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Todoric K, Merrill S. Oral Immunotherapy: An Overview. Med Clin North Am 2024; 108:719-731. [PMID: 38816113 DOI: 10.1016/j.mcna.2023.08.011] [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] [Indexed: 06/01/2024]
Abstract
Oral immunotherapy (OIT) is an alternative treatment of IgE-mediated food allergy that has been shown to increase tolerance threshold to many of the top food allergens, although this effect may be dependent on age, dose, frequency, and duration. OIT has been shown to be effective and safe in infants, and early initiation can improve rates of desensitization even for those foods whose natural history favors loss of allergy. Studies looking at protocol modification to improve OIT success are ongoing as is the evaluation of clinical tools to help monitor OIT effects.
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Affiliation(s)
- Krista Todoric
- Medical Arts Allergy, 220 Wilson Street Suite 200, Carlisle, PA 17013, USA.
| | - Sarah Merrill
- Family Medicine Department, UC San Diego Health, 402 Dickinson Street, San Diego, CA 92103, USA
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Abstract
Cow's milk allergy refers to an immunological reaction to milk protein. It is one of the commonest food protein allergies with an estimated prevalence of 0.5% to 3% at 1 y of life. The disease may be IgE or non-IgE mediated or mixed with a wide range of symptoms often involving multiple organ systems. Gastrointestinal manifestations are common in non-IgE disease and may consist of enteropathy, proctocolitis, colic, reflux-like symptoms, constipation, enterocolitis syndrome and eosinophilic esophagitis. The gold standard for diagnosis remains a double-blind placebo-controlled oral challenge. Specific IgE and skin prick tests may predict severe and persistent disease, and aid in deciding on reintroduction or oral immunotherapy; however, they do not contribute to a definitive diagnosis as they indicate only sensitization. In practice, an elimination diet followed by open challenge under medical supervision is often used for diagnosis except when symptoms are severe such as anaphylaxis. Management consists of the elimination of the allergen with resolution of symptoms between 1-4 wk later depending on the type of allergy. Extensively hydrolyzed and Amino acid formulas are used to substitute milk in infants. Soy-based formulas are often utilized in resource-limited settings. Tolerance to the protein develops over time and periodic reintroduction should be attempted every six months after the initial one year of elimination diet. Oral immunotherapy is a newer treatment technique for IgE-mediated disease. There is no firm evidence on prevention apart from recommending breast feeding in early life along with initiating complementary feeding between 4-6 mo age.
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Affiliation(s)
- Rohan Malik
- Division of Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
| | - Sanjeevani Kaul
- Division of Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Sánchez-Fernández S, Lasa EM, Terrados S, Sola-Martínez FJ, Martínez-Molina S, López de Calle M, Cabrera-Freitag P, Goikoetxea MJ. Mobile App/Web Platform for Monitoring Food Oral Immunotherapy in Children: Longitudinal Clinical Validation Study. JMIR Pediatr Parent 2024; 7:e54163. [PMID: 38477961 DOI: 10.2196/54163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Milk and egg allergies significantly impact the quality of life, particularly in children. In this regard, food oral immunotherapy (OIT) has emerged as an effective treatment option; however, the occurrence of frequent adverse reactions poses a challenge, necessitating close monitoring during treatment. OBJECTIVE This study aims to evaluate the ability of a new mobile/web app called OITcontrol to monitor milk and egg OIT. METHODS Patients undergoing milk or egg OIT were recruited and divided into 2 groups: the active group used the OITcontrol app in conjunction with standard written monitoring methods, whereas the control group relied solely on written diaries. Investigators documented hospital doses, hospital reactions, and administered treatments on the website. Patients recorded their daily allergen home-dose intake, home reactions, and administered treatments using the app. The following variables were compared between both groups: number and severity of hospital and reported home reactions, patient's adhesion to the OITcontrol app or written diary or both in terms of daily home-dose intake and home reactions recording, and treatment and dose adjustment compliance at home in case of reaction. RESULTS Sixteen patients were assigned to be monitored using the OITcontrol app along with additional written methods (active group), while 14 patients relied solely on a written paper diary (control group). A similar distribution was observed in terms of sex, age, basal characteristics, allergen treated in OIT, premedication, and sensitization profile. Active patients reported a comparable number of hospital and home reactions compared with the control group. In terms of recording system usage, 13/16 (81%) active patients used the OITcontrol app, while 10/14 (71%) control patients relied on the written diary. Among active patients, 6/16 (38%) used both methods, and 1 active patient used only written methods. However, control patients recorded home reactions more frequently than active patients (P=.009). Among active patients, the app was the preferred method for recording reactions (59/86, 69%), compared with the written diary (15/86, 17%) or both methods (12/86, 14%; P<.001). Treatment compliance in home-recorded reactions was similar between both groups (P=.15). However, treatment indications after an adverse reaction were more frequently followed (P=.04) in reactions recorded solely in the app (36/59, 61%) than in the written diary (29/71, 41%) or both systems (4/12, 33%). Moreover, compliance with dose adjustments after a moderate-severe reaction in home-recorded reactions was higher in the active group than in the control group (P<.001). Home reactions recorded only in the app (16/19, 84%) were more likely to follow dose adjustments (P<.001) than those recorded in the written diary (3/20, 15%) or using both methods (2/3, 67%). CONCLUSIONS The OITcontrol app appears to be a valuable tool for monitoring OIT treatment in children with food allergies. It proves to be a suitable method for recording daily home dose intakes and reactions, and it seems to enhance adherence to treatment indications following an adverse reaction as well as compliance with dose adjustments in home reactions. However, additional studies are necessary to comprehensively grasp the benefits and limitations of using the OITcontrol app in the management of OIT.
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Affiliation(s)
| | - Eva María Lasa
- Pediatric Allergy Unit, Allergy Service, Hospital Universitario Donostia, Donostia-San Sebastián, Spain
| | - Soledad Terrados
- Department of Pediatric Allergy, Ramón y Cajal Hospital, Madrid, Spain
| | | | - Sara Martínez-Molina
- Pediatric Allergy Unit, Allergy Service, Hospital Universitario Donostia, Donostia-San Sebastián, Spain
| | - Marta López de Calle
- Allergy and Clinical Immunology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Paula Cabrera-Freitag
- Pediatric Allergy Unit, Allergy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
| | - María José Goikoetxea
- Allergy and Clinical Immunology Department, Clínica Universidad de Navarra, Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
- RICORS Red De Enfermedades Inflamatorias - RD21/0002/0028, Madrid, Spain
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Abstract
Oral immunotherapy (OIT) is an alternative treatment of IgE-mediated food allergy that has been shown to increase tolerance threshold to many of the top food allergens, although this effect may be dependent on age, dose, frequency, and duration. OIT has been shown to be effective and safe in infants, and early initiation can improve rates of desensitization even for those foods whose natural history favors loss of allergy. Studies looking at protocol modification to improve OIT success are ongoing as is the evaluation of clinical tools to help monitor OIT effects.
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Duman Senol H, Topyildiz E, Ulusoy Severcan E, Eren Akercan S, Cigerci Gunaydin N, Gulen F, Demir E. Could Age and Oral Challenge Outcomes Identify High-Risk Patients During Cow's Milk Oral Immunotherapy? PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2022; 35:95-101. [PMID: 35675663 DOI: 10.1089/ped.2022.0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Objective: Severe immunglobuline E (IgE)-mediated reactions during oral immunotherapy (OIT) are major obstacles to treatment. The present study aimed to evaluate and identify clinical and laboratory biomarkers of adverse events during OIT among children with cow's milk (CM) allergy. Study Design: Eighty-six children older than 36 months who had undergone OIT with milk were enrolled. Clinical data, oral food challenge (OFC) test results, and laboratory data were recorded retrospectively. Results: The median duration of the build-up phase of OIT was 19 weeks (min 10-max 40) and the duration of the maintenance phase was 86.5 (min 1-max 132) months. A total of 11,767 CM doses were administered during the build-up phase and adverse reactions were seen in 62 (73.8%) patients with reactions registered for 157 doses among 11,767 (1/75 doses). The number of reactions during the maintenance phase was 41 (47.6%) in 24 (27.9%) patients. There was a significant reduction in the number of reactions (P = 0.000) between the build-up phase and maintenance phase. Adverse reactions and anaphylaxis were higher for patients who had cough during OFC (P = 0.003, P = 0.002, respectively) during the build-up phase and also during the maintenance phase too (P = 0.000). Evaluation for all reactions and anaphylaxis (during build-up and maintenance) with Kaplan-Meier and Cox regression analysis showed class IV-VI of CM-specific immunoglobulin E (sIgE), casein-sIgE and cough during OFC were significantly associated with increased probability of reaction and anaphylaxis. Younger age at onset of OIT was associated with risk reduction (0.017). Conclusion: Laboratory data and reactions during the OFC (especially cough) can help to identify high-risk patients during OIT.
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Affiliation(s)
- Handan Duman Senol
- Department of Pediatric Allergy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ezgi Topyildiz
- Department of Pediatric Allergy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ezgi Ulusoy Severcan
- Department of Pediatric Allergy, Health Sciences University Dr. Sami Ulus Gynecology, Obstetrics and Gynecology Education and Research Hospital, Ankara, Turkey
| | - Sanem Eren Akercan
- Department of Pediatric Allergy, Health Sciences University Tepecik Education and Research Hospital, Izmir, Turkey
| | - Nursen Cigerci Gunaydin
- Department of Pediatric Allergy, Namik Kemal University Faculty of Medicine, Tekirdağ, Turkey
| | - Figen Gulen
- Department of Pediatric Allergy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Esen Demir
- Department of Pediatric Allergy, Ege University Faculty of Medicine, Izmir, Turkey
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Badina L, Burlo F, Belluzzi B, Babich S, Berti I, Barbi E. Life-threatening anaphylaxis in children with cow's milk allergy during oral immunotherapy and after treatment failure. Immun Inflamm Dis 2022; 10:e607. [PMID: 35349753 PMCID: PMC8962636 DOI: 10.1002/iid3.607] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/09/2022] [Accepted: 02/28/2022] [Indexed: 01/22/2023] Open
Abstract
Background Oral immunotherapy (OIT) is a promising therapeutic approach for children with persistent IgE‐mediated cow's milk allergy (CMA) but data are still limited. Objective To analyze the prevalence of life‐threatening anaphylaxis in children with persistent CMA undergoing OIT and to evaluate potential risk factors. Methods This is a retrospective cohort study among children with persistent CMA undergoing OIT over a 20‐year period, following a specific Oral Tolerance Induction protocol. Adverse reactions during the whole period and data on long‐term outcome were registered. Descriptive and nondescriptive statistics were used to describe data. Results Three hundred forty‐two children were evaluated. During OIT, 12 children (3.5%) presented severe anaphylactic reactions that needed an adrenaline injection. None required intubation, intensive care unit (ICU) admission, or showed a fatal outcome. Five of them abandoned OIT, five reached unrestricted diet and the others are still undergoing OIT. As far as outcome is concerned, 51.2% reached an unrestricted diet; 13.5% are at the build‐up stage; and 28.0% (97 patients) stopped the OIT. Among these 96 children, 6.3% experienced a severe reaction induced by accidental ingestion of milk with two fatal outcomes. Conclusions The risk of life‐threatening reactions was nearly two times lower (3.5% vs. 6.3%) among patients assuming milk during OIT than in those who stopped the protocol. A trend in favor of more severe reactions, requiring ICU admission, or fatal, was shown in patients who stopped OIT.
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Affiliation(s)
- Laura Badina
- Department of Pediatric, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Francesca Burlo
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Beatrice Belluzzi
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Sara Babich
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Irene Berti
- Department of Pediatric, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Egidio Barbi
- Department of Pediatric, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy.,Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
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Nagendran S, Patel N, Turner PJ. Oral immunotherapy for food allergy in children: is it worth it? Expert Rev Clin Immunol 2022; 18:363-376. [PMID: 35285356 DOI: 10.1080/1744666x.2022.2053675] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Oral immunotherapy (OIT) is effective at inducing desensitization in food-allergic individuals, and is a valid therapeutic option for those allergic to peanut, cow's milk and egg. However, there is a high rate of dose-related adverse events, and at least one fatality to OIT has been reported. AREAS COVERED We provide an update on the broader framework of issues which will impact on the availability and uptake of OIT. EXPERT OPINION The need for standardized products remains controversial. A licensed product exists for peanut-OIT, but OIT can also be safely achieved using peanut-containing foods at much lower cost. For other allergens, OIT can only be done with non-pharma products - something which has been done safely for over 2 decades. There is a need to develop personalized protocols for OIT, particularly for the 20% of patients unable to tolerate standard OIT. Cost-effectiveness is dependent on improved quality of life, but evidence for this is currently lacking, and is a key evidence gap. OIT is likely to be cost-effective, particularly if noncommercial products are used. There may be a trade-off: in patients with lower reaction thresholds, a commercial product may be needed for initial updosing, until a level of desensitization is achieved when they can be switched to natural food products.
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Affiliation(s)
| | - Nandinee Patel
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, UK
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Nachshon L, Levy MB, Goldberg MR, Epstein-Rigbi N, Schwartz N, Katz Y, Elizur A. Triggers for Home Epinephrine-Treated Reactions During Oral Immunotherapy for Food Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1070-1076.e2. [PMID: 34982978 DOI: 10.1016/j.jaip.2021.12.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Home reactions requiring epinephrine treatment represent a significant obstacle to oral immunotherapy (OIT) and impair treatment outcome. OBJECTIVE To identify potential triggers for such reactions for improvement of patient safety. METHODS All patients aged older than 3.7 years who began an open-label OIT treatment program to milk, peanut, egg, sesame, or tree nuts in the Institute of Allergy, Immunology, and Pediatric Pulmonology at Shamir Medical Center between April 2010 and March 2018 were enrolled. Information on home epinephrine-treated reactions (HETRs) during the up-dosing phase of OIT was collected from the documentation in patients' files and the reports were transmitted by email and via a web reporting system. RESULTS A total 1,270 OIT treatments were included (milk 780; peanut 256; egg 63; sesame 72; and tree nuts 99). Home epinephrine was administered in 200 treatments (15.7%) and in 70 of them a second epinephrine-treated reaction occurred. The leading identified triggers for HETRs were physical exercise temporally associated with administration of home dose (20%), and dose consumption during infectious disease (16.7%), or when fatigued (13.8%). The rate of first HETRs was highest (10.1%) to doses of 500 mg protein or less and particularly to 300 mg or less. The occurrence of first HETRs was highest (35.5%) during the first and decreased to 13.8% by the last of the 4-week home-treatment phase. Second HETRs occurred in a similar rate throughout these 4 weeks. The incidence of HETRs was highest during pollen season and vacation months. CONCLUSIONS The identification of factors, some protocol-dependent, that trigger HETRs should assist in improving OIT safety.
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Affiliation(s)
- Liat Nachshon
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yankov, Zerifin, Israel; Department of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Michael B Levy
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yankov, Zerifin, Israel
| | - Michael R Goldberg
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yankov, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Epstein-Rigbi
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yankov, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Schwartz
- School of Public Health, University of Haifa, Haifa, Israel
| | - Yitzhak Katz
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yankov, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yankov, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Optimizing drug inhibition of IgE-mediated anaphylaxis in mice. J Allergy Clin Immunol 2022; 149:671-684.e9. [PMID: 34186142 PMCID: PMC9187951 DOI: 10.1016/j.jaci.2021.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 05/19/2021] [Accepted: 06/17/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Administering allergens in increasing doses can temporarily suppress IgE-mediated allergy and anaphylaxis by desensitizing mast cells and basophils; however, allergen administration during desensitization therapy can itself induce allergic responses. Several small molecule drugs and nutraceuticals have been used clinically and experimentally to suppress these allergic responses. OBJECTIVES This study sought to optimize drug inhibition of IgE-mediated anaphylaxis. METHODS Several agents were tested individually and in combination for ability to suppress IgE-mediated anaphylaxis in conventional mice, FcεRIα-humanized mice, and reconstituted immunodeficient mice that have human mast cells and basophils. Hypothermia was the readout for anaphylaxis; therapeutic efficacy was measured by degree of inhibition of hypothermia. Serum mouse mast cell protease 1 level was used to measure extent of mast cell degranulation. RESULTS Histamine receptor 1 (HR1) antagonists, β-adrenergic agonists, and a spleen tyrosine kinase (Syk) inhibitor were best at individually inhibiting IgE-mediated anaphylaxis. A Bruton's tyrosine kinase (BTK) inhibitor, administered alone, only inhibited hypothermia when FcεRI signaling was suboptimal. Combinations of these agents could completely or nearly completely inhibit IgE-mediated hypothermia in these models. Both Syk and BTK inhibition decreased mast cell degranulation, but only Syk inhibition also blocked desensitization. Many other agents that are used clinically and experimentally had little or no beneficial effect. CONCLUSIONS Combinations of an HR1 antagonist, a β-adrenergic agonist, and a Syk or a BTK inhibitor protect best against IgE-mediated anaphylaxis, while an HR1 antagonist plus a β-adrenergic agonist ± a BTK antagonist is optimal for inhibiting IgE-mediated anaphylaxis without suppressing desensitization.
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Cohen CG, Zhao WW, Ke D, Beaudette L, Lejtenyi D, McCusker C, Zhang X, Chan ES, Upton JEM, Grunebaum E, Clarke AE, Mazer BD, Ben-Shoshan M. Elevated Cow's Milk-Specific IgE Levels Prior to Oral Immunotherapy Decrease the Likelihood of Reaching the Maintenance Dose. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:215-221.e2. [PMID: 34793979 DOI: 10.1016/j.jaip.2021.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 11/01/2021] [Accepted: 11/04/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Food desensitization via oral immunotherapy (OIT) is gaining acceptance in clinical practice. Owing to adverse reactions, the duration of the buildup phase until a maintenance dose is achieved may be prolonged, and in a minority of cases, OIT is stopped. OBJECTIVE We aimed to assess factors associated with the probability of reaching the maintenance dose in cow's milk (CM) OIT. METHODS We collected data from patients undergoing CM OIT at the Montreal Children's Hospital, BC Children's Hospital, and Hospital for Sick Children. We compared univariable and multivariable Cox regressions to evaluate sociodemographic factors, comorbidities, clinical characteristics, and biomarkers at study entry associated with the likelihood of reaching a maintenance dose of 200 mL of CM. RESULTS Among 69 children who reached 4 mL of milk, the median age was 12 years (interquartile range, 9-15 years); 59% were male. Median duration of buildup phase from 4 to 200 mL was 24.0 weeks (interquartile range, 17.7-33.4 weeks). After adjusting for age and sex, higher baseline levels of specific IgE antibodies for α-lactalbumin (hazard ratio [HR] = 0.80; 95% confidence interval [CI], 0.67-0.95), β-lactoglobulin (HR = 0.86; 95% CI, 0.76-0.98), casein (HR = 0.82; 95% CI, 0.72-0.94), and total CM (HR = 0.79; 95% CI, 0.65-0.97) were associated with a decreased probability of reaching maintenance. In addition, for every 10-mL increase in CM tolerated at entry challenge, the probability of reaching maintenance increased by 10%. CONCLUSIONS The data suggest that higher levels of CM-specific IgE decreased the likelihood of reaching maintenance, whereas an increased cumulative CM dose at entry challenge increased the likelihood. Assessing these factors before therapy may assist in predicting the success of CM OIT.
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Affiliation(s)
- Casey G Cohen
- Research Institute of the McGill University Health Centre, Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada.
| | - Wei W Zhao
- Research Institute of the McGill University Health Centre, Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Danbing Ke
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Liane Beaudette
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Duncan Lejtenyi
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Christine McCusker
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Xun Zhang
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julia E M Upton
- Division of Immunology and Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Eyal Grunebaum
- Division of Immunology and Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ann E Clarke
- Division of Rheumatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bruce D Mazer
- Research Institute of the McGill University Health Centre, Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Moshe Ben-Shoshan
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Dantzer J, Dunlop J, Psoter KJ, Keet C, Wood R. Efficacy and Safety of Baked Milk Oral Immunotherapy in Children with Severe Milk Allergy: A Randomized, Double-blind, Placebo-controlled Phase 2 Trial. J Allergy Clin Immunol 2021; 149:1383-1391.e17. [PMID: 34740607 DOI: 10.1016/j.jaci.2021.10.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cow's milk allergy is the most common food allergy in young children and has no current treatment. Oral immunotherapy studies to date have shown efficacy but high rates of adverse reactions. OBJECTIVE We sought to evaluate the safety and efficacy of baked milk oral immunotherapy (BMOIT) in baked milk allergic children. METHODS Participants (3-18 years) were randomized to receive BMOIT or placebo for 12 months. Efficacy was assessed by double-blind placebo-controlled food challenge after 12 months of treatment. Safety, quality of life, and mechanistic parameters were also evaluated. RESULTS 11/15 (73%) of the BMOIT participants reached the primary endpoint, tolerating 4044 mg of baked milk protein after 12 months of OIT, compared to 0/15 (0%) on placebo. The median maximal tolerated dose (MTD) and median change from baseline was significantly higher in the BMOIT group compared to placebo (median MTD 4044mg vs 144mg; p=0.001; median change in MTD of 3900mg vs 0mg, p=0.0001). Dose-related reactions were common but >95% in both groups were mild. There was no significant change in CM- or beta lactoglobulin-IgE from baseline for either group. CM-sIgG4 did significantly increase and casein IgE decreased in the BMOIT group. For proxy-reported food allergy quality of life, there was a significant difference in the emotional impact domain only with more improving while on placebo compared BMOIT. The majority of children and adolescents in the BMOIT group directly reported improvement in at least one domain. CONCLUSION BMOIT was well tolerated and induced a substantial level of desensitization after 12 months of treatment.
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Affiliation(s)
- Jennifer Dantzer
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, John Hopkins University School of Medicine, Baltimore, MD.
| | - Joan Dunlop
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, John Hopkins University School of Medicine, Baltimore, MD
| | - Kevin J Psoter
- Division of General Pediatrics, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Corinne Keet
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, John Hopkins University School of Medicine, Baltimore, MD
| | - Robert Wood
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, John Hopkins University School of Medicine, Baltimore, MD
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Oral Immunotherapy for Children with Cow's Milk Allergy. Pathogens 2021; 10:pathogens10101328. [PMID: 34684278 PMCID: PMC8539286 DOI: 10.3390/pathogens10101328] [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: 09/09/2021] [Revised: 09/30/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
Cow's milk allergy (CMA) is one of the most common IgE-dependent food allergies in children. Some children develop severe and persistent CMA, with near-fatal reactions after exposure to trace amounts of cow's milk (CM). Because milk and dairy products are included in various processed food products, it is difficult to completely remove milk, which negatively affects the quality of life of children with CMA. Oral immunotherapy (OIT) can alleviate food allergen-induced anaphylaxis under continuous ingestion of a little of the causative food. Children with severe CMA may benefit from OIT, but the treatment requires a long time and poses a risk of anaphylaxis. Moreover, in recent years, new therapies, including omalizumab, sublingual immunotherapy, and epicutaneous immunotherapy, have played the role of optional OIT. In this review, we present the current methods of and other attempts at OIT, and discuss OIT for safely treating CMA.
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Nachshon L, Goldberg MR, Levy MB, Epstein-Rigbi N, Koren Y, Elizur A. Home epinephrine-treated reactions in food allergy oral immunotherapy: Lessons from the coronavirus disease 2019 lockdown. Ann Allergy Asthma Immunol 2021; 127:451-455.e1. [PMID: 34010698 PMCID: PMC9338684 DOI: 10.1016/j.anai.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/20/2021] [Accepted: 05/09/2021] [Indexed: 11/28/2022]
Abstract
Background Oral immunotherapy (OIT) is effective in desensitizing patients with food allergy but adverse reactions limit its use. Objective To study the effect of the coronavirus disease 2019 lockdown in Israel between March 15, 2020, and April 30, 2020, on the incidence of home epinephrine-treated reactions. Methods All patients who were in the up-dosing phase of OIT for greater than or equal to 1 month during the lockdown, or a respective period in years 2015 to 2019, were studied. The incidence of home-epinephrine treated reactions during the 2020 lockdown was compared with that in the respective period in 2015 to 2019 and to periods before and after the lockdown. Results A total of 1163 OIT treatments were analyzed. Two epinephrine injections occurred during 2020 (0.7%) compared with 29 injections (3.28%) during 2015 to 2019 (P = .03). Patients treated in 2020 were older (8.1 vs 7 years, P < .01) and had a significantly lower single highest tolerated dose (12 vs 20 mg protein, P < .01). The rate of milk-OIT was lower (P = .01), but the total number of milk treatments was higher (99 vs 71 to 82) in 2020 compared with 2015 to 2019. On multivariate analysis, treatments during the 2020 lockdown were performed in older patients (P = .001), primarily for nonmilk (P = .03), began with a lower single highest tolerated dose (P = .006), and were associated with significantly less home epinephrine-treated reactions (P = .05) compared with those in 2015 to 2019. Patients treated in 2020 experienced more epinephrine-treated reactions in adjacent periods before (n = 8) and after (n = 6) the lockdown. Conclusion The lower rate of home epinephrine-treated reactions during the coronavirus disease 2019 lockdown in Israel suggests that potentially avoidable triggers contribute significantly to the rate of adverse reactions during OIT.
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Affiliation(s)
- Liat Nachshon
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel; Department of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Michael R Goldberg
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael B Levy
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel
| | - Naama Epstein-Rigbi
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Koren
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Çelebioğlu E, Akarsu A, Şahiner ÜM. IgE-mediated food allergy throughout life. Turk J Med Sci 2021; 51:49-60. [PMID: 32892543 PMCID: PMC7991859 DOI: 10.3906/sag-2006-95] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/29/2020] [Indexed: 01/31/2023] Open
Abstract
Food allergy (FA) has become an increasing problem throughout the world. Over the last 2 decades, the frequency of FA has increased in both children and adults. The prevalence differs according to the research methodology, age, and geographic regions, ranging between 2.0% and 10.0%. The most common form of FA is immunoglobulin E (IgE)-mediated FA. In this form, patients may present with life-threatening conditions, such as anaphylaxis, or milder conditions, such as urticaria, angioedema, sneezing, and nausea alone. The gold standard in the diagnosis of FA is oral provocation tests. Epidermal skin prick tests and specific IgE measurements, as well as component-resolved diagnostic techniques are helpful in the diagnosis and follow-up of patients. In this review, the epidemiology, diagnosis, follow-up, and prognosis of IgE-mediated FA in children and adults were discussed and some specific forms of FA, such as pollen FA syndrome, alpha-gal allergy, and food-dependent exercise-induced anaphylaxis were explained.
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Affiliation(s)
- Ebru Çelebioğlu
- Department of Allergy and Clinical Immunology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ayşegül Akarsu
- Department of Pediatric Allergy and Asthma, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ümit Murat Şahiner
- Department of Pediatric Allergy and Asthma, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Sugiura S, Kitamura K, Makino A, Matsui T, Furuta T, Takasato Y, Kando N, Ito K. Slow low-dose oral immunotherapy: Threshold and immunological change. Allergol Int 2020; 69:601-609. [PMID: 32444309 DOI: 10.1016/j.alit.2020.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 02/26/2020] [Accepted: 03/12/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND We examined the feasibility, efficacy and safety of slow low-dose oral immunotherapy (SLOIT) for egg, milk, wheat allergies, with accepted severity-stratified initial and maintenance doses. METHODS Children with food allergies defined by low-dose oral food challenges (LD-OFCs) to hen's egg (cumulative protein dose up to 983 mg, n = 133), cow's milk (287 mg, n = 50), and wheat (226 mg, n = 45) were recruited. Participants were divided into two groups [SLOIT and control (complete avoidance]) based on their preferences. Participants who selected SLOIT were instructed to take the safe dose daily, with monthly increases, aiming to increase the dose by 10 times in one year. The primary outcome was the proportion of participants who passed the LD-OFCs following 1 year of therapy. RESULTS The participants in SLOIT group ingested their antigen 92.9% of the therapy's day on average. The proportion of participants who passed LD-OFCs was 35.9% (61/170) in the SLOIT group and 8.7% (4/46) in the control group (P < .001); no large differences were observed among allergens. Among the subjects who failed LD-OFCs, the median change in the total dose in the LD-OFC was 235% (interquartile range: 100%-512%) in the SLOIT group and 100% (42%-235%) in the control group (P < .001). Provoked allergic symptoms were observed in only 0.58% (280/48,486) per programmed intake and approximately 50% of the SLOIT group did not experience any obvious allergic symptoms throughout therapy. CONCLUSIONS SLOIT showed significant feasibility, efficacy and safety, providing a promising option to manage patients with severe food allergies.
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Affiliation(s)
- Shiro Sugiura
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan.
| | - Katsumasa Kitamura
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
| | - Atsushi Makino
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
| | - Teruaki Matsui
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
| | - Tomoko Furuta
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
| | - Yoshihiro Takasato
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
| | - Naoyuki Kando
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
| | - Komei Ito
- Department of Allergy, Aichi Children's Health and Medical Center, Obu, Japan
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Nachshon L, Schwartz N, Tsviban L, Levy MB, Goldberg MR, Epstein-Rigby N, Katz Y, Elizur A. Patient Characteristics and Risk Factors for Home Epinephrine-Treated Reactions During Oral Immunotherapy for Food Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:185-192.e3. [PMID: 32750430 DOI: 10.1016/j.jaip.2020.07.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Oral immunotherapy (OIT) is effective in desensitizing food-allergic patients but adverse events limit its applicability. OBJECTIVE To identify risk factors for home epinephrine-treated reactions during the build-up phase of OIT. METHODS A retrospective cohort study of patients older than 3.7 years undergoing OIT for food allergy at Shamir Medical Center between April 2010 and March 2019. All patients with a final disposition of full desensitization, partial desensitization, or failure were analyzed. Risk factors and outcome of home epinephrine-treated reactions were examined. RESULTS A total of 1037 patients (mean age, 8.4 years) who underwent 1100 OIT treatments (milk, n = 710; peanut, n = 213; egg, n = 50; sesame, n = 57; and tree nuts, n = 70) reached a final disposition and were analyzed. Full desensitization was achieved in 763 (69.4%) treatments, partial desensitization in 219 (19.9%), and 118 (10.7%) failed. Epinephrine was administered to 121 patients (11.7%) during 10.8% of treatments. Milk OIT was a significant risk factor both for epinephrine-treated reactions (odds ratio, 2.15; 95% CI, 1.25-3.68) and for low rate of full desensitization following such reactions compared with nonmilk OIT (18.2% vs 73.9%, respectively; P < .0001). Risk factors during milk OIT included asthma, pre-OIT reaction severity, lower tolerated dose, and epinephrine-treated reactions during clinic updosing, whereas risk factors during nonmilk OIT were male sex and lower tolerated dose. CONCLUSIONS Milk OIT poses a significant risk for home epinephrine-treated reactions during OIT and for poor outcome following such reactions. Together with the additional risk factors described for both milk and nonmilk OIT, this information may assist in patient selection for treatment.
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Affiliation(s)
- Liat Nachshon
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel; Department of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Naama Schwartz
- School of Public Health, University of Haifa, Haifa, Israel
| | - Lior Tsviban
- Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael B Levy
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel
| | - Michael R Goldberg
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Epstein-Rigby
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel
| | - Yitzhak Katz
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Demir E, Ciğerci Günaydın N, Gülen F, Tanaç R. Oral Immunotherapy for Cow’s Milk Allergy: Five Years’ Experience from a Single Center in Turkey. Balkan Med J 2020; 37:316-323. [PMID: 32648410 PMCID: PMC7590548 DOI: 10.4274/balkanmedj.galenos.2020.2020.1.140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Oral immunotherapy for cow’s milk allergy is an effective treatment option because of its ability to increase the threshold for clinical reactions. Aims: To present our experience of oral immunotherapy for cow’s milk allergy in the pediatric allergy outpatient clinic, and to evaluate the long-term efficacy of oral immunotherapy and risk factors for adverse reactions during oral immunotherapy. Study Design: Single-center retrospective cohort study. Methods: Forty-two patients with Immunoglobulin-E-mediated cow’s milk allergy who complied with the oral immunotherapy protocol were evaluated in this study. The treatment consisted of a rapid escalation phase with an oral food challenge step that included milk doses. During the build-up phase, increasing quantities of cow’s milk were administered until the patient was able to consume 200 mL of cow’s milk daily. Results: The mean age of starting the oral immunotherapy was 40.2±3.2 (range, 36-156) months, and 54.8% (n=23) of the patients were males. The mean duration of the build-up phase was 18.1±5.6 (range, 9-41) weeks, and the mean maintenance phase was 29.1±11.6 (range, 12-63) months. During the oral immunotherapy, 36 adverse reactions (78% mild and 22% moderate) occurred in 16 (38%) patients. There were no differences in the age of starting the oral immunotherapy (p=0.19), cow’s milk-specific Immunoglobulin-E levels (p=0.17), and cumulative provocative doses of oral food challenges (p=0.78) between the two groups of patients with and without adverse reactions. The wheal diameters to cow’s milk were higher in the group with adverse reactions (p=0.03). There was no difference in the oral immunotherapy onset age between patients with and without a history of anaphylaxis (p=0.38). The patients with a history of anaphylaxis had more adverse reactions (p=0.04) and a higher number of reactions during the oral immunotherapy (p=0.01), and a higher mean duration of the up-dosing phase (p=0.04) compared with patients without anaphylaxis. Conclusion: Oral immunotherapy is a treatment option in patients with cow’s milk allergy because of its high efficacy. Adverse reactions occur in about 40% of cases and are mostly mild. It should be administered with caution to patients with a history of anaphylaxis and a higher wheal diameter to cow’s milk in the skin prick test.
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Affiliation(s)
- Esen Demir
- Department of Pediatrics, Ege University School of Medicine, İzmir, Turkey
| | | | - Figen Gülen
- Department of Pediatrics, Ege University School of Medicine, İzmir, Turkey
| | - Remziye Tanaç
- Department of Pediatrics, Ege University School of Medicine, İzmir, Turkey
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Matsui T, Naito M, Tagami K, Tajima I, Teshigawara M, Makino A, Kitamura K, Takasato Y, Sugiura S, Yamada C, Izumi H, Tsuge I, Kondo Y, Ito K. Changes in passively-sensitized basophil activation to αS1-casein after oral immunotherapy. IMMUNITY INFLAMMATION AND DISEASE 2020; 8:188-197. [PMID: 32125071 PMCID: PMC7212200 DOI: 10.1002/iid3.294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/20/2020] [Accepted: 02/23/2020] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Immune response to cow's milk allergen (CMA) has been analyzed mostly using crude milk antigen or a mixture of various caseins. This study aimed to assess the changes in the immunological response against αS1-casein during oral immunotherapy (OIT) and to investigate the mechanism of tolerance. METHODS We have performed rush OIT to 39 patients with CMA and obtained the serum samples up to 3 years after OIT. Immunoglobulin E (IgE) and IgG4 antibodies specific to highly purified αS1-casein as well as passively-sensitized basophil activation were evaluated using the serial samples. Furthermore, we examined whether basophil activation led by the pre-OIT serum was suppressed by the post-OIT serum, or by the tolerant serum obtained from naturally outgrown patients. RESULTS Specific IgE to αS1-casein was significantly reduced after OIT. Specific IgG4 (sIgG4) to αS1-casein was also detected in most of the pre-OIT sera, which was not significantly increased after OIT. Activation of passively-sensitized basophils to αS1-casein was significantly reduced after 2 years (14% ± 19%) and 3 years (19% ± 18%) post-OIT compared with pre-OIT (%CD63high basophils; 51% ± 27%). Furthermore, the addition of post-OIT or tolerant serum to pre-OIT serum significantly suppressed the basophil activation. This suppression was abrogated by washing the supernatant after passive sensitization, but not by depleting IgG antibodies from post-OIT or tolerant sera, nor by blocking FcγRIIb using an anti-FcγR antibody. CONCLUSIONS αS1-casein-sIgG4 plays a minor role in tolerance mechanisms in cases of CMA; humoral factors other than antigen-sIgG4 may be involved.
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Affiliation(s)
- Teruaki Matsui
- Department of Allergy, Aichi Children's Health and Medical Center
| | - Michihiro Naito
- Department of Nutritional Sciences, Nagoya University of Arts and Sciences
| | - Kazunori Tagami
- Department of Allergy, Aichi Children's Health and Medical Center.,Department of Nutritional Sciences, Kasugai Municipal Hospital
| | - Iwao Tajima
- Department of Allergy, Aichi Children's Health and Medical Center.,Department of Pediatrics, Toyohashi Municipal Hospital
| | | | - Atsushi Makino
- Department of Allergy, Aichi Children's Health and Medical Center
| | | | | | - Shiro Sugiura
- Department of Allergy, Aichi Children's Health and Medical Center
| | - Chikako Yamada
- Department of Nutritional Sciences, Nagoya University of Arts and Sciences
| | - Hidehiko Izumi
- Department of Nutritional Sciences, Nagoya University of Arts and Sciences
| | - Ikuya Tsuge
- Department of Pediatrics, Fujita Health University
| | - Yasuto Kondo
- Department of Pediatrics, Fujita Health University
| | - Komei Ito
- Department of Allergy, Aichi Children's Health and Medical Center
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Vázquez-Cortés S, Jaqueti P, Arasi S, Machinena A, Alvaro-Lozano M, Fernández-Rivas M. Safety of Food Oral Immunotherapy: What We Know, and What We Need to Learn. Immunol Allergy Clin North Am 2019; 40:111-133. [PMID: 31761113 DOI: 10.1016/j.iac.2019.09.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Oral immunotherapy (OIT) for food allergy entails a risk of adverse reactions, including anaphylaxis. This safety concern is the major barrier for OIT to become a therapeutic option in clinical practice. The high heterogeneity in safety reporting of OIT studies prevents setting the safety profile accurately. An international consensus is needed to facilitate the analysis of large pooled clinical data with homogeneous safety reporting, that together with integrated omics, and patients/families' opinions, may help stratify the patients' risk and needs, and help developing safe(r) individualized care pathways. This will give OIT the right place in the food allergy therapy.
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Affiliation(s)
- Sonia Vázquez-Cortés
- Allergy Department, Hospital Clinico San Carlos, IdISSC, ARADyAL, Prof. Martin Lagos s/n, Madrid 28040, Spain
| | - Paloma Jaqueti
- Allergy Department, Hospital Clinico San Carlos, IdISSC, Prof. Martin Lagos s/n, Madrid 28040, Spain
| | - Stefania Arasi
- Pediatric Allergology Unit, Department of Pediatric Medicine, Bambino Gesù Children's Research Hospital (IRCCS), Piazza S. Onofrio, Rome 00161, Italy
| | - Adrianna Machinena
- Allergy and Clinical Immunology Department, Hospital Sant Joan de Deu, Secció d'Al-lergia i Immunologia Clínica, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, Barcelona 08590, Spain
| | - Montserrat Alvaro-Lozano
- Allergy and Clinical Immunology Department, Hospital Sant Joan de Deu, Secció d'Al-lergia i Immunologia Clínica, Passeig Sant Joan de Déu 2, Esplugues de Llobregat, Barcelona 08590, Spain
| | - Montserrat Fernández-Rivas
- Allergy Department, Hospital Clinico San Carlos, Medicine UCM, IdISSC, ARADyAL, Prof. Martin Lagos s/n, Madrid 28040, Spain.
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Oral Immunotherapy (OIT): A Personalized Medicine. ACTA ACUST UNITED AC 2019; 55:medicina55100684. [PMID: 31614929 PMCID: PMC6843277 DOI: 10.3390/medicina55100684] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/04/2019] [Accepted: 10/09/2019] [Indexed: 01/05/2023]
Abstract
Oral Immunotherapy (OIT), a promising allergen-specific approach in the management of Food Allergies (FA), is based on the administration of increasing doses of the culprit food until reaching a maintenance dose. Each step should be adapted to the patient, and OIT should be considered an individualized treatment. Recent studies focused on the standardization and identification of novel biomarkers in order to correlate endotypes with phenotypes in the field of FA.
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Burks AW, Sampson HA, Plaut M, Lack G, Akdis CA. Treatment for food allergy. J Allergy Clin Immunol 2019; 141:1-9. [PMID: 29307409 DOI: 10.1016/j.jaci.2017.11.004] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/01/2017] [Accepted: 11/10/2017] [Indexed: 12/30/2022]
Abstract
The prevalence of IgE-mediated food allergy is an increasing public health concern effecting millions of persons worldwide. The current standard of treatment is strict avoidance of the offending food or foods, and to date, there are no regulatory approved treatments for food allergy. A significant amount of research has been directed at various forms of food immunotherapy, including oral, sublingual, and epicutaneous delivery routes. Although oral immunotherapy has shown the greatest promise for efficacy in terms of the amount of protein that can be ingested, it has also demonstrated less tolerability and a less favorable safety profile compared with sublingual immunotherapy and epicutaneous immunotherapy, which offers the least protection but has the best safety and tolerability profile. Studies have been conducted with adding adjuvants and anti-IgE to enhance either the efficacy or safety of food immunotherapy. Multiple concepts of food immunotherapy beyond these first-generation treatments are in either animal or early phase 1 studies.
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Affiliation(s)
- A Wesley Burks
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC.
| | - Hugh A Sampson
- The Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Marshall Plaut
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | - Gideon Lack
- Department of Paediatric Allergy, Division of Asthma, Allergy and Lung Biology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
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Adverse Events in Oral Immunotherapy for the Desensitization of Cow's Milk Allergy in Children: A Randomized Controlled Trial. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1912-1919. [DOI: 10.1016/j.jaip.2019.02.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 02/03/2023]
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Kauppila TK, Paassilta M, Kukkonen AK, Kuitunen M, Pelkonen AS, Makela MJ. Outcome of oral immunotherapy for persistent cow's milk allergy from 11 years of experience in Finland. Pediatr Allergy Immunol 2019; 30:356-362. [PMID: 30685892 DOI: 10.1111/pai.13025] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 12/20/2018] [Accepted: 01/15/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND The safety and efficacy of long-term milk oral immunotherapy (OIT) in Finnish children with persistent cow's milk allergy (CMA) were evaluated in an open-label, non-randomized study. METHODS During the 11-year study, 296 children aged 5 years or older with immunoglobulin E (IgE)-mediated CMA started milk OIT. Follow-up data were collected at three time points: the post-buildup phase, 1 year thereafter, and at the cross-sectional long-term follow-up between January 2016 and December 2017. Patients were divided according to baseline milk-specific IgE (sIgE) level and by the amount of milk consumption at the long-term follow-up. The high-dose group consumed ≥2 dL of milk daily, while the failure group consumed <2 dL of milk or were on a milk-avoidance diet. RESULTS Out of the initial study group, 244/296 (83%) patients participated in the long-term follow-up. Among these patients, 136/244 (56%) consumed ≥2 dL of milk daily. The median follow-up time was 6.5 years. Of the recorded markers and clinical factors, the baseline milk sIgE level was most associated with maintaining milk OIT (P < 0.001). Respiratory symptoms in the post-buildup phase increased the risk of treatment failure (OR 3.5, 95% CI: 1.5-8.1, P = 0.003) and anaphylaxis (OR 14.3, 95% CI: 1.8-114, P = 0.01). CONCLUSION More than half of the patients were able to maintain the targeted milk dose in their daily diet. Baseline milk sIgE level and reactivity during the early treatment stage strongly predicted the long-term outcome and safety of milk OIT.
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Affiliation(s)
- Tiina Kaisa Kauppila
- University of Helsinki, Helsinki, Finland.,Helsinki University Hospital, Skin and Allergy Hospital, Helsinki, Finland
| | | | | | - Mikael Kuitunen
- Children's Hospital, University of Helsinki, Helsinki, Finland
| | - Anna S Pelkonen
- Helsinki University Hospital, Skin and Allergy Hospital, Helsinki, Finland
| | - Mika J Makela
- Helsinki University Hospital, Skin and Allergy Hospital, Helsinki, Finland
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van Bilsen JHM, Verschuren L, Wagenaar L, Vonk MM, van Esch BCAM, Knippels LMJ, Garssen J, Smit JJ, Pieters RHH, van den Broek TJ. A network-based approach for identifying suitable biomarkers for oral immunotherapy of food allergy. BMC Bioinformatics 2019; 20:206. [PMID: 31014233 PMCID: PMC6480866 DOI: 10.1186/s12859-019-2802-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/09/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Oral immunotherapy (OIT) is a promising therapeutic approach to treat food allergic patients. However, concerns with regards to safety and long-term efficacy of OIT remain. There is a need to identify biomarkers that predict, monitor and/or evaluate the effects of OIT. Here we present a method to select candidate biomarkers for efficacy and safety assessment of OIT using the computational approaches Bayesian networks (BN) and Topological Data Analysis (TDA). RESULTS Data were used from fructo-oligosaccharide diet-supported OIT experiments performed in 3 independent cow's milk allergy (CMA) and 2 independent peanut allergy (PNA) experiments in mice. Bioinformatical approaches were used to understand the data structure. The BN predicted the efficacy of OIT in the CMA with 86% and indicated a clear effect of scFOS/lcFOS on allergy parameters. For the PNA model, this BN (trained on CMA data) predicted an efficacy of OIT with 76% accuracy and shows similar effects of the allergen, treatment and diet as compared to the CMA model. The TDA identified clusters of biomarkers closely linked to biologically relevant clinical symptoms and also unrelated and redundant parameters within the network. CONCLUSIONS Here we provide a promising application of computational approaches to a) compare mechanistic features of two different food allergies during OIT b) determine the biological relevance of candidate biomarkers c) generate new hypotheses to explain why CMA has a different disease pattern than PNA and d) select relevant biomarkers for future studies.
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Affiliation(s)
| | | | - Laura Wagenaar
- Institute of Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
| | - Marlotte M Vonk
- Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Betty C A M van Esch
- Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Danone Nutricia Research, Utrecht, The Netherlands
| | - Léon M J Knippels
- Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Danone Nutricia Research, Utrecht, The Netherlands
| | - Johan Garssen
- Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Danone Nutricia Research, Utrecht, The Netherlands
| | - Joost J Smit
- Institute of Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
| | - Raymond H H Pieters
- Institute of Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
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Wagenaar L, van Roest M, Kruijssen LJW, Simons PJ, Boon L, Vonk MM, van Esch BCAM, Knippels LMJ, Garssen J, Pieters RHH, Smit JJ. Non-digestible oligosaccharides scFOS/lcFOS facilitate safe subcutaneous immunotherapy for peanut allergy. Clin Mol Allergy 2019; 17:7. [PMID: 30988664 PMCID: PMC6448225 DOI: 10.1186/s12948-019-0111-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 03/26/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Improving the safety of subcutaneous immunotherapy (SCIT) for food allergy is necessary to reduce side effects and achieve long-term tolerance. We determined the effect of dietary supplementation with 1% non-digestible short- and long-chain fructo-oligosaccharides (scFOS/lcFOS) on safety and efficacy of SCIT using a peanut allergy mouse model. METHODS After sensitization, mice received a scFOS/lcFOS or control diet for the rest of the study. To study safety of SCIT, mice were dosed with a single subcutaneous injection of peanut extract (PE) or PBS. To study efficacy, mice were dosed subcutaneously (SCIT, 3 times/week) with PE or PBS for 3 weeks. Hereafter, acute allergic skin responses, anaphylactic shock symptoms and body temperature were assessed. To study the mechanism in vitro, the human IgE receptor (FcεRI)-transfected rat mast cell (RBL) line was sensitized with an oligoclonal pool of chimeric human (chu)IgE antibodies against bovine β-lactoglobulin (BLG) and incubated with the oligosaccharides before exposure to BLG to assess direct the effect on degranulation. RESULTS scFOS/lcFOS reduced anaphylaxis caused by a single PE SCIT dose. scFOS/lcFOS alone also reduced the acute allergic skin response. Moreover, scFOS/lcFOS supplementation resulted in lower MMCP-1 levels in serum after PE SCIT dose compared to control diet, while antibody levels were not affected by the diet. In vitro incubation with scFOS/lcFOS at 0.5% suppressed the degranulation of IgE-sensitized RBL cells. However, dietary supplementation with scFOS/lcFOS did not improve the efficacy of SCIT. CONCLUSIONS We show that scFOS/lcFOS diet improves the safety of SCIT, as evidenced by lower anaphylactic responses without compromising the efficacy in a mouse model for peanut allergy. This effect is likely to result from the suppression of mast cell effector function.
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Affiliation(s)
- Laura Wagenaar
- Department of Immunotoxicology, Faculty of Veterinary Medicine, Institute for Risk Assessment Sciences, Utrecht University, Yalelaan 104, 3508 TD Utrecht, The Netherlands
| | - Manon van Roest
- Department of Immunotoxicology, Faculty of Veterinary Medicine, Institute for Risk Assessment Sciences, Utrecht University, Yalelaan 104, 3508 TD Utrecht, The Netherlands
| | - Laura J. W. Kruijssen
- Department of Immunotoxicology, Faculty of Veterinary Medicine, Institute for Risk Assessment Sciences, Utrecht University, Yalelaan 104, 3508 TD Utrecht, The Netherlands
| | | | | | - Marlotte M. Vonk
- Department of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Immunology, Danone Nutricia Research, Utrecht, The Netherlands
| | - Betty C. A. M. van Esch
- Department of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Immunology, Danone Nutricia Research, Utrecht, The Netherlands
| | - Leon M. J. Knippels
- Department of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Immunology, Danone Nutricia Research, Utrecht, The Netherlands
| | - Johan Garssen
- Department of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Immunology, Danone Nutricia Research, Utrecht, The Netherlands
| | - Raymond H. H. Pieters
- Department of Immunotoxicology, Faculty of Veterinary Medicine, Institute for Risk Assessment Sciences, Utrecht University, Yalelaan 104, 3508 TD Utrecht, The Netherlands
| | - Joost J. Smit
- Department of Immunotoxicology, Faculty of Veterinary Medicine, Institute for Risk Assessment Sciences, Utrecht University, Yalelaan 104, 3508 TD Utrecht, The Netherlands
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Oral and Sublingual Immunotherapy for Treatment of IgE-Mediated Food Allergy. Clin Rev Allergy Immunol 2018; 55:139-152. [PMID: 29656306 DOI: 10.1007/s12016-018-8677-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Development of active therapies for IgE-mediated food allergy is a critical action step toward alleviating the adverse medical, psychosocial, and economic burdens on affected patients and families. Significant progress has been observed specifically in the application of single-allergen oral and sublingual immunotherapy for treatment of IgE-mediated food allergy, with emphasis on milk, egg, and peanut as the primary allergens. Oral immunotherapy (OIT) has demonstrated efficacy in promoting immunomodulatory effects that lead to the clinical outcome of desensitization, defined as reduced reactivity while on active OIT, in the majority of treated individuals; however, achievement of sustained unresponsiveness following cessation of therapy has been observed in a smaller subset of treated subjects. The potential therapeutic benefits of OIT must be carefully considered in light of the significant potential for adverse events ranging from self-limited or easily treated oropharyngeal, respiratory or gastrointestinal symptoms, to persistent abdominal complaints that lead to cessation of therapy in an estimated 10-15% of treated individuals. To date, the majority of studies have focused on single-allergen OIT approaches; however, multi-allergen OIT has shown promise in initial trials and is the subject of ongoing investigation to address the complex needs of multi-food allergic individuals. Sublingual immunotherapy (SLIT) has been utilized for the treatment of food allergy and pollen-food allergy syndrome, demonstrating moderate efficacy, a favorable safety profile and variable tolerability, with oropharyngeal symptoms most commonly observed. Although studies directly comparing OIT and SLIT are limited, in general, the favorable safety profile associated with SLIT comes at the expense of reduced efficacy, while the more robust clinical effects observed with OIT come at the risk of potentially intolerable, treatment-limiting side effects. Future investigation to address specific knowledge gaps including optimal dose, duration, age of initiation, maintenance schedule, mechanisms, predictors of risk and therapeutic response will be important to maximize efficacy, minimize risk and develop personalized, effective approaches to targeting food allergy.
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Mota I, Piedade S, Gaspar Â, Benito-Garcia F, Sampaio G, Borrego LM, Morais-Almeida M. Cow's milk oral immunotherapy in real life: 8-year long-term follow-up study. Asia Pac Allergy 2018; 8:e28. [PMID: 30079306 PMCID: PMC6073178 DOI: 10.5415/apallergy.2018.8.e28] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 07/13/2018] [Indexed: 11/29/2022] Open
Abstract
Background Oral immunotherapy (OIT) has been recognized as a promising treatment for severe and long-lasting cow's milk (CM) allergy. Once maintenance has been achieved, patients should maintain daily intake of CM to ensure desensitization. Clinical experience concerning long-term follow-up is scarce. Objective The authors aimed to assess long-term efficacy and safety of a maintenance phase of OIT in real life. Methods Prospective study of all children and adolescents, who underwent CM-OIT and were subsequently followed at our allergy center on maintenance dose (200 mL daily) for at least 36 months after reaching the maintenance phase (from 2009 to 2016). Results Forty-two patients were enrolled: 60% male, 36% with history of anaphylaxis and 57% with asthma. The median time of follow-up was 69 months (range, 39–105 months) and the median age at the last clinical evaluation was 13 years (range, 6–23 years). Regarding adherence to the protocol: 92% are on free diet (at least 200 mL of CM daily; 7-g protein); 14% had transient interruptions and 7% definitely withdrawn with loss of tolerance. During maintenance, 45% developed mild to severe allergic reactions, and 7% had more than 3 episodes. A positive correlation between the occurrence of allergic reactions and history of anaphylaxis (p < 0.001) was found. The coexistence of asthma was risk factor for the occurrence of allergic reactions during maintenance. Conclusion This real-life study supports long-term efficacy and safety of CM-OIT. Despite daily intake, 41% had symptoms at some moment during the complete follow-up period; a total of 33 symptomatic days in patients with mean follow-up time of 67.5 months. Clinical tolerance depends on daily intake. The protective effect reached can be lost after CM withdrawal. History of anaphylaxis was a risk factor for the occurrence of allergic reactions during the maintenance phase.
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Affiliation(s)
- Inês Mota
- Immunoallergy Department, CUF Descobertas Hospital, Lisbon, Portugal
| | - Susana Piedade
- Immunoallergy Department, CUF Descobertas Hospital, Lisbon, Portugal
| | - Ângela Gaspar
- Immunoallergy Department, CUF Descobertas Hospital, Lisbon, Portugal
| | | | - Graça Sampaio
- Immunoallergy Department, CUF Descobertas Hospital, Lisbon, Portugal
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Arasi S, Caminiti L, Crisafulli G, Pajno GB. A general strategy for de novo immunotherapy design: the active treatment of food allergy. Expert Rev Clin Immunol 2018; 14:665-671. [PMID: 29984605 DOI: 10.1080/1744666x.2018.1498784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION IgE-mediated food allergy (FA) has been emerging as a public health priority. It is a potentially life-threatening condition with negative impact on the quality of life of patients and their family and its prevalence is increasing in westernized countries in the recent two decades. The current standard approach to FA consists of the strict avoidance of the triggering food. However, an elimination diet may be difficult and frustrating, above all for those foods (e.g. milk and egg) that are pivotal in the common diet. Oral immunotherapy (OIT) may increase the amount of food that the patient can intake without reaction and reduce the risk of potential life-threatening allergic reactions. It is currently considered the most promising treatment for FA. However, many gaps are still unsolved. Areas covered: The aim of this review is to shed light on the current evidence and the main needs in OIT in order to stimulate the development of longitudinal, prospective, and well-designed studies with the final goal of a 'precision medicine.' Expert commentary: Clinical trials for OIT conducted so far are extremely heterogeneous. The aim in the near future is to identify the most suitable candidates to OIT and algorithms for treatments tailored on well-characterized subpopulations of patients.
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Affiliation(s)
- Stefania Arasi
- a Department of Pediatrics- Allergy Unit , University of Messina , Messina , Italy.,b SIAF- Schweizerischers Institut für Allergie- und Asthmaforschung , Davos , Switzerland.,c Pediatric Allergy Unit , Bambino Gesù Children's Hospital, IRCCS , Rome , Italy
| | - Lucia Caminiti
- a Department of Pediatrics- Allergy Unit , University of Messina , Messina , Italy
| | - Giuseppe Crisafulli
- a Department of Pediatrics- Allergy Unit , University of Messina , Messina , Italy
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30
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Oral food challenge using different target doses and time intervals between doses. Curr Opin Allergy Clin Immunol 2018; 18:222-227. [DOI: 10.1097/aci.0000000000000444] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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31
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Graham F, Eigenmann PA. Clinical implications of food allergen thresholds. Clin Exp Allergy 2018; 48:632-640. [DOI: 10.1111/cea.13144] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- F. Graham
- Pediatric Allergy Unit; University Hospitals of Geneva and University of Geneva; Geneva Switzerland
| | - P. A. Eigenmann
- Pediatric Allergy Unit; University Hospitals of Geneva and University of Geneva; Geneva Switzerland
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32
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Kulmala P, Pelkonen AS, Kuitunen M, Paassilta M, Remes S, Schultz R, Dunder T, Turunen S, Mäkelä MJ. Wheat oral immunotherapy was moderately successful but was associated with very frequent adverse events in children aged 6-18 years. Acta Paediatr 2018; 107:861-870. [PMID: 29345001 DOI: 10.1111/apa.14226] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/07/2017] [Accepted: 01/12/2018] [Indexed: 01/01/2023]
Abstract
AIM This study investigated oral immunotherapy (OIT) for children aged 6-18 years with wheat allergies. METHODS Well-cooked wheat spaghetti was given to 100 children with wheat allergies every day for 17 weeks, increasing from 0.3 to 2000 mg of wheat protein, followed by three- and nine-month maintenance phases. Blood samples were taken before therapy and at follow-up visits. The study was carried out in 2009-2015 in four Finnish paediatric allergology units. RESULTS The children (67% male) had a mean age of 11.6 years (range 6.1-18.6), and 57 were using wheat daily 16 months after the initiation of therapy. Allergic symptoms occurred in 94/100 children: mild in 34, moderate in 36 and severe in 24. Specific immunoglobulin E (IgE) for ω-5-gliadin was significantly higher in patients who did not reach the target dose and were related to the intensity of reactions. CONCLUSION The majority (57%) of children with wheat allergies could use wheat in their daily diet 16 months after the initiation of OIT, but 94/100 had adverse reactions and 60 were moderate or severe. Specific IgE to ω-5-gliadin may provide a biomarker for how much wheat can be tolerated and the intensity of the reactions to immunotherapy.
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Affiliation(s)
- Petri Kulmala
- PEDEGO Research Unit; Medical Research Center (MRC) Oulu; University of Oulu and Oulu University Hospital; Oulu Finland
- Biomedicine Research Unit; Clinical Microbiology and Immunology; University of Oulu; Oulu Finland
| | - Anna S. Pelkonen
- Department of Allergy, Skin and Allergy Hospital; Helsinki University Hospital; Helsinki Finland
- University of Helsinki; Helsinki Finland
| | - Mikael Kuitunen
- Children's Hospital; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | | | - Sami Remes
- Department of Pediatrics; Kuopio University Hospital; Kuopio Finland
| | - Rüdiger Schultz
- Allergy Center; Tampere University Hospital; Tampere Finland
- Pihlajalinna Medical Center; Tampere Finland
| | - Teija Dunder
- PEDEGO Research Unit; Medical Research Center (MRC) Oulu; University of Oulu and Oulu University Hospital; Oulu Finland
| | - Sami Turunen
- PEDEGO Research Unit; Medical Research Center (MRC) Oulu; University of Oulu and Oulu University Hospital; Oulu Finland
| | - Mika J. Mäkelä
- Department of Allergy, Skin and Allergy Hospital; Helsinki University Hospital; Helsinki Finland
- University of Helsinki; Helsinki Finland
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33
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Pajno GB, Fernandez-Rivas M, Arasi S, Roberts G, Akdis CA, Alvaro-Lozano M, Beyer K, Bindslev-Jensen C, Burks W, Ebisawa M, Eigenmann P, Knol E, Nadeau KC, Poulsen LK, van Ree R, Santos AF, du Toit G, Dhami S, Nurmatov U, Boloh Y, Makela M, O'Mahony L, Papadopoulos N, Sackesen C, Agache I, Angier E, Halken S, Jutel M, Lau S, Pfaar O, Ryan D, Sturm G, Varga EM, van Wijk RG, Sheikh A, Muraro A. EAACI Guidelines on allergen immunotherapy: IgE-mediated food allergy. Allergy 2018; 73:799-815. [PMID: 29205393 DOI: 10.1111/all.13319] [Citation(s) in RCA: 334] [Impact Index Per Article: 55.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2017] [Indexed: 02/05/2023]
Abstract
Food allergy can result in considerable morbidity, impairment of quality of life, and healthcare expenditure. There is therefore interest in novel strategies for its treatment, particularly food allergen immunotherapy (FA-AIT) through the oral (OIT), sublingual (SLIT), or epicutaneous (EPIT) routes. This Guideline, prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Task Force on Allergen Immunotherapy for IgE-mediated Food Allergy, aims to provide evidence-based recommendations for active treatment of IgE-mediated food allergy with FA-AIT. Immunotherapy relies on the delivery of gradually increasing doses of specific allergen to increase the threshold of reaction while on therapy (also known as desensitization) and ultimately to achieve post-discontinuation effectiveness (also known as tolerance or sustained unresponsiveness). Oral FA-AIT has most frequently been assessed: here, the allergen is either immediately swallowed (OIT) or held under the tongue for a period of time (SLIT). Overall, trials have found substantial benefit for patients undergoing either OIT or SLIT with respect to efficacy during treatment, particularly for cow's milk, hen's egg, and peanut allergies. A benefit post-discontinuation is also suggested, but not confirmed. Adverse events during FA-AIT have been frequently reported, but few subjects discontinue FA-AIT as a result of these. Taking into account the current evidence, FA-AIT should only be performed in research centers or in clinical centers with an extensive experience in FA-AIT. Patients and their families should be provided with information about the use of FA-AIT for IgE-mediated food allergy to allow them to make an informed decision about the therapy.
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Petroni D, Spergel JM. Eosinophilic esophagitis and symptoms possibly related to eosinophilic esophagitis in oral immunotherapy. Ann Allergy Asthma Immunol 2018; 120:237-240.e4. [PMID: 29397272 DOI: 10.1016/j.anai.2017.11.016] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/22/2017] [Accepted: 11/20/2017] [Indexed: 01/07/2023]
Affiliation(s)
- Daniel Petroni
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
| | - Jonathan M Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Andorf S, Purington N, Block WM, Long AJ, Tupa D, Brittain E, Rudman Spergel A, Desai M, Galli SJ, Nadeau KC, Chinthrajah RS. Anti-IgE treatment with oral immunotherapy in multifood allergic participants: a double-blind, randomised, controlled trial. Lancet Gastroenterol Hepatol 2017; 3:85-94. [PMID: 29242014 PMCID: PMC6944204 DOI: 10.1016/s2468-1253(17)30392-8] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 11/15/2017] [Accepted: 11/16/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite progress in single food oral immunotherapy (OIT), there is little evidence concerning the safety and efficacy of treating individuals with multiple food (multifood) allergies. We conducted a pilot study testing whether anti-IgE (omalizumab) combined with multifood OIT benefitted multifood allergic patients. METHODS In this blinded, phase 2 clinical trial conducted at Stanford University, 48 participants, aged 4-15 years, with multifood allergies validated by double-blind, placebo-controlled food challenges (DBPCFCs) to their offending foods were block randomized (3:1) to receive multifood OIT to 2-5 foods, together with omalizumab (n=36) or placebo (n=12). Omalizumab or placebo was administered subcutaneously for 16 weeks with OIT starting at week 8; omalizumab or placebo was stopped 20 weeks before exit DBPCFCs (week 36) to determine the primary endpoint: the proportion of participants who passed DBPCFCs to at least 2 of their offending foods. This completed trial is registered with ClinicalTrials.gov, . FINDINGS At week 36, a significantly greater proportion of the omalizumab (30/36, 83%) vs. placebo (4/12, 33%) participants passed DBPCFCs to 2 g protein for ≥ 2 of their offending foods (odds ratio (OR): 10, 95% confidence interval (CI): 1·8, 58·3, P=0·004). The same individuals also tolerated 4 g protein of ≥ 2 foods (secondary endpoint, P=0·004). A greater proportion of omalizumab (13/17, 77%) vs. placebo (0/5, 0%) participants passed a DBPCFC to 2 g protein for ≥ 4 of their offending foods (OR: 33, 95% CI: 1·9, ∞, P=0·01). All participants completed the study. There were no serious or severe (≥ grade 3) adverse events. INTERPRETATION In multifood allergic patients, omalizumab improves the efficacy of multifood OIT and enables safe and rapid desensitization. FUNDING NIH U19 AADCRC and Opportunity Fund, Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Simons Foundation, Myra Reinhard Foundation, FARE Center of Excellence, Department of Pathology, and Department of Pediatrics, Stanford University.
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Affiliation(s)
- Sandra Andorf
- Sean N Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Natasha Purington
- Sean N Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, USA; Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Whitney M Block
- Sean N Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew J Long
- Sean N Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Dana Tupa
- Sean N Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Erica Brittain
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | | | - Manisha Desai
- Sean N Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, USA; Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephen J Galli
- Sean N Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, USA; Departments of Pathology and of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
| | - Kari C Nadeau
- Sean N Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, USA
| | - R Sharon Chinthrajah
- Sean N Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, USA.
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36
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Vonk MM, Diks MAP, Wagenaar L, Smit JJ, Pieters RHH, Garssen J, van Esch BCAM, Knippels LMJ. Improved Efficacy of Oral Immunotherapy Using Non-Digestible Oligosaccharides in a Murine Cow's Milk Allergy Model: A Potential Role for Foxp3+ Regulatory T Cells. Front Immunol 2017; 8:1230. [PMID: 29033945 PMCID: PMC5626810 DOI: 10.3389/fimmu.2017.01230] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/19/2017] [Indexed: 01/05/2023] Open
Abstract
Background Oral immunotherapy (OIT) is a promising therapeutic approach to treat food allergic patients. However, there are some concerns regarding its safety and long-term efficacy. The use of non-digestible oligosaccharides might improve OIT efficacy since they are known to directly modulate intestinal epithelial and immune cells in addition to acting as prebiotics. Aim To investigate whether a diet supplemented with plant-derived fructo-oligosaccharides (FOS) supports the efficacy of OIT in a murine cow’s milk allergy model and to elucidate the potential mechanisms involved. Methods After oral sensitization to the cow’s milk protein whey, female C3H/HeOuJ mice were fed either a control diet or a diet supplemented with FOS (1% w/w) and received OIT (10 mg whey) 5 days a week for 3 weeks by gavage. Intradermal (i.d.) and intragastric (i.g.) challenges were performed to measure acute allergic symptoms and mast cell degranulation. Blood and organs were collected to measure antibody levels and T cell and dendritic cell populations. Spleen-derived T cell fractions (whole spleen- and CD25-depleted) were transferred to naïve recipient mice to confirm the involvement of regulatory T cells (Tregs) in allergy protection induced by OIT + FOS. Results OIT + FOS decreased acute allergic symptoms and mast cell degranulation upon challenge and prevented the challenge-induced increase in whey-specific IgE as observed in sensitized mice. Early induction of Tregs in the mesenteric lymph nodes (MLN) of OIT + FOS mice coincided with reduced T cell responsiveness in splenocyte cultures. CD25 depletion in OIT + FOS-derived splenocyte suspensions prior to transfer abolished protection against signs of anaphylaxis in recipients. OIT + FOS increased serum galectin-9 levels. No differences in short-chain fatty acid (SCFA) levels in the cecum were observed between the treatment groups. Concisely, FOS supplementation significantly improved OIT in the acute allergic skin response, %Foxp3+ Tregs and %LAP+ Th3 cells in MLN, and serum galectin-9 levels. Conclusion FOS supplementation improved the efficacy of OIT in cow’s milk allergic mice. Increased levels of Tregs in the MLN and abolished protection against signs of anaphylaxis upon transfer of CD25-depleted cell fractions, suggest a role for Foxp3+ Tregs in the protective effect of OIT + FOS.
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Affiliation(s)
- Marlotte M Vonk
- Faculty of Science, Department of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands.,Immunology Platform, Nutricia Research, Utrecht, Netherlands
| | - Mara A P Diks
- Faculty of Science, Department of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Laura Wagenaar
- Faculty of Veterinary Medicine, Department of Immunotoxicology, Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands
| | - Joost J Smit
- Faculty of Veterinary Medicine, Department of Immunotoxicology, Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands
| | - Raymond H H Pieters
- Faculty of Veterinary Medicine, Department of Immunotoxicology, Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands
| | - Johan Garssen
- Faculty of Science, Department of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands.,Immunology Platform, Nutricia Research, Utrecht, Netherlands
| | - Betty C A M van Esch
- Faculty of Science, Department of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands.,Immunology Platform, Nutricia Research, Utrecht, Netherlands
| | - Léon M J Knippels
- Faculty of Science, Department of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands.,Immunology Platform, Nutricia Research, Utrecht, Netherlands
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Vonk MM, Wagenaar L, Pieters RHH, Knippels LMJ, Willemsen LEM, Smit JJ, van Esch BCAM, Garssen J. The efficacy of oral and subcutaneous antigen-specific immunotherapy in murine cow's milk- and peanut allergy models. Clin Transl Allergy 2017; 7:35. [PMID: 29021893 PMCID: PMC5622477 DOI: 10.1186/s13601-017-0170-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 09/14/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Antigen-specific immunotherapy (AIT) is a promising therapeutic approach for both cow's milk allergy (CMA) and peanut allergy (PNA), but needs optimization in terms of efficacy and safety. AIM Compare oral immunotherapy (OIT) and subcutaneous immunotherapy (SCIT) in murine models for CMA and PNA and determine the dose of allergen needed to effectively modify parameters of allergy. METHODS Female C3H/HeOuJ mice were sensitized intragastrically (i.g.) to whey or peanut extract with cholera toxin. Mice were treated orally (5 times/week) or subcutaneously (3 times/week) for three consecutive weeks. Hereafter, the acute allergic skin response, anaphylactic shock symptoms and body temperature were measured upon intradermal (i.d.) and intraperitoneal (i.p.) challenge, and mast cell degranulation was measured upon i.g. challenge. Allergen-specific IgE, IgG1 and IgG2a were measured in serum at different time points. Single cell suspensions derived from lymph organs were stimulated with allergen to induce cytokine production and T cell phenotypes were assessed using flow cytometry. RESULTS Both OIT and SCIT decreased clinically related signs upon challenge in the CMA and PNA model. Interestingly, a rise in allergen-specific IgE was observed during immunotherapy, hereafter, treated mice were protected against the increase in IgE caused by allergen challenge. Allergen-specific IgG1 and IgG2a increased due to both types of AIT. In the CMA model, SCIT and OIT reduced the percentage of activated Th2 cells and increased the percentage of activated Th1 cells in the spleen. OIT increased the percentage of regulatory T cells (Tregs) and activated Th2 cells in the MLN. Th2 cytokines IL-5, IL-13 and IL-10 were reduced after OIT, but not after SCIT. In the PNA model, no differences were observed in percentages of T cell subsets. SCIT induced Th2 cytokines IL-5 and IL-10, whereas OIT had no effect. CONCLUSION We have shown clinical protection against allergic manifestations after OIT and SCIT in a CMA and PNA model. Although similar allergen-specific antibody patterns were observed, differences in T cell and cytokine responses were shown. Whether these findings are related to a different mechanism of AIT in CMA and PNA needs to be elucidated.
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Affiliation(s)
- Marlotte M Vonk
- Department of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Immunology Platform, Nutricia Research, Utrecht, The Netherlands
| | - Laura Wagenaar
- Department of Immunotoxicology, Faculty of Veterinary Medicine, Institute for Risk Assessment Sciences, Utrecht University, PO Box 80177, 3508 TD Utrecht, The Netherlands
| | - Raymond H H Pieters
- Department of Immunotoxicology, Faculty of Veterinary Medicine, Institute for Risk Assessment Sciences, Utrecht University, PO Box 80177, 3508 TD Utrecht, The Netherlands.,Yalelaan 104, 3594 CM Utrecht, The Netherlands
| | - Leon M J Knippels
- Department of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Immunology Platform, Nutricia Research, Utrecht, The Netherlands
| | - Linette E M Willemsen
- Department of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Joost J Smit
- Department of Immunotoxicology, Faculty of Veterinary Medicine, Institute for Risk Assessment Sciences, Utrecht University, PO Box 80177, 3508 TD Utrecht, The Netherlands
| | - Betty C A M van Esch
- Department of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Immunology Platform, Nutricia Research, Utrecht, The Netherlands
| | - Johan Garssen
- Department of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Immunology Platform, Nutricia Research, Utrecht, The Netherlands
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Arasi S, Pajno GB. Evidence Gaps in Oral Immunotherapy for Food Allergy. CURRENT TREATMENT OPTIONS IN ALLERGY 2017. [DOI: 10.1007/s40521-017-0146-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Affiliation(s)
- Stacie M Jones
- From the Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (S.M.J.); and the Department of Pediatrics, University of North Carolina, Chapel Hill (A.W.B.)
| | - A Wesley Burks
- From the Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock (S.M.J.); and the Department of Pediatrics, University of North Carolina, Chapel Hill (A.W.B.)
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40
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Oral immunotherapy for food allergy: A Spanish guideline. Egg and milk immunotherapy Spanish guide (ITEMS GUIDE). Part 2: Maintenance phase of cow milk (CM) and egg oral immunotherapy (OIT), special treatment dosing schedules. Models of dosing schedules of OIT with CM and EGG. Allergol Immunopathol (Madr) 2017; 45:508-518. [PMID: 28676231 DOI: 10.1016/j.aller.2017.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/19/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Cow's milk and egg are the most frequent causes of food allergy in the first years of life. Treatments such as oral immunotherapy (OIT) have been investigated as an alternative to avoidance diets. No clinical practice guides on the management of OIT with milk and egg are currently available. OBJECTIVES To develop a clinical guide on OIT based on the available scientific evidence and the opinions of experts. METHODS A review was made of studies published in the period between 1984 and June 2016, Doctoral Theses published in Spain, and summaries of communications at congresses (SEAIC, SEICAP, EAACI, AAAAI), with evaluation of the opinion consensus established by a group of experts pertaining to the scientific societies SEICAP and SEAIC. RESULTS Recommendations have been established regarding the indications, requirements and practical aspects of the different phases of OIT, as well as special protocols for patients at high risk of suffering adverse reactions. CONCLUSIONS A clinical practice guide is presented for the management of OIT with milk and egg, based on the opinion consensus of Spanish experts.
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Martorell A, Alonso E, Echeverría L, Escudero C, García-Rodríguez R, Blasco C, Bone J, Borja-Segade J, Bracamonte T, Claver A, Corzo JL, De la Hoz B, Del Olmo R, Dominguez O, Fuentes-Aparicio V, Guallar I, Larramona H, Martín-Muñoz F, Matheu V, Michavila A, Ojeda I, Ojeda P, Piquer M, Poza P, Reche M, Rodríguez Del Río P, Rodríguez M, Ruano F, Sánchez-García S, Terrados S, Valdesoiro L, Vazquez-Ortiz M. Oral immunotherapy for food allergy: A Spanish guideline. Immunotherapy egg and milk Spanish guide (items guide). Part I: Cow milk and egg oral immunotherapy: Introduction, methodology, rationale, current state, indications contraindications and oral immunotherapy build-up phase. Allergol Immunopathol (Madr) 2017; 45:393-404. [PMID: 28662773 DOI: 10.1016/j.aller.2017.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/19/2017] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Cow's milk and egg are the most frequent causes of food allergy in the first years of life. Treatments such as oral immunotherapy (OIT) have been investigated as an alternative to avoidance diets. No clinical practice guides on the management of OIT with milk and egg are currently available. OBJECTIVES To develop a clinical guide on OIT based on the available scientific evidence and the opinions of experts. METHODS A review was made of studies published in the period between 1984 and June 2016, Doctoral Theses published in Spain, and summaries of communications at congresses (SEAIC, SEICAP, EAACI, AAAAI), with evaluation of the opinion consensus established by a group of experts pertaining to the scientific societies SEICAP and SEAIC. RESULTS Recommendations have been established regarding the indications, requirements and practical aspects of the different phases of OIT, as well as special protocols for patients at high risk of suffering adverse reactions. CONCLUSIONS A clinical practice guide is presented for the management of OIT with milk and egg, based on the opinion consensus of Spanish experts.
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Affiliation(s)
- A Martorell
- Department of Allergology, University General Hospital, Valencia, Spain.
| | - E Alonso
- Department of Pediatric Allergy, Gregorio Marañón Hospital, Madrid, Spain
| | - L Echeverría
- Department of Pediatric Allergy, Severo Ochoa University Hospital, Leganés, Spain
| | - C Escudero
- Department of Pediatric Allergy, Niño Jesús University Children's Hospital, Madrid, Spain
| | - R García-Rodríguez
- Department of Allergology, University General Hospital, Ciudad Real, Spain
| | - C Blasco
- Department of Pediatric Allergy, Vall d'Hebron Hospital, Barcelona, Spain
| | - J Bone
- Department of Pediatric Allergy, Miguel Servet University Hospital, Zaragoza, Spain
| | - J Borja-Segade
- Department of Allergology, University General Hospital, Ciudad Real, Spain
| | - T Bracamonte
- Department of Pediatric Allergy, Severo Ochoa University Hospital, Leganés, Spain
| | - A Claver
- Quirón Dexeus University Hospital, Barcelona, Spain
| | - J L Corzo
- Department of Pediatric Allergy, Carlos Haya University Hospital, Málaga, Spain
| | - B De la Hoz
- Department of Allergology, Ramón y Cajal Hospital, Madrid, Spain
| | - R Del Olmo
- Department of Pediatric Allergy, University Hospital, Móstoles, Spain
| | - O Dominguez
- Department of Pediatric Allergy, San Joan de Deu Hospital, Barcelona, Spain
| | | | - I Guallar
- Department of Pediatric Allergy, Miguel Servet University Hospital, Zaragoza, Spain
| | - H Larramona
- Department of Pediatric Allergy, Parc Taulí University Hospital, Sabadell, Spain
| | - F Martín-Muñoz
- Department of Allergology, La Paz Children's Hospital, Madrid, Spain
| | - V Matheu
- Allergology Unit-North Chest Hospital, Santa Cruz de Tenerife, Spain
| | - A Michavila
- Department of Pediatric Allergy, General Hospital, Castellón, Spain
| | | | | | - M Piquer
- Department of Pediatric Allergy, San Joan de Deu Hospital, Barcelona, Spain
| | - P Poza
- Allergology Unit-North Chest Hospital, Santa Cruz de Tenerife, Spain
| | - M Reche
- Department of Allergology, Infanta Sofía Hospital, San Sebastián de los Reyes, Spain
| | - P Rodríguez Del Río
- Department of Pediatric Allergy, Niño Jesús University Children's Hospital, Madrid, Spain
| | - M Rodríguez
- Department of Allergology, Alcorcón Foundation Hospital, Alcorcón, Spain
| | - F Ruano
- Department of Allergy, Infanta Leonor Hospital, Madrid, Spain
| | - S Sánchez-García
- Department of Pediatric Allergy, Niño Jesús University Children's Hospital, Madrid, Spain
| | - S Terrados
- Department of Pediatric Allergy, Ramón y Cajal Hospital, Madrid, Spain
| | - L Valdesoiro
- Department of Pediatric Allergy, Parc Taulí University Hospital, Sabadell, Spain
| | - M Vazquez-Ortiz
- Pediatric Allergy, Department of Medicine, Imperial College London, United Kingdom
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Alvaro M, Escarrer M. Food allergy in childhood: Are we close to having an effective treatment? Allergol Immunopathol (Madr) 2017; 45:313-315. [PMID: 28688477 DOI: 10.1016/j.aller.2017.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/16/2017] [Indexed: 12/22/2022]
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Okada Y, Akasawa A. A successful case of egg allergy tolerance achieved at a local clinic. Allergol Int 2017; 66:504-506. [PMID: 28216056 DOI: 10.1016/j.alit.2017.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/09/2016] [Accepted: 12/18/2016] [Indexed: 10/20/2022] Open
Affiliation(s)
- Yuki Okada
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Niijima Clinic, Tokyo, Japan; Department of Pediatrics, Jichi Medical University, Tochigi, Japan.
| | - Akira Akasawa
- Department of Allergy, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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Barbosa C, Castro A, Yonamine G, Gushken A, Beck C, Macedo P, Dorna M, Santos C, Pastorino A, Jacob C. Baked milk tolerant patient: Is there any special feature? Allergol Immunopathol (Madr) 2017; 45:283-289. [PMID: 28159383 DOI: 10.1016/j.aller.2016.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/06/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Determining whether patients with cow's milk allergy (CMA) can tolerate foods produced with baked milk could provide a better quality of life, a better prognosis, and an option for desensitization. OBJECTIVES The aim of this study was to identify which patients over four years of age with persistent CMA could tolerate baked milk, to compare the clinical and laboratory characteristics of reactive and non-reactive groups and to describe their clinical evolution. MATERIALS AND METHODS A cross-sectional study was conducted (January/13 to November/14) that included all the patients followed at a food allergy center who met the inclusion criteria. The patients underwent an oral food challenge (OFC) with a muffin (2.8g of cow's milk protein). To exclude cow's milk (CM) tolerance, the patients were subsequently challenged with unheated CM. RESULTS Thirty patients met all the inclusion criteria. Fourteen patients (46.7%) were considered non-reactive to baked milk and reactive to unheated CM. When the groups that were reactive and non-reactive to baked milk were compared, no statistically significant differences in clinical features were found. The prick test for α-lactalbumin (p=0.01) and casein (p=0.004) and the serum specific IgE for casein (p=0.05) presented statistical differences. After one year, none of the patients who were reactive to baked milk were ingesting CM, while 28% of the tolerant patients were consuming fresh CM (p=0.037). CONCLUSIONS Baked milk can be tolerated by patients with CMA, especially those with lower levels of casein and α-lactalbumin. This option can improve quality of life and accelerate tolerance.
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Mori F, Cianferoni A, Brambilla A, Barni S, Sarti L, Pucci N, de Martino M, Novembre E. Side effects and their impact on the success of milk oral immunotherapy (OIT) in children. Int J Immunopathol Pharmacol 2017; 30:182-187. [PMID: 28466667 PMCID: PMC5806791 DOI: 10.1177/0394632017697986] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Oral immunotherapy (OIT) has been introduced as a new immune-modulating treatment under investigation for food allergies. The aim of our study was to evaluate the success of OIT in a cohort of children with milk allergy. These children underwent OIT in a clinical practice and were followed for up to ten years. The secondary endpoint was to describe the main adverse events during OIT and compare them to those reported in the literature. Eighty-two milk-allergic children started OIT. According to the OIT endpoint reached after one year, all of the children enrolled in the study were divided into four groups: complete desensitization; partial desensitization; step down; and stop groups. Any adverse events that occurred during OIT were also recorded. Of the 82 patients, eight were recruited in the last months of 2010 so they were still ongoing at the end of the study. For that reason, they were excluded from the analysis. The majority (73%) of the 74 children evaluated (51 boys, 23 girls; median age, 7 years; age range, 2–18 years; specific serum IgE for cow’s milk, 36 KUA/L [range, 3–100 KUA/L]; milk SPT wheal diameter, 7 mm [range, 2–15 mm]) reached complete (58.1%) or partial (14.9%) desensitization, 9.4% were subjected to step down. The remaining 17.6% of the children discontinued OIT because of the occurrence of chronic gastroenteric (GE) symptoms (46.1%) or acute asthma (15.3%) following milk intake. In agreement with the literature, we found that chronic GE symptoms was the main reason for OIT discontinuation. OIT represents a valid tool for the treatment of food allergies in children; however, the risk of potential adverse reactions, both IgE- and non-IgE-mediated, should be discussed with parents prior to the initiation of OIT.
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Affiliation(s)
- Francesca Mori
- 1 Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
| | - Antonella Cianferoni
- 2 Allergy and Immunology Division, The Children's Hospital of Philadelphia, PA, USA
| | - Alice Brambilla
- 1 Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
| | - Simona Barni
- 1 Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
| | - Lucrezia Sarti
- 1 Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
| | - Neri Pucci
- 1 Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
| | - Maurizio de Martino
- 3 Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
| | - Elio Novembre
- 1 Allergy Unit, Department of Pediatric, Anna Meyer Children's University Hospital, Florence, Italy
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Gernez Y, Nowak-Węgrzyn A. Immunotherapy for Food Allergy: Are We There Yet? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:250-272. [DOI: 10.1016/j.jaip.2016.12.004] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/23/2016] [Accepted: 12/19/2016] [Indexed: 12/21/2022]
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Virkud YV, Burks AW, Steele PH, Edwards LJ, Berglund JP, Jones SM, Scurlock AM, Perry TT, Pesek RD, Vickery BP. Novel baseline predictors of adverse events during oral immunotherapy in children with peanut allergy. J Allergy Clin Immunol 2017; 139:882-888.e5. [PMID: 27609653 PMCID: PMC5337444 DOI: 10.1016/j.jaci.2016.07.030] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 06/02/2016] [Accepted: 07/01/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Though peanut oral immunotherapy (OIT) is a promising investigational therapy, its potential is limited by substantial adverse events (AEs), which are relatively understudied. OBJECTIVE A retrospective analysis was conducted, pooling data from 3 pediatric peanut OIT trials, comprising the largest analysis of peanut OIT safety to date. METHODS We pooled data from 104 children with peanut allergy from 3 peanut OIT studies. We catalogued AEs from parental reports, daily symptom diaries, and dose escalations. We included events that were considered likely related to OIT and identified potential baseline predictors of higher AE rates using generalized linear regression models. RESULTS Eighty percent of subjects experienced likely related AEs during OIT (72% during buildup and 47% during maintenance). Of these AEs, over 90% occurred while at home. Approximately 42% of subjects experienced systemic reactions, and 49% experienced gastrointestinal symptoms. Twenty percent of subjects dropped out, with half (10% of the overall group) due to persistent gastrointestinal symptoms. Baseline allergic rhinitis (AR) and peanut SPT wheal size were significant predictors of higher overall AE rates. SPT wheal size predicted increased gastrointestinal AEs, and AR predicted increased systemic reactions. Over the course of OIT, 61% of subjects received treatment for likely related AEs, 59% with antihistamines and 12% with epinephrine. CONCLUSIONS Peanut OIT is associated with frequent AEs, with rates declining over time, and most graded mild. However, systemic reactions and intolerable gastrointestinal AEs do occur and are significantly associated with AR and peanut SPT wheal size, respectively. Further study is needed of predictive biomarkers and the overall risks and benefits of OIT.
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Affiliation(s)
- Yamini V Virkud
- Department of Pediatrics, Massachusetts General Hospital, Boston, Mass
| | - A Wesley Burks
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Pamela H Steele
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Lloyd J Edwards
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC
| | | | - Stacie M Jones
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Ark
| | - Amy M Scurlock
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Ark
| | - Tamara T Perry
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Ark
| | - Robert D Pesek
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Ark
| | - Brian P Vickery
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC.
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Dhanapala P, Withanage-Dona D, Tang MLK, Doran T, Suphioglu C. Hypoallergenic Variant of the Major Egg White Allergen Gal d 1 Produced by Disruption of Cysteine Bridges. Nutrients 2017; 9:E171. [PMID: 28230769 PMCID: PMC5331602 DOI: 10.3390/nu9020171] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/09/2017] [Accepted: 02/15/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Gal d 1 (ovomucoid) is the dominant allergen in the chicken egg white. Hypoallergenic variants of this allergen can be used in immunotherapy as an egg allergy treatment approach. We hypothesised that disruption of two of the nine cysteine-cysteine bridges by site-directed mutagenesis will allow the production of a hypoallergenic variant of the protein; Methods: Two cysteine residues at C192 and C210 in domain III of the protein were mutated to alanine using site-directed mutagenesis, to disrupt two separate cysteine-cysteine bridges. The mutated and non-mutated proteins were expressed in Escherichia coli (E. coli) by induction with isopropyl β-d-1-thiogalactopyranoside (IPTG). The expressed proteins were analysed using sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and immunoblotting to confirm expression. Immunoglobulin E (IgE) reactivity of the two proteins was analysed, by immunoblotting, against a pool of egg-allergic patients' sera. A pool of non-allergic patients' sera was also used in a separate blot as a negative control; Results: Mutant Gal d 1 showed diminished IgE reactivity in the immunoblot by showing lighter bands when compared to the non-mutated version, although there was more of the mutant protein immobilised on the membrane when compared to the wild-type protein. The non-allergic negative control showed no bands, indicating an absence of non-specific binding of secondary antibody to the proteins; Conclusion: Disruption of two cysteine bridges in domain III of Gal d 1 reduces IgE reactivity. Following downstream laboratory and clinical testing, this mutant protein can be used in immunotherapy to induce tolerance to Gal d 1 and in egg allergy diagnosis.
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Affiliation(s)
- Pathum Dhanapala
- Neuro Allergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 75 Pigdons Road, Geelong 3216 VIC, Australia.
- Australian Animal Health Laboratory (AAHL), Biosecurity Flagship, Commonwealth Scientific and Industrial Research Organisation (CSIRO), 5 Portarlington Road, East Geelong 3219 VIC, Australia.
- Poultry CRC, P.O. Box U242, University of New England, Armidale 2351 NSW, Australia.
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, 02115 MA, USA.
| | - Dulashi Withanage-Dona
- Neuro Allergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 75 Pigdons Road, Geelong 3216 VIC, Australia.
| | - Mimi L K Tang
- Department of Allergy and Immunology, Royal Children's Hospital, 50 Flemington Road, Parkville 3052 VIC, Australia.
- Allergy and Immune Disorders, Murdoch Children's Research Institute, 50 Flemington Road, Parkville 3052 VIC, Australia.
- The University of Melbourne, Parkville 3010 VIC, Australia.
| | - Tim Doran
- Australian Animal Health Laboratory (AAHL), Biosecurity Flagship, Commonwealth Scientific and Industrial Research Organisation (CSIRO), 5 Portarlington Road, East Geelong 3219 VIC, Australia.
- Poultry CRC, P.O. Box U242, University of New England, Armidale 2351 NSW, Australia.
| | - Cenk Suphioglu
- Neuro Allergy Research Laboratory (NARL), School of Life and Environmental Sciences, Faculty of Science, Engineering and Built Environment, Deakin University, 75 Pigdons Road, Geelong 3216 VIC, Australia.
- Poultry CRC, P.O. Box U242, University of New England, Armidale 2351 NSW, Australia.
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Kukkonen AK, Uotila R, Malmberg LP, Pelkonen AS, Mäkelä MJ. Double-blind placebo-controlled challenge showed that peanut oral immunotherapy was effective for severe allergy without negative effects on airway inflammation. Acta Paediatr 2017; 106:274-281. [PMID: 27859599 DOI: 10.1111/apa.13668] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/12/2016] [Accepted: 11/08/2016] [Indexed: 12/01/2022]
Abstract
AIM This study examined the efficacy and the safety of peanut oral immunotherapy (OIT). METHODS We recruited 60 patients aged six years to 18 years who had a moderate-to-severe reaction to a double-blind placebo-controlled peanut challenge: 39 received OIT during an eight-month build-up phase and maintenance phase and 21 controls avoided peanuts. We measured specific immunoglobulin E and G4 (IgE and IgG4) to peanuts and to Ara h 1, 2, 3, 8 and 9 and monitored adverse events, bronchial hyper-responsiveness (BHR) to methacholine and fractional concentrations of exhaled nitric oxide (FeNO). The median follow-up period was 30 months. RESULTS Most (85%) of the OIT patients passed the build-up phase and 67% tolerated 5 g of peanuts during the post-treatment challenge. No controls were desensitised, with a risk ratio of 29 and 95% confidence interval of 1.9-455. During OIT, IgE to peanut, Ara h 1, 2 and 3 decreased and IgG4 increased. Consuming peanuts had no harmful effects on BHR or FeNO. The annual incidence rate of emergency visits during the follow-up period was 11% or 3.0 per 10 000 patient-days. CONCLUSION Peanut OIT was efficacious in severe allergies without negative effects on airway inflammation, but unpredictable long-term reactions might occur.
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Affiliation(s)
- Anna Kaarina Kukkonen
- The Skin and Allergy Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Riikka Uotila
- The Skin and Allergy Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Leo Pekka Malmberg
- The Skin and Allergy Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Anna Susanna Pelkonen
- The Skin and Allergy Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Mika Juhani Mäkelä
- The Skin and Allergy Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
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Breastfeeding and IL-10 levels in children affected by cow’s milk protein allergy: A restrospective study. Immunobiology 2017; 222:358-362. [PMID: 27622938 DOI: 10.1016/j.imbio.2016.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 08/30/2016] [Accepted: 09/07/2016] [Indexed: 12/30/2022]
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