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Ünal D, Eyice-Karabacak D, Kutlu A, Demir S, Tüzer C, Arslan AF, Işık SR, Gelincik A. Oral immunotherapy in alpha-gal red meat allergy: Could specific IgE be a potential biomarker in monitoring management? Allergy 2023; 78:3241-3251. [PMID: 37545316 DOI: 10.1111/all.15840] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 06/21/2023] [Accepted: 07/05/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Oral immunotherapy (OIT) is a promising treatment for food allergies. Our aim was to establish the long-term safety and efficacy of a novel red meat (RM) OIT in galactose-alpha-1,3-galactose (alpha-gal) allergy in adults. METHODS Out of 20 patients with confirmed RM allergy, five (41.66%) underwent an early OIT, seven (58.33%) underwent a delayed protocol and eight patients who were not desensitized formed the patient control group. 15 and 27 day RM OIT for early-onset and delayed-onset alpha-gal allergy were administered, respectively. Desensitized patients were recommended to continue eating at least 100 g RM every day for 6 months and every other day in the following 6 months. After a year, the consumption was recommended 2/3 times in a week. Patients were followed up with skin tests with commercial beef and lamb extracts, fresh raw/cooked beef and lamb and cetuximab and also with serum alpha-gal specific Immunoglobulin-E (sIgE) in the first and fifth years. RESULTS All patients who underwent OIT became tolerant to RM. During the 5 year follow-up, the median alpha-gal sIgE concentration gradually decreased in nine patients who consumed RM uneventfully while remained unchanged in the control group (p = .016). In two patients, rare tick bites acted as inducers of hypersensitivity reactions with concomitant elevation of alpha-gal sIgE concentrations whereas one patient with low follow-up alpha-gal sIgE concentrations consumed RM uneventfully after frequent tick bites. CONCLUSIONS Our study showed the long-term safety and efficacy of alpha-gal OIT. Additionally, alpha-gal sIgE seems to be a potential biomarker to monitor OIT.
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Affiliation(s)
- D Ünal
- Division of Immunology and Allergy Diseases, Internal Medicine Department, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - D Eyice-Karabacak
- Division of Immunology and Allergy Diseases, Internal Medicine Department, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - A Kutlu
- Medical Park Hospital Ordu, Ordu, Turkey
| | - S Demir
- Division of Immunology and Allergy Diseases, Internal Medicine Department, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - C Tüzer
- Division of Immunology and Allergy Diseases, Internal Medicine Department, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - A F Arslan
- Division of Immunology and Allergy Diseases, Internal Medicine Department, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - S R Işık
- Division of Immunology and Allergy Diseases, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - A Gelincik
- Division of Immunology and Allergy Diseases, Internal Medicine Department, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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2
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Bird JA, Nilsson C, Brown K, Pham T, Tilles S, du Toit G, Assa’ad A. Long-term safety and immunologic outcomes of daily oral immunotherapy for peanut allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100120. [PMID: 37779517 PMCID: PMC10509957 DOI: 10.1016/j.jacig.2023.100120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/13/2023] [Accepted: 03/21/2023] [Indexed: 10/03/2023]
Abstract
Background Oral immunotherapy containing peanut (Arachis hypogaea) allergen powder-dnfp (PTAH) (Palforzia [Aimmune Therapeutics, Brisbane, Calif]) for 9 to 12 months resulted in higher tolerated amounts of peanut protein in PTAH-treated individuals aged 4 to 17 years with peanut allergy than in placebo-treated participants. Objective We aimed to describe additional long-term pooled safety data and changes in peanut sensitization markers from baseline through approximately 5 years of treatment. Methods The results from 6 clinical trials of PTAH (3 controlled and 3 open-label extension studies [N = 1227]) were pooled, and analysis of safety outcomes and immunologic data was performed. The PTAH doses were administered sequentially as follows: initial dose escalation (dose increased to 6 mg over 2 days), updosing (dose increased every 2 weeks to 300 mg for a minimum of 6 months), and maintenance dosing (300 mg per day). Results There was a trend toward decreased adverse events (AEs) at years 1 and 2 that was maintained up to 5 years, with 94% of patients experiencing mild or moderate AEs and only 13% discontinuing PTAH use because of AEs overall. Gastrointestinal symptoms were the most commonly reported treatment-related AEs. A downward trend in systemic allergic reactions was also reported. PTAH treatment resulted in reduced levels of peanut-specific IgE after the first year and increased levels of peanut-specific IgG4, with a lowered peanut-specific IgE:IgG4 ratio. A reduction in median peanut skin prick test wheal diameter was observed (11.50 mm at baseline vs 5.75 mm at year 5). Conclusion Long-term immunomodulation without any new safety signals was reported with PTAH immunotherapy in the largest safety data set and longest treatment duration for oral immunotherapy published to date.
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Affiliation(s)
- J. Andrew Bird
- Department of Pediatrics, University of Texas Southwestern, Dallas, Tex
| | - Caroline Nilsson
- Clinical Research and Education, Karolinska Institutet, Sachs’ Children and Youth Hospital, Stockholm, Sweden
| | | | | | | | - George du Toit
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Amal Assa’ad
- Division of Allergy and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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3
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Coppola S, Carucci L, De Michele R, Berni Canani R. The potential role of preventive and therapeutic immunonutrition strategies for pediatric food allergy: A mini-review. Front Nutr 2022; 9:1050554. [DOI: 10.3389/fnut.2022.1050554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/01/2022] [Indexed: 12/05/2022] Open
Abstract
Food allergy (FA) represents one of the main chronic conditions of the pediatric population. The gut microbiome (GM)-immune system axis is a milestone in affecting FA susceptibility. The dynamic and bidirectional crosstalk between the GM and immune system starts early in life, and it is deeply modulated during the first 1,000 days of life. Nutritional factors during this crucial period mainly influence the proper GM-immune system development and function across the lifespan, with potential beneficial or detrimental effects on health status. Immunonutrition strategies, applied from conception, could represent an innovative target for prevention and treatment of pediatric FA. Here we described the potential role of preventive and therapeutic immunonutrition strategies for pediatric FA, highlighting putative future perspectives in this field.
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Arasi S, Cafarotti A, Fiocchi A. Cow's milk allergy. Curr Opin Allergy Clin Immunol 2022; 22:181-187. [PMID: 35266897 DOI: 10.1097/aci.0000000000000823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW To highlight the most recent insights on cow's milk allergy (CMA), its treatment, and management. RECENT FINDINGS CMA is one of the most common food allergies among children. Burdened by the risk for fatal reaction, CMA may imply also a severe impairment of health-related quality of life at individual and family level as well as well as individual and societal costs. The updated Diagnosis and Rationale for Action against Cow's Milk Allergy series is going to provide a series of manuscripts that will offer a comprehensive state-of-the-art specifically on CMA, including international evidence-based recommendations. The current results from randomized clinical trials highlight that oral immunotherapy may be effective by itself in providing desensitization. Preliminary data suggest that biologicals such as omalizumab may be able to increase the threshold of reactivity to milk or several foods (if multiple food allergies) without requiring allergen exposure. Breastfeeding is the first choice for infants with CMA. Extensively hydrolyzed formula and amino-acid formula are valid alternatives and may be particularly helpful when eliminating multiple foods, with severe complex gastrointestinal food allergies, eosinophilic esophagitis, severe eczema, or symptoms while exclusively breastfeeding. Heed is needed to ensure the formula is nutritionally sufficient. Due to a high degree of cross-reactivity with cow's milk proteins and risk for allergic reactions, goats' milk or other mammals' milk should not be used. SUMMARY The adoption and implementation of evidence-based recommendations may guide a proper diagnostics and management and awaited advances in knowledge will allow the development of a personalized treatment tailored on the specific CMA patient's profile.
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Affiliation(s)
- Stefania Arasi
- Translational Research in Pediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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5
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World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines update – I – Plan and definitions. World Allergy Organ J 2022; 15:100609. [PMID: 35145603 PMCID: PMC8818560 DOI: 10.1016/j.waojou.2021.100609] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/08/2021] [Accepted: 11/04/2021] [Indexed: 12/12/2022] Open
Abstract
Since the World Allergy Organization (WAO) Diagnosis and Rationale against Cow's Milk Allergy (DRACMA) Guidelines were published 10 years ago, new evidence has accumulated about the diagnosis, therapy, and specific immunotherapy for cow's milk allergy (CMA). For this reason, WAO has felt the need to update the guidelines. We introduce here this update. The new DRACMA guidelines aim to comprehensively address the guidance on diagnosis and therapy of both IgE non-IgE-mediated forms of cow's milk allergy in children and adults. They will be divided into 18 chapters, each of which will be dedicated to an aspect. The focus will be on the meta-analyzes and recommendations that will be expressed for the 3 most relevant clinical aspects: (a) the diagnostic identification of the condition; (b) the choice of the replacement formula in case of CMA in infancy when the mother is not able to breastfeed, and (c) the use of specific immunotherapy for cow's milk protein allergy.
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6
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Brown KR, Baker J, Vereda A, Beyer K, Burks AW, du Toit G, O'B Hourihane J, Jones SM, Norval D, Dana A, Shreffler W, Vickery BP, Casale T, Skeel B, Adelman D. Safety of Peanut (Arachis hypogaea) Allergen Powder-dnfp in Children and Teenagers With Peanut Allergy: A Pooled Summary of Phase 3 and Extension Trials. J Allergy Clin Immunol 2021; 149:2043-2052.e9. [PMID: 34971646 DOI: 10.1016/j.jaci.2021.12.780] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 12/09/2021] [Accepted: 12/20/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Peanut (Arachis hypogaea) allergen powder-dnfp (PTAH; previously known as AR101) is a daily oral immunotherapy approved to mitigate allergic reactions following accidental peanut exposure in peanut-allergic individuals aged 4-17 years. OBJECTIVE To comprehensively summarize the PTAH safety profile for up to ∼2 years of treatment. METHODS Safety and adverse event (AE) data from participants aged 4-17 years from three controlled, phase 3 and two open-label extension trials were pooled and assessed. RESULTS Of the 944 individuals receiving ≥1 PTAH dose, median exposure was ∼49 weeks; most participants experienced ≥1 treatment-related AE (TRAE; n=853; 90.4%). A total of 829 participants experienced TRAEs with a maximum severity of mild (n=497; 52.6%) or moderate (n=332; 35.2%); 24 participants (2.5%) experienced TRAEs graded as severe. Overall, 80 (9.5%) participants discontinued due to AEs; most experienced gastrointestinal symptoms and discontinued during the first 6 months. When adjusted for exposure, AEs and TRAEs occurred at a rate of 76.4 and 58.7 events/participant-year of exposure (PYE), respectively, during updosing; AEs and TRAEs decreased to 23.0 and 14.2, respectively, during 300-mg maintenance. Overall, exposure-adjusted rates of systemic allergic reactions were 0.12 events/PYE (mild), 0.11 events/PYE (moderate), and 0.01 events/PYE (severe [anaphylaxis]). CONCLUSION The safety profile of PTAH was consistent across trials, manageable, and improved over time. AEs were predominantly mild to moderate and all grades declined in frequency with continued treatment. These data can be used to facilitate shared decision-making discussions with patients and families considering treatment with PTAH. CLINICAL IMPLICATIONS During treatment with PTAH, the majority of children and teenagers experienced allergic symptoms that decreased in frequency and severity over time. These symptoms were consistent across PTAH trials, comparable with other allergen immunotherapies, and are familiar to allergists who practice allergen immunotherapy.
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Affiliation(s)
- Kari R Brown
- Aimmune Therapeutics, a Nestlé Health Science company, Brisbane, CA, USA.
| | - James Baker
- Mary H Weiser Food Allergy Center, University of Michigan, Ann Arbor, MI, USA
| | - Andrea Vereda
- Aimmune Therapeutics, a Nestlé Health Science company, London, United Kingdom
| | | | - A Wesley Burks
- Department of Pediatrics, University of North Carolina Food Allergy Initiative, Division of Allergy, Immunology and Rheumatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - George du Toit
- Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Stacie M Jones
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - David Norval
- Aimmune Therapeutics, a Nestlé Health Science company, London, United Kingdom
| | - Adrian Dana
- Aimmune Therapeutics, a Nestlé Health Science company, Brisbane, CA, USA
| | | | | | | | - Ben Skeel
- Aimmune Therapeutics, a Nestlé Health Science company, London, United Kingdom
| | - Daniel Adelman
- Aimmune Therapeutics, a Nestlé Health Science company, Brisbane, CA, USA; Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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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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8
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Cow's Milk Protein Allergy as a Model of Food Allergies. Nutrients 2021; 13:nu13051525. [PMID: 33946553 PMCID: PMC8147250 DOI: 10.3390/nu13051525] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/18/2021] [Accepted: 04/26/2021] [Indexed: 01/14/2023] Open
Abstract
Cow's milk allergy (CMA) is one of the most common food allergies in infants, and its prevalence has increased over recent years. In the present paper, we focus on CMA as a model of food allergies in children. Understanding the diagnostic features of CMA is essential in order to manage patients with this disorder, guide the use of an elimination diet, and find the best moment to start an oral food challenge (OFC) and liberalize the diet. To date, no shared tolerance markers for the diagnosis of food allergy have been identified, and OFC remains the gold standard. Recently, oral immunotherapy (OIT) has emerged as a new therapeutic strategy and has changed the natural history of CMA. Before this, patients had to strictly avoid the food allergen, resulting in a decline in quality of life and subsequent nutritional, social, and psychological impairments. Thanks to the introduction of OIT, the passive approach involving rigid exclusion has changed to a proactive one. Both the heterogeneity in the diagnostic process among the studies and the variability of OIT data limit the comprehension of the real epidemiology of CMA, and, consequentially, its natural history. Therefore, well-planned randomized controlled trials are needed to standardize CMA diagnosis, prevention, and treatment strategies.
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9
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Nagakura KI, Sato S, Miura Y, Nishino M, Takahashi K, Asaumi T, Ogura K, Ebisawa M, Yanagida N. A randomized trial of oral immunotherapy for pediatric cow's milk-induced anaphylaxis: Heated vs unheated milk. Pediatr Allergy Immunol 2021; 32:161-169. [PMID: 32869399 PMCID: PMC7821001 DOI: 10.1111/pai.13352] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/25/2020] [Accepted: 08/14/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Severe reactions may develop during cow's milk (CM) oral immunotherapy (OIT). We investigated the safety and efficacy of low-dose OIT with heated milk (HM) or unheated milk (UM) in children with anaphylaxis. METHODS Children with symptom onset after ingestion of 3-mL HM on a double-blind, placebo-controlled food challenge were randomly assigned to the HM (n = 17) or UM (n = 16) group. HM group ingested milk powder heated at 125°C for 30 seconds, whereas the UM group used UM. Patients were hospitalized for 5 days; the HM or UM was gradually increased to 3 mL/day; 3-mL/day ingestion was continued at home. One year later, the patients underwent 2-day consecutive 3- and 25-mL HM-oral food challenges (OFCs) after 2-week avoidance. RESULTS At baseline, milk- and casein-specific immunoglobulin E (IgE) levels were 56.0 and 51.4 kUA/L in the HM group, and 55.2 and 65.6 kUA/L in the UM group, respectively. One year later, 35% and 18% in the HM group and 50% and 31% in UM group passed the 3 and 25 mL OFCs, respectively. Rates of moderate or severe symptoms and respiratory symptoms per home dose were significantly lower in the HM than in the UM group (0.7% and 1.2% vs 1.4% and 2.6%, respectively, P < .001). β-lactoglobulin-specific IgG4 levels significantly increased from baseline only in the UM group, whereas casein-specific IgG4 levels significantly increased from baseline in both groups. CONCLUSIONS HM-OIT induced immunological changes more safely than the UM-OIT. The possibility of lower treatment efficacy with HM-OIT needs to be evaluated in larger studies.
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Affiliation(s)
- Ken-Ichi Nagakura
- Department of Pediatrics, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan.,Department of Pediatrics, Jikei University School of Medicine, Tokyo, Japan
| | - Sakura Sato
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yoko Miura
- Department of Pediatrics, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | - Makoto Nishino
- Department of Pediatrics, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Kyohei Takahashi
- Department of Pediatrics, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tomoyuki Asaumi
- Department of Pediatrics, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | - Kiyotake Ogura
- Department of Pediatrics, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Motohiro Ebisawa
- Department of Pediatrics, Jikei University School of Medicine, Tokyo, Japan.,Department of Allergy, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | - Noriyuki Yanagida
- Department of Pediatrics, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
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Vickery BP, Vereda A, Nilsson C, du Toit G, Shreffler WG, Burks AW, Jones SM, Fernández-Rivas M, Blümchen K, O'B Hourihane J, Beyer K, Anagnostou A, Assa'ad AH, Ben-Shoshan M, Bird JA, Carr TF, Carr WW, Casale TB, Chong HJ, Ciaccio CE, Dorsey MJ, Fineman SM, Fritz SB, Greiner AN, Greos LS, Hampel FC, Ibáñez MD, Jeong DK, Johnston DT, Kachru R, Kim EH, Lanser BJ, Leonard SA, Maier MC, Mansfield LE, Muraro A, Ohayon JA, Oude Elberink JNG, Petroni DH, Pongracic JA, Portnoy JM, Rachid R, Rupp NT, Sanders GM, Sharma HP, Sharma V, Sher ER, Sher L, Sindher SB, Siri D, Spergel JM, Sprikkelman AB, Sussman GL, Tsoumani M, Varshney P, Vitalpur G, Wang J, Yang WH, Zubeldia JM, Smith A, Ryan R, Adelman DC. Continuous and Daily Oral Immunotherapy for Peanut Allergy: Results from a 2-Year Open-Label Follow-On Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1879-1889.e13. [PMID: 33359589 DOI: 10.1016/j.jaip.2020.12.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/24/2020] [Accepted: 12/10/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The randomized, controlled PALISADE trial demonstrated the benefit of daily oral immunotherapy with Peanut (Arachis Hypogaea) allergen powder-dnfp (PTAH, formerly AR101) in peanut-allergic children and adolescents. OBJECTIVE ARC004, the open-label follow-on study to PALISADE, used 5 dosing cohorts to explore PTAH treatment beyond 1 year and alternative dosing regimens in peanut-allergic individuals. METHODS Active arm (PTAH-continuing) PALISADE participants who tolerated 300-mg peanut protein at the exit double-blind placebo-controlled food challenge and placebo arm (PTAH-naive) participants could enter ARC004. PTAH-continuing participants were assigned to receive daily (cohorts 1 and 3A) or non-daily (cohorts 2, 3B, and 3C) dosing regimens; PTAH-naive participants were built up to 300 mg/d PTAH, followed by maintenance dosing. At study completion, participants underwent an exit double-blind placebo-controlled food challenge with doses up to 2000 mg peanut protein. Data were assessed using descriptive statistics. RESULTS Overall, 358 (87.5%) eligible participants (4-17 years) entered ARC004 (PTAH-continuing, n = 256; PTAH-naive, n = 102). Among PTAH-continuing participants, exposure-adjusted adverse event rates were 12.94 to 17.54/participant-year and 25.95 to 42.49/participant-year in daily and non-daily dosing cohorts, respectively; most participants (83%) experienced mild or moderate adverse events. Daily dosing cohorts appeared to have higher desensitization rates than non-daily dosing cohorts. Of all PTAH-continuing cohorts, cohort 3A had the longest daily dosing duration and the highest desensitization rates. Changes in immune markers with PTAH continuation demonstrated ongoing immunomodulation. Outcomes in PTAH-naive participants mirrored those of the PALISADE active arm. CONCLUSIONS Continued daily PTAH treatment beyond 1 year showed sustained safety and efficacy. Ongoing immunomodulation was observed during the second year of treatment.
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Affiliation(s)
| | | | - Caroline Nilsson
- Clinical Science and Education, Karolinska Institutet, Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - George du Toit
- Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - A Wesley Burks
- Department of Pediatrics, University of North Carolina Food Allergy Initiative, Division of Allergy and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stacie M Jones
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | | | - Katharina Blümchen
- Adolescent Medicine, Division of Allergology, Pneumology and Cystic Fibrosis, Goethe University Frankfurt, Frankfurt, Germany
| | - Jonathan O'B Hourihane
- Paediatrics and Child Health, Royal College of Surgeons in Ireland, Dublin, Ireland; Infant Centre and Pediatrics and Child Health, University College Cork, HRB Clinical Research Facility-Cork, Cork, Ireland
| | - Kirsten Beyer
- Department of Pediatrics, Division of Pulmonology, Immunology and Critical Care Medicine, Charité Universtãtsmedizin Berlin, Berlin, Germany
| | | | - Amal H Assa'ad
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Moshe Ben-Shoshan
- McGill University Health Centre - Montreal Children's Hospital, Montreal, Quebec, Canada
| | | | - Tara F Carr
- Banner University of Arizona Medical Center, Tucson, Ariz 647
| | - Warner W Carr
- Allergy & Asthma Associates of Southern California dba Southern California Research, Mission Viejo, Calif
| | - Thomas B Casale
- University of South Florida, Asthma, Allergy & Immunology Clinical Research Unit, Tampa, Fla
| | - Hey Jin Chong
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pa
| | | | - Morna J Dorsey
- University of California, San Francisco, San Francisco, Calif
| | | | | | | | - Leon S Greos
- Colorado Allergy and Asthma Centers, PC, Denver, Colo
| | | | - Maria Dolores Ibáñez
- Hospital Clínico San Carlos, Hospital Universitario Niño Jesús, Alergology Department, Madrid, Spain
| | | | | | - Rita Kachru
- UCLA Medical Center, Santa Monica, Santa Monica, Calif
| | - Edwin H Kim
- University of North Carolina at Chapel Hill CTRC, Chapel Hill, NC
| | | | | | - Mary C Maier
- Baker Allergy, Asthma and Dermatology Research Center, LLC, Portland, Ore
| | | | - Antonella Muraro
- Azienda Ospedaliera di Padova e UOSD Allergie Alimentari, Padova, Italy
| | | | - Joanna N G Oude Elberink
- University Medical Center Groningen, Department of Internal Medicine, Division of Allergology, Groningen, Netherlands
| | | | | | | | | | - Ned T Rupp
- National Allergy and Asthma Research, LLC, N. Charleston, SC
| | | | | | - Vibha Sharma
- Central Manchester University Hospitals NHS Foundation Trust, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | | | - Lawrence Sher
- Peninsula Research Associates, Inc., Rolling Hills Estates, Calif
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research, LPCH at El Camino Hospital, Mountain View, Calif
| | - Dareen Siri
- Sneeze, Wheeze, & Itch Associates, LLC, Normal, Ill
| | | | - Aline B Sprikkelman
- University Medical Center Groningen, Beatrix Children's Hospital, Department of Pediatric Pulmonology & Allergology, Groningen, Netherlands
| | - Gordon L Sussman
- Gordon Sussman Clinical Research, Inc., Toronto, Ontario, Canada
| | - Marina Tsoumani
- Manchester University NHS Foundation Trust eWythenshawe Hospital, Manchester, United Kingdom
| | - Pooja Varshney
- Specially for Children Allergy, Asthma, and Immunology Clinic, Austin, Texas
| | - Girish Vitalpur
- Indiana University North Hospital, Riley Children's Specialists, Carmel, Ind
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, Clinical Research Unit, New York, NY
| | - William H Yang
- Ottawa Allergy Research Corporation, Ottawa, Ontario, Canada
| | - José Manuel Zubeldia
- Hospital General Universitario Gregorio Marañón, Alergology Department, Madrid, Spain
| | | | - Robert Ryan
- Aimmune Therapeutics, London, United Kingdom
| | - Daniel C Adelman
- Aimmune Therapeutics, Brisbane, Calif; Department of Medicine, University of California San Francisco, San Francisco, Calif.
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Ogura K, Yanagida N, Sato S, Imai T, Ito K, Kando N, Ikeda M, Shibata R, Murakami Y, Fujisawa T, Nagao M, Kawamoto N, Kondo N, Urisu A, Tsuge I, Kondo Y, Sugai K, Uchida O, Urashima M, Taniguchi M, Ebisawa M. Evaluation of oral immunotherapy efficacy and safety by maintenance dose dependency: A multicenter randomized study. World Allergy Organ J 2020; 13:100463. [PMID: 33024480 PMCID: PMC7527748 DOI: 10.1016/j.waojou.2020.100463] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 12/03/2022] Open
Abstract
Background Generally, oral immunotherapy (OIT) aims for daily administration. Recently, the efficacy of treatment with OIT at a low dose has been reported. However, the optimal dose and the evaluation of dose-dependent OIT outcome have not been described. Methods A multicenter, parallel, open-labeled, prospective, non-placebo controlled, randomized study enrolled 101 Japanese patients for treatment with OIT. We hypothesized that target dose OIT would induce short-term unresponsiveness (StU) earlier than reduced dose OIT. StU was defined as no response to 6200 mg whole egg, 3400 mg milk, and 2600 mg wheat protein, as evaluated by oral food challenge after 2-week ingestion cessation. To compare the two doses of OIT efficacy, the maximum ingestion doses during the maintenance phase of OIT were divided into 100%-dose or 25%-dose groups against their target StU dose, respectively. A total of 51 patients were assigned to the 100%-dose group [hen's egg (HE) = 26, cow's milk (CM) = 13, wheat = 12] and 50 to the 25%-dose group (HE = 25, CM = 13, wheat = 12). Primary outcome was established by comparing StU at 1 year. Secondary outcome was StU at 2 years and established by comparing allergic symptoms and immunological changes. Results The year 1 StU rates (%) for the 100%- and 25%-dose groups were 26.9 vs. 20.0 (HE), 7.7 vs. 15.4 (CM), and 50.0 vs. 16.7 (wheat), respectively. The year 2 StU rates were 30.8 vs. 36.0 (HE), 7.7 vs. 23.1 (CM), and 58.3 vs. 58.3 (wheat), respectively. There were no statistically significant differences in StU between years 1 and 2. The total allergic symptom rate in the 25%-dose group was lower than that in the 100%-dose group for egg, milk, and wheat. Antigen-specific IgE levels for egg-white, milk, and wheat decreased at 12 months. Conclusions Reduced maintenance dose of egg OIT showed similar therapeutic efficacy to the target dose. However, we were not able to clearly demonstrate the efficacy, particularly for milk and wheat. Reducing the maintenance dose for eggs, milk, and wheat may effectively lower the symptoms associated with their consumption compared to the target OIT dose. Furthermore, aggressive reduction of the maintenance dose might be important for milk and wheat, compared to the 25%-dose OIT. Trial registration UMIN000009373, Multicenter Oral Immunotherapy for Hen's Egg, Cow's Milk, and Wheat-Allergic Children at Outpatient Clinic.
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Key Words
- CM, cow’s milk
- Desensitization
- Dose-response relationship
- EPIT, epicutaneous immunotherapy
- FA, food allergy
- Food hypersensitivity
- HE, hens’ egg
- Immunotherapy
- OFC, oral food challenge
- OIT, oral immunotherapy
- SLIT, sublingual immunotherapy
- SU, sustained unresponsiveness
- StU, short-term unresponsiveness
- sIgE, specific immunoglobulin E
- sIgG, specific immunoglobulin G
- sIgG4, specific immunoglobulin G4
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Affiliation(s)
- Kiyotake Ogura
- Department of Pediatrics, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan.,Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Noriyuki Yanagida
- Department of Pediatrics, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
| | - Sakura Sato
- Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Department of Allergy, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
| | - Takanori Imai
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Komei Ito
- Department of Allergy, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Naoyuki Kando
- Department of Allergy, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Masanori Ikeda
- Department of Pediatrics, National Hospital Organization, Fukuyama Medical Center, Hiroshima, Japan.,Department of Pediatric Acute Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Rumiko Shibata
- Department of Pediatrics, National Hospital Organization, Fukuoka National Hospital, Fukuoka, Japan
| | - Yoko Murakami
- Department of Pediatrics, National Hospital Organization, Fukuoka National Hospital, Fukuoka, Japan
| | - Takao Fujisawa
- Institute for Clinical Research, National Hospital Organization, Mie National Hospital, Mie, Japan
| | - Mizuho Nagao
- Institute for Clinical Research, National Hospital Organization, Mie National Hospital, Mie, Japan
| | - Norio Kawamoto
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Naomi Kondo
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Atsuo Urisu
- Department of Pediatrics, Fujita Health University, The Second Teaching Hospital, Aichi, Japan
| | - Ikuya Tsuge
- Department of Pediatrics, Fujita Health University, The Second Teaching Hospital, Aichi, Japan
| | - Yasuto Kondo
- Department of Pediatrics, Fujita Health University, The Second Teaching Hospital, Aichi, Japan
| | - Kazuko Sugai
- Department of Pediatrics, National Hospital Organization, Yokohama Medical Center, Kanagawa, Japan
| | - Osamu Uchida
- Department of Pediatrics, National Hospital Organization, Yokohama Medical Center, Kanagawa, Japan
| | - Mitsuyoshi Urashima
- Division of Molecular Epidemiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Masami Taniguchi
- Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Department of Allergy, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
| | - Motohiro Ebisawa
- Course of Allergy and Clinical Immunology, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Department of Allergy, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
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12
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Bégin P, Chan ES, Kim H, Wagner M, Cellier MS, Favron-Godbout C, Abrams EM, Ben-Shoshan M, Cameron SB, Carr S, Fischer D, Haynes A, Kapur S, Primeau MN, Upton J, Vander Leek TK, Goetghebeur MM. CSACI guidelines for the ethical, evidence-based and patient-oriented clinical practice of oral immunotherapy in IgE-mediated food allergy. Allergy Asthma Clin Immunol 2020; 16:20. [PMID: 32206067 PMCID: PMC7079444 DOI: 10.1186/s13223-020-0413-7] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/14/2020] [Indexed: 12/17/2022] Open
Abstract
Background Oral immunotherapy (OIT) is an emerging approach to the treatment of patients with IgE-mediated food allergy and is in the process of transitioning to clinical practice. Objective To develop patient-oriented clinical practice guidelines on oral immunotherapy based on evidence and ethical imperatives for the provision of safe and efficient food allergy management. Materials and methods Recommendations were developed using a reflective patient-centered multicriteria approach including 22 criteria organized in five dimensions (clinical, populational, economic, organizational and sociopolitical). Data was obtained from: (1) a review of scientific and ethic literature; (2) consultations of allergists, other healthcare professionals (pediatricians, family physicians, nurses, registered dieticians, psychologists, peer supporters), patients and caregivers; and patient associations through structured consultative panels, interviews and on-line questionnaire; and (3) organizational and economic data from the milieu of care. All data was synthesized by criteria in a multicriteria deliberative guide that served as a platform for structured discussion and development of recommendations for each dimension, based on evidence, ethical imperatives and other considerations. Results The deliberative grid included 162 articles from the literature and media reviews and data from consultations involving 85 individuals. Thirty-eight (38) recommendations were made for the practice of oral immunotherapy for the treatment of IgE mediated food allergy, based on evidence and a diversity of ethical imperatives. All recommendations were aimed at fostering a context conducive to achieving objectives identified by patients and caregivers with food allergy. Notably, specific recommendations were developed to promote a culture of shared responsibility between patients and healthcare system, equity in access, patient empowerment, shared decision making and personalization of OIT protocols to reflect patients' needs. It also provides recommendations to optimize organization of care to generate capacity to meet demand according to patient choice, e.g. OIT or avoidance. These recommendations were made acknowledging the necessity of ensuring sustainability of the clinical offer in light of various economic considerations. Conclusions This innovative CPG methodology was guided by patients' perspectives, clinical evidence as well as ethical and other rationales. This allowed for the creation of a broad set of recommendations that chart optimal clinical practice and define the conditions required to bring about changes to food allergy care that will be sustainable, equitable and conducive to the well-being of all patients in need.
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Affiliation(s)
- P Bégin
- 1Division of Clinical Immunology, Rheumatology and Allergy, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC Canada.,2Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC Canada.,3Research Center of the Sainte-Justine University Hospital Center, Montreal, QC Canada
| | - E S Chan
- 4Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC Canada
| | - H Kim
- 5Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON Canada.,6Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON Canada
| | - M Wagner
- 7Unit Methods, Ethics and Participation, INESSS, National Institute for Excellence in Health and Social Services, Montreal, QC Canada
| | - M S Cellier
- 3Research Center of the Sainte-Justine University Hospital Center, Montreal, QC Canada
| | - C Favron-Godbout
- 8Department of Bioethics, School of Public Health of the University of Montreal, Montreal, Canada
| | - E M Abrams
- 9Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, MB Canada
| | - M Ben-Shoshan
- 10Division of Allergy Immunology and Dermatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, QC Canada
| | - S B Cameron
- 4Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC Canada.,Community Allergy Clinic, Victoria, BC Canada
| | - S Carr
- 12Department of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - D Fischer
- 5Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON Canada
| | - A Haynes
- 13Discipline of Pediatrics, Memorial University of Newfoundland, St. John's, NL Canada
| | - S Kapur
- 14Department of Pediatrics, Dalhousie University, Halifax, NS Canada
| | - M N Primeau
- 15Division of Allergy and Clinical Immunology, Department of Medicine, CISSS Laval, Laval, QC Canada
| | - J Upton
- 16Division of Immunology and Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - T K Vander Leek
- 12Department of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - M M Goetghebeur
- 7Unit Methods, Ethics and Participation, INESSS, National Institute for Excellence in Health and Social Services, Montreal, QC Canada
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13
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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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14
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Chiera F, Viola I, Spinuzza A, Caminiti L, Crisafulli G, Panasiti I, Battista Pajno G. Allergen-Specific Immunotherapy for Immunoglobulin E-Mediated Food Allergy. EUROPEAN MEDICAL JOURNAL 2019. [DOI: 10.33590/emj/10310420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Food allergy is a potentially life-threatening condition and a significant public health concern worldwide. The current management includes food avoidance and use of emergency medications. The growing prevalence of food allergy drives research towards specific allergen immunotherapy (AIT), which represents a potential disease-modifying approach. AIT consists of the progressive administration of amounts of the offending allergen in order to induce food desensitisation, creating an increase in reaction threshold with regular exposure to the allergen. AIT can be performed through oral, sublingual, epicutaneous, and subcutaneous routes. The target is to achieve post desensitisation effectiveness: a long-lasting condition allowing patients to introduce food without reactions, even after a period of discontinuation of the offending food.
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Affiliation(s)
- Fernanda Chiera
- Department of Pediatrics, Ospedale San Giovanni di Dio, Crotone, Italy
| | - Irene Viola
- Department of Pediatrics, Allergy Unit, University of Messina, Messina, Italy
| | - Antonietta Spinuzza
- Department of Pediatrics, Allergy Unit, University of Messina, Messina, Italy
| | - Lucia Caminiti
- Department of Pediatrics, Allergy Unit, University of Messina, Messina, Italy
| | - Giuseppe Crisafulli
- Department of Pediatrics, Allergy Unit, University of Messina, Messina, Italy
| | - Ilenia Panasiti
- Department of Pediatrics, Allergy Unit, University of Messina, Messina, Italy
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15
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Pajno GB, Castagnoli R, Muraro A, Alvaro-Lozano M, Akdis CA, Akdis M, Arasi S. Allergen immunotherapy for IgE-mediated food allergy: There is a measure in everything to a proper proportion of therapy. Pediatr Allergy Immunol 2019; 30:415-422. [PMID: 30770574 DOI: 10.1111/pai.13042] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/29/2019] [Accepted: 01/31/2019] [Indexed: 12/30/2022]
Abstract
IgE-mediated food allergy (FA) is a potentially life-threatening condition with a negative impact on quality of life and an increasing prevalence in westernized countries in the recent two decades. A strict avoidance of the triggering food(s) represents the current standard approach. However, an elimination diet may be difficult and frustrating, in particular for common foods, (eg, milk, egg, and peanut). Food allergy immunotherapy (FA-AIT) may provide an active treatment that enables to increase the amount of food that the patient can intake without reaction during treatment (ie, desensitization), and reduces the risk of potential life-threatening allergic reaction in the event of accidental ingestion. However, several gaps need still to be filled. A memorable Latin orator stated: "Est modus in rebus" (Horace, Sermones I, 1, 106-07). This sentence remembers that there is a measure in everything to a proper proportion of therapy. The common sense of measure should find application in each stage of treatment. A personalized approaching should consider the specific willing and features of each patient. Efforts are devoted to improve the efficacy, the safety but also the quality of life of patients suffering from FA. In the near future, it will be important to clarify immunologic pathways of FA-AIT, and to identify reliable biomarkers in order to recognize the most suitable candidates to FA-AIT and algorithms for treatments tailored on well-characterized subpopulations of patients.
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Affiliation(s)
| | - Riccardo Castagnoli
- Pediatric Clinic, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Antonella Muraro
- Department of Women and Child Health, Food Allergy Referral Centre Veneto Region, Padua General University Hospital, Padua, Italy
| | - Montserrat Alvaro-Lozano
- Paediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Cezmi A Akdis
- Swiss Institute for Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland.,Christine Kühne-Center for Allergy Research and Education, Davos, Switzerland
| | - Műbeccel Akdis
- Swiss Institute for Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Stefania Arasi
- Department of Pediatric Medicine, Pediatric Allergology Unit, Bambino Gesù Children's research Hospital (IRCCS), Rome, Italy
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16
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17
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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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18
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Ramesh M, Karagic M. New modalities of allergen immunotherapy. Hum Vaccin Immunother 2018; 14:2848-2863. [PMID: 30183485 PMCID: PMC6343630 DOI: 10.1080/21645515.2018.1502126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 06/27/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022] Open
Abstract
Allergen immunotherapy is a rapidly evolving field. Although subcutaneous immunotherapy has been practiced for over a hundred years, improved understanding of the underlying immunological mechanisms has led to the development of new, efficacious and better tolerated allergen-derivatives, adjuvants and encapsulated allergens. Diverse routes of allergen immunotherapy - oral, sublingual, epicutanoeus and intralymphatic - are enabling immunotherapy for anaphylactic food allergies and pollen-food allergy syndrome, while improving the tolerability and effectiveness of aeroallergen immunotherapy. The addition of Anti-IgE therapy decreases adverse effects of subcutaneous and oral immunotherapy.
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19
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Dahdah L, Fierro V, Mennini M, Arasi S, Fiocchi A. What’s next for DRACMA? Expert Rev Clin Immunol 2018; 14:649-651. [DOI: 10.1080/1744666x.2018.1500900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Lamia Dahdah
- Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Vatican City
| | - Vincenzo Fierro
- Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Vatican City
| | - Maurizio Mennini
- Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Vatican City
| | - Stefania Arasi
- Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Vatican City
| | - Alessandro Fiocchi
- Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Vatican City
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20
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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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21
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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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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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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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Hamad A, Burks WA. Emerging Approaches to Food Desensitization in Children. Curr Allergy Asthma Rep 2017; 17:32. [PMID: 28429307 DOI: 10.1007/s11882-017-0700-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the recent advances in food desensitization in children with food allergy. RECENT FINDINGS Recent advancements in epicutaneous, sublingual, and oral immunotherapy for food allergy in the future may offer children with food allergy and their families a viable option to reduce risk or severity of anaphylaxis with phase III trials ongoing for two of these treatment modalities. Food allergy prevalence in children is estimated to be up to 8%. These children are at risk of significant allergic reactions and anaphylaxis. Food avoidance and use of antihistamines or epinephrine has been the standard of care for these patients. This approach also has a significant socioeconomic effects on patients and their families. Recent advancements in understanding food allergy have allowed for exploring new methods of treatment. There is an increasing interest in oral immunotherapy, epicutaneous immunotherapy, or sublingual immunotherapy for food allergy. There have been also innovative approaches to immunotherapy by modification of food allergens (to make them less allergenic while maintain their immunogenicity) or adding adjunctive treatments (probiotics, anti-IgE, etc.) to increase efficacy or safety.
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Affiliation(s)
- Ahmad Hamad
- Division of Allergy and Immunology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, 27517, USA.
| | - Wesley A Burks
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, USA
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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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Abstract
PURPOSE OF REVIEW Food allergy is common, affecting up to 8% of children in the USA. Currently, therapy is limited to avoidance of the implicated allergen and availability of self-injectable epinephrine. However, several new approaches to food allergy are under investigation. This article reviews the published data on these new approaches. RECENT FINDINGS Oral immunotherapy, in which allergic subjects are exposed to increasing amounts of antigen, can be accomplished in the majority of allergic individuals. However, this approach is not a cure as most patients will react after cessation of regular intake. In addition, there is a high rate of side effects. Other approaches include epicutaneous immunotherapy, therapy with anti-IgE medications, and use of Chinese herbs. Several novel approaches on food allergy are under study. At the current time, these approaches show promise for preventing severe reactions to accidental exposures. However, there is little evidence that current approaches will represent a true cure for food allergy.
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Affiliation(s)
- Andrew MacGinnite
- Division of Immunology, Boston Children's Hospital, 300 Longwood Ave/Fegan 6, Boston, MA, 02115, USA. .,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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Perezábad L, Reche M, Valbuena T, López-Fandiño R, Molina E, López-Expósito I. Oral Food Desensitization in Children With IgE-Mediated Cow's Milk Allergy: Immunological Changes Underlying Desensitization. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2017; 9:35-42. [PMID: 27826960 PMCID: PMC5102834 DOI: 10.4168/aair.2017.9.1.35] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 06/18/2016] [Accepted: 06/26/2016] [Indexed: 01/30/2023]
Abstract
Purpose This study aimed to evaluate the safety and efficacy to induce clinical desensitization to cow's milk (CM) of an oral immunotherapy (OIT) protocol in a pediatric population with cow's milk allergy (CMA). In addition, the immune responses against β-casein, of peripheral blood mononuclear cells (PBMCs) from CMA patients, before and after the protocol were evaluated and compared to a nonallergic population. Methods A group of 20 children with IgE-mediated CMA and 15 nonallergic children were recruited. Allergic subjects underwent an OIT protocol based on weekly doses of commercial semi-skimmed ultra-high temperature treated (UHT) CM, followed by a maintenance phase. Immune profiles and changes in all subjects were investigated by measuring Th1, Th2, and Treg cytokines, transcription factors, and specific IgE and IgG4 levels. Results The CM-OIT protocol enabled to desensitize 70% of the allergic patients. Successful OIT was accompanied by significant increases in casein-specific IgG4 levels, together with a reduction in the concentration of antigen-specific IgE and in IL-5, IL-13, and IL-10 production by β-casein-stimulated PBMCs. Baseline significant differences observed between allergic and nonallergic children in IL-13 and IL-5 levels were no longer found once the protocol had finished. Conclusions The OIT protocol was safe and effective in inducing milk desensitization in 70% of the children with CMA, leading to alterations in their immune profiles toward a nonallergic phenotype.
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Affiliation(s)
- Laura Perezábad
- Instituto de Investigación en Ciencias de la Alimentación (CIAL) (CSIC-UAM), Madrid, Spain
| | - Marta Reche
- Servicio de alergología, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - Teresa Valbuena
- Servicio de alergología, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - Rosina López-Fandiño
- Instituto de Investigación en Ciencias de la Alimentación (CIAL) (CSIC-UAM), Madrid, Spain
| | - Elena Molina
- Instituto de Investigación en Ciencias de la Alimentación (CIAL) (CSIC-UAM), Madrid, Spain.
| | - Iván López-Expósito
- Instituto de Investigación en Ciencias de la Alimentación (CIAL) (CSIC-UAM), Madrid, Spain
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Abstract
Food allergy is a potentially life-threatening condition with no approved therapies, apart from avoidance and injectable epinephrine for acute allergic reactions. Oral immunotherapy (OIT) is an experimental treatment in which food-allergic patients consume gradually increasing quantities of the food to increase their threshold for allergic reaction. This therapy carries significant risk of allergic reactions. The ability of OIT to desensitize patients to particular foods is well-documented, although the ability to induce tolerance has not been established. This review focuses on recent studies for the treatment of food allergies such as cow's milk, hen's egg, and peanut.
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Local Side Effects of Sublingual and Oral Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:13-21. [PMID: 27527548 DOI: 10.1016/j.jaip.2016.06.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/09/2016] [Accepted: 06/14/2016] [Indexed: 01/23/2023]
Abstract
Sublingual immunotherapy (SLIT) is increasingly used worldwide, and several products have been recently registered as drugs for respiratory allergy by the European Medicine Agency and the Food and Drug Administration. Concerning inhalant allergens, the safety of SLIT is overall superior to that of subcutaneous immunotherapy in terms of systemic adverse events. No fatality has been ever reported, and episodes of anaphylaxis were described only exceptionally. Looking at the historical and recent trials, most (>90%) adverse events are "local" and confined to the site of administration. For this reason, a specific grading system has been developed by the World Allergy Organization to classify and describe local adverse events. There is an increasing amount of literature concerning oral desensitization for food allergens, referred to as oral immunotherapy. Also, in this case, local side effects are predominant, although systemic adverse events are more frequent than with inhalant allergens. We review herein the description of local side effects due to SLIT, with a special focus on large trials having a declared sample size calculation. The use of the Medical Dictionary for Regulatory Activities nomenclature for adverse events is mentioned in this context, as recommended by regulatory agencies. It is expected that a uniform classification/grading of local adverse events will improve and harmonize the surveillance and reporting on the safety of SLIT.
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Ilesanmi AO, Ekwe GJ, Ilesanmi RI, Ogundele DT, Akintunde JK, Olalubi OA. Prevalence of latent eosinophilia among occupational gardeners at Babcock University, Nigeria. Asian Pac J Trop Biomed 2016. [DOI: 10.1016/j.apjtb.2015.12.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Song TW. A practical view of immunotherapy for food allergy. KOREAN JOURNAL OF PEDIATRICS 2016; 59:47-53. [PMID: 26958062 PMCID: PMC4781731 DOI: 10.3345/kjp.2016.59.2.47] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/05/2015] [Accepted: 10/12/2015] [Indexed: 11/27/2022]
Abstract
Food allergy is common and sometimes life threatening for Korean children. The current standard treatment of allergen avoidance and self-injectable epinephrine does not change the natural course of food allergy. Recently, oral, sublingual, and epicutaneous immunotherapies have been studied for their effectiveness against food allergy. While various rates of desensitization (36% to 100%) and tolerance (28% to 75%) have been induced by immunotherapies for food allergy, no single established protocol has been shown to be both effective and safe. In some studies, immunologic changes after immunotherapy for food allergy have been revealed. Adverse reactions to these immunotherapies have usually been localized, but severe systemic reactions have been observed in some cases. Although immunotherapy cannot be recommended for routine practice yet, results from recent studies demonstrate that immunotherapies are promising for the treatment of food allergy.
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Affiliation(s)
- Tae Won Song
- Department of Pediatrics, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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The Heterogeneity of Oral Immunotherapy Clinical Trials: Implications and Future Directions. Curr Allergy Asthma Rep 2016; 16:25. [DOI: 10.1007/s11882-016-0602-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Okada Y, Yanagida N, Sato S, Ebisawa M. Better management of wheat allergy using a very low-dose food challenge: A retrospective study. Allergol Int 2016; 65:82-7. [PMID: 26666490 DOI: 10.1016/j.alit.2015.07.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/21/2015] [Accepted: 07/28/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Low-dose reactive wheat-allergic children are at a high risk of a positive oral food challenge (OFC). The present study aimed to evaluate whether the results of a very low-dose (VL) OFC would contribute to better wheat allergy management in this population. METHODS We retrospectively reviewed wheat-allergic subjects who underwent a VL OFC with 2 g of udon noodles (equivalent to 53 mg of wheat protein) and had a previous allergic reaction to <15 g of udon noodles (equivalent to 400 mg of wheat protein) within 2 years before the OFC. Subjects who passed the OFC were defined as VL tolerant; those who failed were considered VL reactive. In VL tolerant subjects, the dose was increased to 15 g of udon noodles either during an OFC in our hospital or gradually at home. RESULTS Of the 57 included subjects (median age, 2.9 years; range, 1.0-11.8 years), 32 (56%) were VL tolerant and 25 (44%) were VL reactive. Most reactions during the OFC could be treated with an antihistamine and/or a nebulized β2 agonist. VL tolerant subjects consumed 2 g of udon noodles or a seasoning containing wheat. Within a year after the OFC, 18 VL tolerant subjects (56%), but no VL reactive subjects, were able to consume 15 g of udon noodles (p < 0.001). CONCLUSIONS A VL OFC can shift the management of some low-dose reactive wheat-allergic children from complete avoidance to partial wheat intake.
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Affiliation(s)
- Yu Okada
- Department of Paediatrics, Sagamihara National Hospital, Kanagawa, Japan; Department of Family Medicine, Kameda Family Clinic Tateyama, Chiba, Japan
| | - Noriyuki Yanagida
- Department of Paediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Sakura Sato
- Department of Allergy, Clinical Research Centre for Allergology and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Centre for Allergology and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan.
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Sánchez-García S, Cipriani F, Ricci G. Food Allergy in childhood: phenotypes, prevention and treatment. Pediatr Allergy Immunol 2015; 26:711-20. [PMID: 26595763 DOI: 10.1111/pai.12514] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 12/30/2022]
Abstract
The prevalence of food allergy in childhood increased in the last decades, especially in Westernized countries where this phenomenon has been indicated as a second wave of the allergic epidemic. In parallel, scientific interest also increased with the effort to explain the reasons of this sudden rise and to identify potential protective and risk factors. A great attention has been focused on early exposures to allergenic foods, as well as on other nutritional factors or supplements that may influence the immune system in a positive direction. Both interventions on maternal diet before birth or during breastfeeding and then directly on infant nutrition have been investigated. Furthermore, the natural history of food allergy also seems to be changing over time; IgE-mediated cow's milk allergy and egg allergy seem to be more frequently a persistent rather than a transient disease in childhood, as described in the last years. Food avoidance and the emergency drugs in case of an adverse event, such as epinephrine self-injector, are currently the first-line treatment in patients with food allergies, with a resulting impairment in the quality of life and social behaviour. During the last decade, oral immunotherapy emerged as an optional treatment with remarkable results, offering a novel perspective in the treatment for and management of food allergy.
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Affiliation(s)
| | - Francesca Cipriani
- Pediatric Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giampaolo Ricci
- Pediatric Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Lanser BJ, Wright BL, Orgel KA, Vickery BP, Fleischer DM. Current Options for the Treatment of Food Allergy. Pediatr Clin North Am 2015; 62:1531-49. [PMID: 26456449 PMCID: PMC4970423 DOI: 10.1016/j.pcl.2015.07.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Food allergy is increasing in prevalence; as a result, there is intense focus on developing safe and effective therapies. Current methods of specific immunotherapy include oral, sublingual, and epicutaneous, while nonspecific methods that have been investigated include: Chinese herbal medicine, probiotics, and anti-IgE antibodies. Although some studies have demonstrated efficacy in inducing desensitization, questions regarding safety and the potential for achieving immune tolerance remain. Although some of these therapies demonstrate promise, further investigation is required before their incorporation into routine clinical practice.
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Affiliation(s)
- Bruce J. Lanser
- Department of Pediatric, University of Colorado Denver School of Medicine, Aurora, CO, USA and National Jewish Health, 1400 Jackson Street, J322, Denver, CO 80206, USA
| | - Benjamin L. Wright
- Department of Pediatric, University of North Carolina at Chapel Hill School of Medicine, Campus Box #7231, Chapel Hill, NC 27599, USA and Allergy, Asthma & Clinical Immunology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Kelly A. Orgel
- Department of Pediatric, University of North Carolina at Chapel Hill School of Medicine, Campus Box #7231, Chapel Hill, NC 27599, USA
| | - Brian P. Vickery
- Department of Pediatric, University of North Carolina at Chapel Hill School of Medicine, Campus Box #7231, Chapel Hill, NC 27599, USA
| | - David M. Fleischer
- Department of Pediatric, University of Colorado Denver School of Medicine, Aurora, CO, USA and Children’s Hospital Colorado, 13123 E. 16th Ave, B518, Aurora, CO 80045, USA
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Nowak-Węgrzyn A, Albin S. Oral immunotherapy for food allergy: mechanisms and role in management. Clin Exp Allergy 2015; 45:368-83. [PMID: 25077670 DOI: 10.1111/cea.12382] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
With the emergence of food allergy as an important public health problem, it has become clear that there is an unmet need in regard to treatment. In particular, IgE-mediated food allergy that is associated with risk of fatal anaphylaxis has been the subject of multiple studies in the past decade. The growing body of evidence derived from multiple centres and various study designs indicates that for IgE-mediated food allergy, immunomodulation through food immunotherapy is possible; however, the extent of protection afforded by such treatment is highly variable. At this time, the capacity for food immunotherapy to restore permanent tolerance to food has not been demonstrated conclusively. This review will discuss these topics as they apply to the most important studies of food oral immunotherapy.
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Affiliation(s)
- A Nowak-Węgrzyn
- Pediatric Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, NY, USA
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Martorell-Aragonés A, Echeverría-Zudaire L, Alonso-Lebrero E, Boné-Calvo J, Martín-Muñoz M, Nevot-Falcó S, Piquer-Gibert M, Valdesoiro-Navarrete L. Position document: IgE-mediated cow's milk allergy. Allergol Immunopathol (Madr) 2015; 43:507-26. [PMID: 25800671 DOI: 10.1016/j.aller.2015.01.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 01/26/2015] [Indexed: 01/17/2023]
Abstract
The present document offers an update on the recommendations for managing patients with cow's milk allergy - a disorder that manifests in the first year of life, with an estimated prevalence of 1.6-3% in this paediatric age group. The main causal allergens are the caseins and proteins in lactoserum (beta-lactoglobulin, alpha-lactoalbumin), and the clinical manifestations are highly variable in terms of their presentation and severity. Most allergic reactions affect the skin, followed by the gastrointestinal and respiratory systems, and severe anaphylaxis may occur. The diagnosis of cow's milk allergy is based on the existence of a suggestive clinical history, a positive allergy study and the subsequent application of controlled exposure testing, which constitutes the gold standard for confirming the diagnosis. The most efficient treatment for cow's milk allergy is an elimination diet and the use of adequate substitution formulas. The elimination diet must include milk from other mammals (e.g., sheep, goat, etc.) due to the risk of cross-reactivity with the proteins of cow's milk. Most infants with IgE-mediated cow's milk allergy become tolerant in the first few years of life. In those cases where cow's milk allergy persists, novel treatment options may include oral immunotherapy, although most authors do not currently recommend this technique in routine clinical practice. Enough evidence is not there to confirm the efficacy of elimination diets in the mother and infant for preventing the appearance of cow's milk allergy. Likewise, no benefits have been observed with prebiotic and probiotic dietetic supplements in infants for preventing food allergy.
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Kuitunen M, Englund H, Remes S, Movérare R, Pelkonen A, Borres MP, Mäkelä MJ. High IgE levels to α-lactalbumin, β-lactoglobulin and casein predict less successful cow's milk oral immunotherapy. Allergy 2015; 70:955-62. [PMID: 25951431 DOI: 10.1111/all.12647] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND A new treatment option for persistent cow's milk allergy (CMA) is oral immunotherapy (OIT). Not all patients develop tolerance during therapy, and markers to identify those who will benefit from it are needed. The objective was to study the IgE and IgG4 antibody profiles to milk and milk proteins before and after OIT in relation to clinical outcome. METHODS Seventy-six children (5-17 years) with challenge-verified CMA were subjected to a 6-month OIT protocol. The treatment aimed at reaching a maintenance dose of 200 ml CM (high dose = HD). Those who did not reach target were analysed as a low-dose (LD) group. Sera were characterized before and after OIT regarding serum levels of IgE and IgG4 to milk and five milk allergen components evaluated together with clinical CMA symptoms and outcome of OIT. RESULTS Fifty-five (72%) patients reached the maintenance dose (HD) during therapy. High specific IgE levels towards the milk allergens α-lactalbumin (P = 0.048), β-lactoglobulin (P = 0.006) and casein (P = 0.015) before OIT start were associated with lower maintenance dose reached. Patients who developed desensitization had a larger increase in IgG4 levels to α-lactalbumin (P = 0.034), β-lactoglobulin (P = 0.010), casein (P = 0.047) and lactoferrin (P = 0.030) during treatment than those who failed. CONCLUSIONS Component-resolved diagnostics before OIT can help to identify children with lower probability of a successful OIT outcome, as high IgE levels to α-lactalbumin, β-lactoglobulin and casein are associated with lower maintenance dose reached. An increase in the IgG4 concentration to milk components during treatment indicated effective desensitization.
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Affiliation(s)
- M. Kuitunen
- Children's Hospital; University of Helsinki; Helsinki Finland
| | - H. Englund
- Thermo Fisher Scientific; Uppsala Sweden
| | - S. Remes
- Kuopio University Hospital; University of Eastern; Finland Finland
| | - R. Movérare
- Thermo Fisher Scientific; Uppsala Sweden
- Department of Medical Sciences, Respiratory Medicine and Allergology; Uppsala University; Uppsala Sweden
| | - A. Pelkonen
- Skin and Allergy Hospital; University of Helsinki; Helsinki Finland
| | - M. P. Borres
- Thermo Fisher Scientific; Uppsala Sweden
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - M. J. Mäkelä
- Skin and Allergy Hospital; University of Helsinki; Helsinki Finland
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Okada Y, Yanagida N, Sato S, Ebisawa M. Better management of cow's milk allergy using a very low dose food challenge test: a retrospective study. Allergol Int 2015; 64:272-6. [PMID: 26117260 DOI: 10.1016/j.alit.2015.04.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 04/01/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Low dose reactive cow's milk (CM) allergic children are at high risk of persistent CM allergy and a positive oral food challenge (OFC). The present study aimed to evaluate if the results of a very low dose (VL) OFC with these children contributes to better management of CM allergy. METHODS We retrospectively reviewed subjects with CM allergy who underwent a VL OFC with 3 mL heated CM and had a previous allergic reaction to <25 mL heated CM in the 2 years before the OFC. Subjects who passed the OFC were defined as VL tolerant, and subjects who failed were defined as VL reactive. VL tolerant subjects increased the dose to 25 mL heated CM either during an OFC in our hospital or gradually at home. RESULTS Of the 83 subjects (median age, 4.3 years; range, 1.0-12.9 years) who were included, 41 (49.4%) were VL tolerant, and 42 (51.6%) were VL reactive. Thirty-nine VL reactive subjects had skin and/or respiratory symptoms during the OFC. Most reactions could be treated with an antihistamine and/or a nebulized β2 agonist. The VL tolerant subjects consumed 3 mL heated CM or 10 g butter. Within the year following the OFC, 18 VL tolerant subjects (45.0%), but none of the VL reactive subjects, were able to consume 25 mL heated CM (p < 0.001). CONCLUSIONS A VL OFC allows the management of some low dose reactive CM allergic children to change from complete avoidance to partial intake of CM.
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O’Keefe AW, De Schryver S, Mill J, Mill C, Dery A, Ben-Shoshan M. Diagnosis and management of food allergies: new and emerging options: a systematic review. J Asthma Allergy 2014; 7:141-64. [PMID: 25368525 PMCID: PMC4216032 DOI: 10.2147/jaa.s49277] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
It is reported that 6% of children and 3% of adults have food allergies, with studies suggesting increased prevalence worldwide over the last few decades. Despite this, our diagnostic capabilities and techniques for managing patients with food allergies remain limited. We have conducted a systematic review of literature published within the last 5 years on the diagnosis and management of food allergies. While the gold standard for diagnosis remains the double-blind, placebo-controlled food challenge, this assessment is resource intensive and impractical in most clinical situations. In an effort to reduce the need for the double-blind, placebo-controlled food challenge, several risk-stratifying tests are employed, namely skin prick testing, measurement of serum-specific immunoglobulin E levels, component testing, and open food challenges. Management of food allergies typically involves allergen avoidance and carrying an epinephrine autoinjector. Clinical research trials of oral immunotherapy for some foods, including peanut, milk, egg, and peach, are under way. While oral immunotherapy is promising, its readiness for clinical application is controversial. In this review, we assess the latest studies published on the above diagnostic and management modalities, as well as novel strategies in the diagnosis and management of food allergy.
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Affiliation(s)
- Andrew W O’Keefe
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
- Department of Pediatrics, Faculty of Medicine, Memorial University of Newfoundland, St John’s, NL, Canada
| | - Sarah De Schryver
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Jennifer Mill
- Division of Clinical Epidemiology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Christopher Mill
- Division of Clinical Epidemiology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Alizee Dery
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Moshe Ben-Shoshan
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
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Pajno GB, Cox L, Caminiti L, Ramistella V, Crisafulli G. Oral Immunotherapy for Treatment of Immunoglobulin E-Mediated Food Allergy: The Transition to Clinical Practice. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2014; 27:42-50. [PMID: 24963452 PMCID: PMC4062106 DOI: 10.1089/ped.2014.0332] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 03/24/2014] [Indexed: 01/15/2023]
Abstract
Today, there is neither an effective nor an active treatment for food allergy. Allergy immunotherapy has been proposed as an attractive strategy to actively treat food allergy. Oral immunotherapy (OIT), also known as oral desensitization, is a method of inducing the body's immune system to tolerate a food that causes an allergic overreaction. It has been studied for the use in treatment of immunoglobulin E-mediated food allergy to the most common foods, including milk, egg, and peanut. OIT has been able to desensitize subjects to varying degrees. However, many questions remain unanswered, including efficient formulation, optimal dosing, and induction protocol to achieve full tolerance, transition of OIT to clinical practice, and maximal safety profile. This review focuses on the use of OIT as a new and active treatment for food allergy. The possibility of transition of OIT to clinical practice represents, in this field, the next pivotal step with the goal of improving the quality of life of patients with food allergy and their families.
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Affiliation(s)
- Giovanni B. Pajno
- Allergy Unit, Department of Pediatrics, University of Messina, Messina, Italy
| | - Linda Cox
- Nova Southeastern University, Fort Lauderdale, Florida
| | - Lucia Caminiti
- Allergy Unit, Department of Pediatrics, University of Messina, Messina, Italy
| | - Vincenzo Ramistella
- Allergy Unit, Department of Pediatrics, University of Messina, Messina, Italy
| | - Giuseppe Crisafulli
- Allergy Unit, Department of Pediatrics, University of Messina, Messina, Italy
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Pajno GB, Caminiti L, Crisafulli G, Salzano G. Recent advances in immunotherapy: the active treatment of food allergy on the horizon. Expert Rev Clin Immunol 2014; 9:891-3. [DOI: 10.1586/1744666x.2013.832625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lee S. Oral immunotherapy for the treatment of immediate type food allergy. ALLERGY ASTHMA & RESPIRATORY DISEASE 2014. [DOI: 10.4168/aard.2014.2.4.229] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Sooyoung Lee
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
- Suwon Center for Environmental Disease and Atopy, Suwon, Korea
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Kostadinova AI, Willemsen LEM, Knippels LMJ, Garssen J. Immunotherapy - risk/benefit in food allergy. Pediatr Allergy Immunol 2013; 24:633-44. [PMID: 24112425 DOI: 10.1111/pai.12122] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2013] [Indexed: 01/23/2023]
Abstract
Food allergy is a growing health concern in the westernized world with approx. 6% of children suffering from it. A lack of approved treatment has led to strict avoidance of the culprit food proteins being the only standard of care. Nowadays in-depth research is conducted to evaluate the possible use of allergen-specific immunotherapy (SIT) as an active therapeutic option for food allergy. Various routes of administration for the immunotherapy are investigated, including subcutaneous, oral, sublingual, and epicutaneous, and some appear to be successful in inducing a temporary tolerant state. Most research has been conducted with oral immunotherapy due to its efficacious and relatively safe profile. Increasing interest is dedicated to safer and more convenient approaches, such as sublingual and epicutaneous SIT; however, doubts exist about their possible capacity to induce temporary tolerant state and permanent oral tolerance. The high frequency of allergic adverse reactions of the various approaches and the inability to achieve permanent oral tolerance have highlighted the need of refinements in the strategies. A promising strategy for preventing IgE cross-linking and thus enhancing safety of SIT, while still activating T cells, is the use of tolerogenic peptides. The implementation of such an immunotherapy approach has the potential of not only increasing the chance of achieving a permanent state of tolerance, but also improving the safety and tolerability of the therapy. Immunotherapy for food allergy is still not ready for the clinic, but current and upcoming studies are dedicated to collect enough evidence for the possible implementation of allergen-SIT as a standard treatment for food allergy.
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Affiliation(s)
- Atanaska I Kostadinova
- Division of Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands; Department of Immunology, Nutricia Research, Utrecht, The Netherlands
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Abstract
In a child that is allergic to milk, the natural next step, following the elimination diet, is the reintroduction of cow's milk. Several questions may arise. When feasible, this reintroduction has many benefits for the child and his family. However, the disease needs to be well defined by physicians and explained to parents. They need to understand that there are different types of allergy to cow's milk, specifically IgE- and non-IgE-mediated, and each of these may exhibit both a variable duration and frequently an incomplete recovery. Deciding where to first reintroduce cow's milk to a child who has previously followed a milk-free diet, whether it be at home or in a hospital, also frequently presents an issue. Following this first reintroduction, the progressive increase of milk into the diet needs to be managed properly, as not all children will go back to a normal dairy products intake. Recent studies show that most children with milk allergy tolerate products containing baked milk and that their consumption might speed up recovery. Hence, the purpose of the milk challenge in a child on a milk-free diet is becoming, even in a child still reactive to milk, the first step of gradual and individually adapted reintroduction of milk or dairy products. When reintroduction of cow's milk does not work, immunotherapy becomes an option, and this is carried out in specialized centers.
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Affiliation(s)
- Christophe Dupont
- Hôpital Necker-Enfants Malades, Université Paris-Descartes, Paris, France
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