issue of a possible long-term sustained unresponsiveness has not been completely addressed. Here, we evaluated current pediatric OIT knowledge, focusing on the results of clinical trials and current guidelines. Specifically, we wanted to highlight what is known in terms of OIT efficacy and effectiveness, safety, and impact on quality of life. For each aspect, we reported the pros and the cons, inferable from published literature. In conclusion, even though many protocols, reviews and meta-analysis have been published on this topic, pediatric OIT remains a controversial therapy and no definitive generalized conclusion may be drawn so far. It should be an option provided by specialized teams, when both patients and their families are prone to adhere to the proposed protocol. Efficacy, long-term effectiveness, possible role of adjuvant therapies, risk of severe reactions including anaphylaxis or eosinophilic esophagitis, and impact on the quality of life of both children and caregivers are all aspects that should be discussed before starting OIT. Future studies are needed to provide firm clinical and scientific evidence, which should also consider patient reported outcomes.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Rodrigo Jiménez-Saiz
- Department of Immunology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-IP), Madrid, Spain.,Department of Immunology & Oncology, Centro Nacional de Biotecnología (CNB)-CSIC, Madrid, Spain.,Faculty of Experimental Sciences, Universidad Francisco de Vitoria (UFV), Madrid, Spain.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Daniel Munblit
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.,Inflammation, Repair and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom.,Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - Benedetta Biagioni
- Allergy Outpatient Clinic, Division of Internal Medicine, IRCCS Azienda Ospedaliera Universitaria, Bologna, Italy
| | - Giulia Liccioli
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Lucia Liotti
- Department of Pediatrics, Salesi Children's Hospital, Azienda Ospedaliera Universitaria (AOU) Ospedali Riuniti Ancona, Ancona, Italy
| | - Silvia Ricci
- Division of Immunology, Section of Pediatrics, Department of Health Sciences, University of Florence and Meyer Children's Hospital, Florence, Italy
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Umit Sahiner
- Department of Pediatric Allergy, Hacettepe University, Ankara, Turkey
| | - Ermanno Baldo
- "Giovan Battista Mattei" Research Institute, Stenico, Italy
| | - Davide Caimmi
- Allergy Unit, CHU de Montpellier, Univ Montpellier, Montpellier, France.,IDESP, UA11, INSERM-Univ Montpellier, Montpellier, France
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9
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Abstract
PURPOSE OF REVIEW The prevalence of food allergy is increasing on a global scale, and therefore increased attention is being paid to specific food allergy epidemiology and management. There has been a large amount of progress made in the last decade on human trials of wheat oral immunotherapy (WOIT). RECENT FINDINGS To date, there has been one multicenter, double-blind, randomized controlled trial of WOIT, one randomized, noncontrolled trial of WOIT, and several smaller, nonrandomized clinical trials of WOIT. WOIT trials are generally limited by smaller sample sizes, affecting the demographic skew of evaluated patients. In addition, there is minimal standardization of efficacy and safety outcomes between trial protocols, making head-to-head comparison challenging. However, some common themes emerge. The majority of WOIT regimens result in successful desensitization, and success is more likely with higher maintenance dosing for longer periods of time. Limited studies have looked at sustained unresponsiveness in WOIT. WOIT can induce allergic reactions, including anaphylaxis, but more severe reactions often have an associated augmenting factor, such as exercise. Lower maintenance doses likely are associated with less severe reactions, and food modification and/or adjunct therapeutics may also decrease the risk of reactions. SUMMARY WOIT trials are ongoing and will optimize updosing protocols and maintenance doses to improve efficacy and safety.
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10
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Wongteerayanee C, Tanticharoenwiwat P, Rutrakool N, Senavonge A, Jeekungwal N, Pacharn P, Vichyanond P. Feasibility of a 3-step protocol of wheat oral immunotherapy in children with severe wheat allergy. Asia Pac Allergy 2020; 10:e38. [PMID: 33178563 PMCID: PMC7610086 DOI: 10.5415/apallergy.2020.10.e38] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 10/19/2020] [Indexed: 11/25/2022] Open
Abstract
Background Wheat allergy is not an uncommon event among Thai children. Despite strict avoidance, some patients developed reactions after accidental exposure to minute amount of wheat and thus disturbed their quality of life. Wheat oral immunotherapy (OIT) has been reported to be an alternative treatment for such patients. Objective We designed a new 3-step wheat OIT protocol for treatment of severe wheat allergy in Thai patients. The feasibility of the protocol is evaluated and is reported here in this paper. Methods We retrospectively reviewed medical records of 26 patients who had undergone wheat OIT during a 30-month period. The 3-step protocol consisted of an initial phase of double-blind, placebo-controlled food challenge (DBPCFC) and initiation of OIT, a build-up phase, and a maintenance phase. Patient retention in the protocol was the main outcome for this feasibility study. Adverse effects during OIT were recorded. Correlation between serum specific IgE (SpIgE) to wheat and eliciting dose in phase I was determined. Results Fourteen females and 12 males with a median age of 6 years were studied. Their median age when wheat allergy began was 8 months. Median SpIgE to wheat was high (198 kUA/L). All patients developed reactions during DBPCFC with 17 of 26 patients had moderate to severe reactions required adrenaline injections. Median of eliciting dose of wheat was exceedingly low, i.e., 20 mg of wheat protein. At the end of the study, 23 of 26 patients (88%) were still in the study. Adverse reactions during the build-up phase was frequent (13 patients, 50%), with adrenaline required in 6 occasions. Six patients reached maintenance phase. Conclusion The new 3-step wheat OIT protocol was feasible in these highly wheat-sensitized patients. Despite a high retention rate, a high rate of adverse effects was observed both during DBPCFC and build-up phases.
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Affiliation(s)
| | | | - Nuntanut Rutrakool
- Samitivej Allergy Institute (SAI), Samitivej Thonburi Hospital, Bangkok, Thailand
| | - Anchalee Senavonge
- Samitivej Allergy Institute (SAI), Samitivej Thonburi Hospital, Bangkok, Thailand
| | - Nivat Jeekungwal
- Samitivej Allergy Institute (SAI), Samitivej Thonburi Hospital, Bangkok, Thailand
| | - Punchama Pacharn
- Samitivej Allergy Institute (SAI), Samitivej Thonburi Hospital, Bangkok, Thailand.,Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Pakit Vichyanond
- Samitivej Allergy Institute (SAI), Samitivej Thonburi Hospital, Bangkok, Thailand.,Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
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11
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Bégin P, Chan ES, Kim H, Wagner M, Cellier MS, Favron-Godbout C, Abrams EM, Ben-Shoshan M, Cameron SB, Carr S, Fischer D, Haynes A, Kapur S, Primeau MN, Upton J, Vander Leek TK, Goetghebeur MM. CSACI guidelines for the ethical, evidence-based and patient-oriented clinical practice of oral immunotherapy in IgE-mediated food allergy. Allergy Asthma Clin Immunol 2020; 16:20. [PMID: 32206067 PMCID: PMC7079444 DOI: 10.1186/s13223-020-0413-7] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/14/2020] [Indexed: 12/17/2022] Open
Abstract
Background Oral immunotherapy (OIT) is an emerging approach to the treatment of patients with IgE-mediated food allergy and is in the process of transitioning to clinical practice. Objective To develop patient-oriented clinical practice guidelines on oral immunotherapy based on evidence and ethical imperatives for the provision of safe and efficient food allergy management. Materials and methods Recommendations were developed using a reflective patient-centered multicriteria approach including 22 criteria organized in five dimensions (clinical, populational, economic, organizational and sociopolitical). Data was obtained from: (1) a review of scientific and ethic literature; (2) consultations of allergists, other healthcare professionals (pediatricians, family physicians, nurses, registered dieticians, psychologists, peer supporters), patients and caregivers; and patient associations through structured consultative panels, interviews and on-line questionnaire; and (3) organizational and economic data from the milieu of care. All data was synthesized by criteria in a multicriteria deliberative guide that served as a platform for structured discussion and development of recommendations for each dimension, based on evidence, ethical imperatives and other considerations. Results The deliberative grid included 162 articles from the literature and media reviews and data from consultations involving 85 individuals. Thirty-eight (38) recommendations were made for the practice of oral immunotherapy for the treatment of IgE mediated food allergy, based on evidence and a diversity of ethical imperatives. All recommendations were aimed at fostering a context conducive to achieving objectives identified by patients and caregivers with food allergy. Notably, specific recommendations were developed to promote a culture of shared responsibility between patients and healthcare system, equity in access, patient empowerment, shared decision making and personalization of OIT protocols to reflect patients' needs. It also provides recommendations to optimize organization of care to generate capacity to meet demand according to patient choice, e.g. OIT or avoidance. These recommendations were made acknowledging the necessity of ensuring sustainability of the clinical offer in light of various economic considerations. Conclusions This innovative CPG methodology was guided by patients' perspectives, clinical evidence as well as ethical and other rationales. This allowed for the creation of a broad set of recommendations that chart optimal clinical practice and define the conditions required to bring about changes to food allergy care that will be sustainable, equitable and conducive to the well-being of all patients in need.
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Affiliation(s)
- P Bégin
- 1Division of Clinical Immunology, Rheumatology and Allergy, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC Canada.,2Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC Canada.,3Research Center of the Sainte-Justine University Hospital Center, Montreal, QC Canada
| | - E S Chan
- 4Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC Canada
| | - H Kim
- 5Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON Canada.,6Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON Canada
| | - M Wagner
- 7Unit Methods, Ethics and Participation, INESSS, National Institute for Excellence in Health and Social Services, Montreal, QC Canada
| | - M S Cellier
- 3Research Center of the Sainte-Justine University Hospital Center, Montreal, QC Canada
| | - C Favron-Godbout
- 8Department of Bioethics, School of Public Health of the University of Montreal, Montreal, Canada
| | - E M Abrams
- 9Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, MB Canada
| | - M Ben-Shoshan
- 10Division of Allergy Immunology and Dermatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, QC Canada
| | - S B Cameron
- 4Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC Canada.,Community Allergy Clinic, Victoria, BC Canada
| | - S Carr
- 12Department of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - D Fischer
- 5Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON Canada
| | - A Haynes
- 13Discipline of Pediatrics, Memorial University of Newfoundland, St. John's, NL Canada
| | - S Kapur
- 14Department of Pediatrics, Dalhousie University, Halifax, NS Canada
| | - M N Primeau
- 15Division of Allergy and Clinical Immunology, Department of Medicine, CISSS Laval, Laval, QC Canada
| | - J Upton
- 16Division of Immunology and Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - T K Vander Leek
- 12Department of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - M M Goetghebeur
- 7Unit Methods, Ethics and Participation, INESSS, National Institute for Excellence in Health and Social Services, Montreal, QC Canada
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Makita E, Yanagida N, Sato S, Asaumi T, Ebisawa M. Long-term prognosis after wheat oral immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:371-374.e5. [DOI: 10.1016/j.jaip.2019.08.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/03/2019] [Accepted: 08/26/2019] [Indexed: 10/26/2022]
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Abstract
The prevalence of food allergies is increasing worldwide. To understand the regional specificities of food allergies and develop effective therapeutic interventions, extensive regional epidemiological studies are necessary. While data regarding incidence, prevalence, regional variation, and treatment in food allergies are available for western countries, such studies may not be available in many Asian countries. China accounts for almost 20% of the world's population and has a vast ethnic diversity, but large-scale meta-analyses of epidemiological studies of food allergy in China are lacking. A literature search revealed 22 publications on the prevalence of food allergy in Chinese populations. A review of these studies showed that the prevalence of food allergies in China is comparable to that in western countries, even though the Chinese diet is vastly different from that of the West and may vary even greatly within China, and finally, specific antigenic triggers of food allergy vary between China and the West and also within China. Current clinical management of food allergy in China includes allergen-specific immunotherapy, Chinese herbal medicine, acupuncture, and Western medicine. This study demonstrates an unmet need in China for a thorough investigation of the prevalence of food allergies in China, the specific foods involved, and characterization of the specific antigenic triggers of food allergy with respect to ethnicity, age, and diet in China.
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Rajakulendran M, Tham EH, Soh JY, Van Bever HP. Novel strategies in immunotherapy for allergic diseases. Asia Pac Allergy 2018; 8:e14. [PMID: 29732290 PMCID: PMC5931921 DOI: 10.5415/apallergy.2018.8.e14] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/02/2018] [Indexed: 11/04/2022] Open
Abstract
Conventional immunotherapy (IT) for optimal control of respiratory and food allergies has been fraught with concerns of efficacy, safety, and tolerability. The development of adjuvants to conventional IT has potentially increased the effectiveness and safety of allergen IT, which may translate into improved clinical outcomes and sustained unresponsiveness even after cessation of therapy. Novel strategies incorporating the successful use of adjuvants such as allergoids, immunostimulatory DNA sequences, monoclonal antibodies, carriers, recombinant proteins, and probiotics have now been described in clinical and murine studies. Future approaches may include fungal compounds, parasitic molecules, vitamin D, and traditional Chinese herbs. More robust comparative clinical trials are needed to evaluate the safety, clinical efficacy, and cost effectiveness of various adjuvants in order to determine ideal candidates in disease-specific and allergen-specific models. Other suggested approaches to further optimize outcomes of IT include early introduction of IT during an optimal window period. Alternative routes of administration of IT to optimize delivery and yet minimize potential side effects require further evaluation for safety and efficacy before they can be recommended.
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Affiliation(s)
- Mohana Rajakulendran
- Khoo Teck Puat - National University Children's Medical Institute, National University Health System, Singapore 119229
| | - Elizabeth Huiwen Tham
- Khoo Teck Puat - National University Children's Medical Institute, National University Health System, Singapore 119229.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119229
| | - Jian Yi Soh
- Khoo Teck Puat - National University Children's Medical Institute, National University Health System, Singapore 119229.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119229
| | - H P Van Bever
- Khoo Teck Puat - National University Children's Medical Institute, National University Health System, Singapore 119229.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119229
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