1
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Burk CM, Shreffler WG. Triggers for eosinophilic esophagitis (EoE): The intersection of food allergy and EoE. J Allergy Clin Immunol 2024; 153:1500-1509. [PMID: 38849185 DOI: 10.1016/j.jaci.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 06/09/2024]
Abstract
Eosinophilic esophagitis and IgE-mediated food allergy are both food-triggered diseases that are increasing in prevalence. They share many clinical links, including significant comorbidity and similar food triggers, and as atopic diseases, they likely share upstream mechanisms related to barrier function and signals leading to TH2 skewing. In this review, we focus on links between eosinophilic esophagitis and IgE-mediated food allergy with an emphasis on what insights may be derived from overlapping food triggers and immune phenotypes. Through further investigation of these connections, we may be able to better understand not only IgE-mediated food allergy and eosinophilic esophagitis but also general atopic response to food proteins and evolution of allergic response to food.
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Affiliation(s)
- Caitlin M Burk
- Food Allergy Center, Division of Pediatric Allergy and Immunology, and Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, and the Department of Pediatrics, Harvard Medical School, Boston, Mass.
| | - Wayne G Shreffler
- Food Allergy Center, Division of Pediatric Allergy and Immunology, and Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, and the Department of Pediatrics, Harvard Medical School, Boston, Mass
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2
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Oliva S, McGowan EC. Associations of Eosinophilic Gastrointestinal Disorders with Other Gastrointestinal and Allergic Diseases. Immunol Allergy Clin North Am 2024; 44:329-348. [PMID: 38575227 DOI: 10.1016/j.iac.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Eosinophilic gastrointestinal disorders (EGIDs) are becoming more common causing significant suffering and reduced quality of life. These conditions can affect different parts of the digestive system, either individually or in combination. Recognition of their link to allergic disorders or other gastrointestinal (GI) diseases has raised questions about their shared underlying mechanisms, which has had implications for diagnosis and management. The authors critically examine the current understanding of the connection between EGIDs and allergic conditions (ie, atopic dermatitis, allergic rhinitis, asthma, and food allergy) and GI diseases (ie, inflammatory bowel disease, celiac disease, gastroesophageal reflux disease, and motility disorders).
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Affiliation(s)
- Salvatore Oliva
- Department of Maternal and Child Health, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, Rome 00161, Italy.
| | - Emily Clarke McGowan
- Division of Allergy and Immunology, Departments of Internal Medicine and Pediatrics, University of Virginia School of Medicine, P.O. Box 801355, Charlottesville, VA 22908, USA
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3
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Wilson BE, Sacta MA, Wright BL, Spergel J, Wolfset N. The Relationship Between Eosinophilic Esophagitis and Immunotherapy. Immunol Allergy Clin North Am 2024; 44:281-291. [PMID: 38575223 PMCID: PMC11008775 DOI: 10.1016/j.iac.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Immunotherapy is a treatment approach based on the principle of incremental allergen exposure to achieve desensitization. Recently, oral immunotherapy has been introduced as a treatment of IgE-mediated food allergy. Some patients receiving oral immunotherapy for food allergy may develop eosinophilic esophagitis. Here, we summarize the literature examining this association, its treatment, and outcomes and discuss possible explanations for this clinical phenomenon. We further identify potential associations with aeroallergen sensitivity and other forms of immunotherapy including subcutaneous immunotherapy and sublingual immunotherapy. Finally, we discuss management of immunotherapy-induced eosinophilic esophagitis. Epicutaneous immunotherapy is highlighted as an area of therapeutic investigation.
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Affiliation(s)
- Bridget E Wilson
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, 13400 E. Shea Boulevard Scottsdale, AZ 85259, USA; Division of Allergy/Immunology, Phoenix Children's, 1919 E. Thomas Road, Phoenix, AZ 85054, USA.
| | - Maria A Sacta
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Benjamin L Wright
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, 13400 E. Shea Boulevard Scottsdale, AZ 85259, USA; Division of Allergy/Immunology, Phoenix Children's, 1919 E. Thomas Road, Phoenix, AZ 85054, USA
| | - Jonathan Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Nicole Wolfset
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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4
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Bauer M, Nguyen N, Liacouras CA. Clinical Evaluation of the Child with Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:157-171. [PMID: 38575215 DOI: 10.1016/j.iac.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
The diagnosis of eosinophilic esophagitis (EoE) is based on clinical symptoms of esophageal dysfunction and eosinophil predominant esophageal inflammation. Clinical symptoms in children with EoE vary based on age and may be nonspecific. EoE has a male predominance with the majority having comorbid atopic disorders. At present, treatment options include medications (proton pump inhibition, swallowed topical steroids), dietary therapy or biologic therapy (dupilumab, approved for those ≥12 years of age). Outside of EoE in the context of oral immunotherapy, EoE is typically chronic requiring lifelong therapy. Long-term complications including feeding difficulties, malnutrition, and fibrostenotic disease.
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Affiliation(s)
- Maureen Bauer
- Department of Pediatric Allergy & Immunology, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 518, Aurora, CO 80045, USA.
| | - Nathalie Nguyen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Gastrointestinal Eosinophilic Diseases Program, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 518, Aurora, CO 80045, USA
| | - Chris A Liacouras
- Department of Gastroenterology, Hepatology and Nutrition, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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5
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Papadopoulou A, Amil-Dias J, Auth MKH, Chehade M, Collins MH, Gupta SK, Gutiérrez-Junquera C, Orel R, Vieira MC, Zevit N, Atkins D, Bredenoord AJ, Carneiro F, Dellon ES, Gonsalves N, Menard-Katcher C, Koletzko S, Liacouras C, Marderfeld L, Oliva S, Ohtsuka Y, Rothenberg ME, Strauman A, Thapar N, Yang GY, Furuta GT. Joint ESPGHAN/NASPGHAN Guidelines on Childhood Eosinophilic Gastrointestinal Disorders Beyond Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2024; 78:122-152. [PMID: 38291684 DOI: 10.1097/mpg.0000000000003877] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 06/13/2019] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Eosinophilic gastrointestinal disorders beyond eosinophilic esophagitis (non-EoE EGIDs) are rare chronic inflammatory disorders of the gastrointestinal (GI) tract. Diagnosis is based on clinical symptoms and histologic findings of eosinophilic inflammation after exclusion of a secondary cause or systemic disease. Currently, no guidelines exist for the evaluation of non-EoE EGIDs. Therefore, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) formed a task force group to provide consensus guidelines for childhood non-EoE EGIDs. METHODS The working group was composed of pediatric gastroenterologists, adult gastroenterologists, allergists/immunologists, and pathologists. An extensive electronic literature search of the MEDLINE, EMBASE, and Cochrane databases was conducted up to February 2022. General methodology was used in the formulation of recommendations according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to meet current standards of evidence assessment. RESULTS The guidelines provide information on the current concept of non-EoE EGIDs, disease pathogenesis, epidemiology, clinical manifestations, diagnostic and disease surveillance procedures, and current treatment options. Thirty-four statements based on available evidence and 41 recommendations based on expert opinion and best clinical practices were developed. CONCLUSION Non-EoE EGIDs literature is limited in scope and depth, making clear recommendations difficult. These consensus-based clinical practice guidelines are intended to assist clinicians caring for children affected by non-EoE EGIDs and to facilitate high-quality randomized controlled trials of various treatment modalities using standardized, uniform disease definitions.
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Affiliation(s)
- Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, University of Athens, Children's Hospital Agia Sofia, Athens, Greece
| | | | - Marcus Karl-Heinz Auth
- Paediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust and University of Liverpool, Liverpool, UK
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Sandeep K Gupta
- Community Health Network; and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University, Indianapolis, IN
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, University Hospital Puerta de Hierro Majadahonda, Autonomous University of Madrid, Madrid, Spain
| | - Rok Orel
- Department of Gastroenterology, Hepatology and Nutrition, Ljubljana University Children's Hospital, Ljubljana, Slovenia
| | - Mario C Vieira
- Center for Pediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba, Brazil
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition, and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dan Atkins
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Fatima Carneiro
- Centro Hospitalar Universitário de São João (CHUSJ)/Faculty of Medicine of the University of Porto (FMUP) and Institute of Molecular Pathology and Immunology of the University of Porto (Ipatimup)/i3S - Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nirmala Gonsalves
- Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Calies Menard-Katcher
- Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology and Nutrition, Gastrointestinal Eosinophilic Disease Program, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Sibylle Koletzko
- Dr. von Hauner Children's Hospital, Department of Pediatrics, University Hospital, LMU Munich, Munich, Germany
- Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Chris Liacouras
- Center for Pediatric Eosinophilic Diseases, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Luba Marderfeld
- The Ottawa Hospital, IBD Center, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada
| | - Salvatore Oliva
- Maternal and Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza - University of Rome, Rome, Italy
| | - Yoshikazu Ohtsuka
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alex Strauman
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Nikhil Thapar
- Stem Cells and Regenerative Medicine, GOS Institute of Child Health, University College London, London, UK
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
| | - Guan-Yu Yang
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Glenn T Furuta
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Gastrointestinal Eosinophilic Disease Program, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, CO
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Goldberg MR, Epstein-Rigbi N, Elizur A. Eosinophil-Associated Gastrointestinal Manifestations During OIT. Clin Rev Allergy Immunol 2023; 65:365-376. [PMID: 37957456 DOI: 10.1007/s12016-023-08974-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 11/15/2023]
Abstract
Gastrointestinal adverse events are common during oral immunotherapy (OIT) for food allergy and range from immediate IgE-mediated reactions to non-anaphylactic clinical presentations. This review aims to summarize recent findings on non-anaphylactic eosinophil-associated gastrointestinal adverse events during OIT. Two clinical presentations of non-anaphylactic eosinophil-associated gastrointestinal adverse events during OIT are identified, each with a different paradigm for treatment, and distinguished by their time of onset. In the first clinical entity, characterized by its onset early in the course of treatment, patients present with abdominal pain, nausea, and/or vomiting. The symptoms become evident typically within weeks to months of starting OIT. These symptoms, however, are not temporally related to the time of dose administration, as in the case of immediate IgE-mediated anaphylactic reactions. While esophageal biopsies, when performed, can demonstrate eosinophilic esophagitis (EoE), baseline esophageal eosinophilia has also been observed in food allergic patients prior to OIT. A potential non-invasive biomarker, the peripheral absolute eosinophil count (AEC), often rises during these reactions and subsides after dose reduction and subsequent resolution of symptoms. OIT can usually then be resumed, albeit at a slower pace, without a recurrence of symptoms. Risk factors for development of symptoms early during OIT include a high starting dose and a baseline AEC of greater than 600. The second, and much less frequently encountered, non-anaphylactic gastrointestinal adverse event related to OIT, presents months to years after initiating OIT. In this latter group, patients present with the classical clinical symptoms and endoscopic findings of EoE. In contrast to the acute onset group, peripheral eosinophilia is usually not observed in these cases. This OIT-associated EoE has shown good response to standard EoE treatment approaches of proton pump inhibitors or swallowed steroids. Most patients with eosinophil-associated adverse reactions are able to continue OIT and remain desensitized. Treatment approaches depend on the specific subtype of these reactions and relate to the stages of OIT treatment.
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Affiliation(s)
- Michael R Goldberg
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center (Assaf Harofeh), Zerifin, 70300, Israel.
- Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Naama Epstein-Rigbi
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center (Assaf Harofeh), Zerifin, 70300, Israel
- Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center (Assaf Harofeh), Zerifin, 70300, Israel
- Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Bauer M, Atkins D, Nguyen N. A case of food and aeroallergen sublingual immunotherapy inducing eosinophilic esophagitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100125. [PMID: 37779515 PMCID: PMC10509844 DOI: 10.1016/j.jacig.2023.100125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 02/28/2023] [Accepted: 03/24/2023] [Indexed: 10/03/2023]
Abstract
Eosinophilic esophagitis (EoE) has been reported secondary to aeroallergen sublingual immunotherapy (SLIT) and food allergen oral immunotherapy. Gastrointestinal symptoms with food allergen SLIT are uncommon, with no prior reports of cases of food allergen SLIT inducing EoE. Here we report a patient who developed EoE secondary to food and aeroallergen SLIT therapy that resolved with SLIT cessation.
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Affiliation(s)
- Maureen Bauer
- Section of Pediatric Allergy and Immunology, Children’s Hospital Colorado, Universtiy of Colorado School of Medicine, Aurora, Colo
| | - Dan Atkins
- Section of Pediatric Allergy and Immunology, Children’s Hospital Colorado, Universtiy of Colorado School of Medicine, Aurora, Colo
| | - Nathalie Nguyen
- Section of Pediatric Gastroenterology, Children’s Hospital Colorado, Universtiy of Colorado School of Medicine, Aurora, Colo
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8
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Muzzone M, Blanc S, Dainese R, Leroy S. Contre le fait que l’immunothérapie allergénique aux aliments et aux pneumallergènes soit contre-indiquée en présence d’une œsophagite à éosinophiles. REVUE FRANÇAISE D'ALLERGOLOGIE 2023. [DOI: 10.1016/j.reval.2023.103332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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9
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Sindher SB, Barshow S, Tirumalasetty J, Arasi S, Atkins D, Bauer M, Bégin P, Collins MH, Deschildre A, Doyle AD, Fiocchi A, Furuta GT, Garcia-Lloret M, Mennini M, Rothenberg ME, Spergel JM, Wang J, Wood RA, Wright BL, Zuberbier T, Chin AR, Long A, Nadeau KC, Chinthrajah RS. The role of biologics in pediatric food allergy and eosinophilic gastrointestinal disorders. J Allergy Clin Immunol 2023; 151:595-606. [PMID: 36872039 PMCID: PMC9993424 DOI: 10.1016/j.jaci.2023.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 03/06/2023]
Abstract
Continuing insight into the molecular mechanisms of atopic disorders has enabled the development of biologics to precisely target these diseases. Food allergy (FA) and eosinophilic gastrointestinal disorders (EGIDs) are driven by similar inflammatory molecular mechanisms and exist along the same atopic disease spectrum. Therefore, many of the same biologics are being investigated to target key drivers of mechanisms shared across the disease states. The enormous potential of biologics for the treatment of FA and EGIDs is highlighted by the significant increases in the number of ongoing clinical trials (more than 30) evaluating their use in these disease states, as well as by the recent US Food and Drug Administration approval of dupilumab for the treatment of eosinophilic esophagitis. Here we discuss past and current research into the use of biologics in FA and EGIDs and their potential role in improving treatment options in the future, with the need to have biologics widely clinically available.
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Affiliation(s)
- Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Suzanne Barshow
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Jyothi Tirumalasetty
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Stefania Arasi
- Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dan Atkins
- Department of Pediatrics, Section of Allergy and Immunology, Digestive Health Institute, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Maureen Bauer
- Department of Pediatrics, Section of Allergy and Immunology, Digestive Health Institute, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Philippe Bégin
- Department of Pediatrics, Service of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montréal; Department of Medicine, Service of Allergy and Clinical Immunology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Antoine Deschildre
- CHU Lille, Université Lille, Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, Lille, France
| | - Alfred D Doyle
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Ariz
| | - Alessandro Fiocchi
- Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Glenn T Furuta
- Department of Pediatrics, Section of Allergy and Immunology, Digestive Health Institute, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Maria Garcia-Lloret
- Department of Pediatrics, Division of Immunology, Allergy, and Rheumatology, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Maurizio Mennini
- Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan M Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai and the Jaffe Food Allergy Institute, New York, NY
| | - Robert A Wood
- Division of Pediatric Allergy, Immunology, and Rheumatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Benjamin L Wright
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Ariz
| | - Torsten Zuberbier
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Andrew R Chin
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Andrew Long
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, Calif.
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10
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Pouessel G, Lezmi G. Oral immunotherapy for food allergy: Translation from studies to clinical practice? World Allergy Organ J 2023; 16:100747. [PMID: 36816599 PMCID: PMC9932561 DOI: 10.1016/j.waojou.2023.100747] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/14/2022] [Accepted: 01/10/2023] [Indexed: 02/05/2023] Open
Abstract
Oral immunotherapy (OIT) is now recognized as an alternative active treatment to strict food avoidance in certain patients with IgE-mediated food allergy. Studies have confirmed the efficacy of OIT to desensitize children with allergy to cow's milk, eggs, and peanuts. The benefits, risks, and constraints of OIT are becoming increasingly well understood. However, there is no consensual criteria to select patients to whom OIT could be proposed, and many issues remain to address including the definitions of desensitization and long-term efficacy, the assessment of patient's experience in real life, the optimization of buildup and maintenance protocols, and the utility of multiple food OIT. The recent authorization by medical agency concerning the first medicine for peanut OIT is a step forward towards higher standardization in the practice of OIT. This article summarizes in comprehensive narrative format data on efficacy, tolerance, impact on quality of life and adverse effects of OIT and discuss elements to consider in clinical practice before starting OIT.
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Affiliation(s)
- Guillaume Pouessel
- Department of Paediatrics, CH Roubaix 59056, France,Paediatric Pneumology and Allergology Unit, CHRU Lille, 59037, France,Corresponding author. Service de Pédiatrie, Pavillon Médicochirurgical de Pédiatrie, Boulevard Lacordaire, F-59056 Roubaix, France. Fax: 0033 3 20 99 30 97
| | - Guillaume Lezmi
- Paediatric Pneumology and Allergology Unit, Children's Hospital Necker, Paris, 75013, France
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11
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Oral Immunotherapy and Risk of Eosinophilic Esophagitis in Children: 15 Years' Experience. J Pediatr Gastroenterol Nutr 2023; 76:53-58. [PMID: 36190840 DOI: 10.1097/mpg.0000000000003631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Oral immunotherapy (OIT) is an effective treatment for children with persistent food allergy, and has concerns about its safety, including eosinophilic esophagitis (EoE). The aim of this study was to evaluate the prevalence of EoE in a large cohort of children who underwent OIT in our center, and to determine if there were any clinical, endoscopic, or histologic differences depending on the food employed for the OIT. METHODS A retrospective study was performed over a 15-year period (2005-2020). Children who underwent cow's milk (CM), egg, and/or peanut OIT and developed EoE were included. RESULTS Six hundred and seven OIT were carried out (277 CM-OIT, 322 egg-OIT, and 8 peanut-OIT). Seventeen patients (2.8%) had a confirmed histologic diagnosis of EoE with a higher prevalence for patients who underwent CM-OIT (3.9%) than egg-OIT (2.2%). Symptoms suggestive of EoE and a confirmed diagnosis occurred at median times of 25 and 36 months, respectively, after the build-up phase of the OIT was completed. Choking, abdominal pain, and dysphagia were the most frequent symptoms and lamina propria fibrosis was observed in 41.2% of patients. No significant differences in clinical symptoms, endoscopic, or histologic findings between patients under CM or egg-OIT were found. One-third of patients reported mild symptoms suggestive of EoE before the OIT. CONCLUSIONS EoE appears to be a rare but important adverse event that can occur even years after OIT. Validated questionnaires to screen EoE before the OIT and in the follow-up of these patients may be the main tool for an early diagnosis.
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12
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Underwood B, Troutman TD, Schwartz JT. Breaking down the complex pathophysiology of eosinophilic esophagitis. Ann Allergy Asthma Immunol 2023; 130:28-39. [PMID: 36351516 PMCID: PMC10165615 DOI: 10.1016/j.anai.2022.10.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/08/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic and progressive immune-mediated disease of the esophagus associated with antigen-driven type 2 inflammation and symptoms of esophageal dysfunction. Our understanding of EoE pathophysiology has evolved since its initial recognition more than 20 years ago and has translated into diagnostic and novel therapeutic approaches that are affecting patient care. The mechanisms underlying disease development and progression are influenced by diverse factors, such as genetics, age, allergic comorbidities, and allergen exposures. Central to EoE pathophysiology is a dysregulated feed-forward cycle that develops between the esophageal epithelium and the immune system. Allergen-induced, type 2-biased immune activation by the esophageal epithelium propagates a cycle of impaired mucosal barrier integrity and allergic inflammation, eventually leading to tissue remodeling and progressive organ dysfunction. Herein, we review the current understanding of fundamental pathophysiological mechanisms contributing to EoE pathogenesis.
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Affiliation(s)
- Brynne Underwood
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ty D Troutman
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Justin T Schwartz
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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13
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García Vega M, Fernández-Fernández S, Echeverría Zudaire L, Bracamonte Bermejo T, Cano Del Águila B, Vega Hernández P, Ortega Sánchez E. Long-term medical treatment efficacy in patients with eosinophilic oesophagitis and oral food immunotherapy. Clin Exp Allergy 2022; 52:1440-1443. [PMID: 35993507 DOI: 10.1111/cea.14219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/22/2022] [Accepted: 08/15/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Marta García Vega
- Pediatric Gastroenterology Department, Severo Ochoa University Hospital, Leganés, Spain
| | | | | | | | | | - Pilar Vega Hernández
- Pediatric Allergology Department, Severo Ochoa University Hospital, Leganés, Spain
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14
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Actualités dans l’immunothérapie orale pour les allergies alimentaires. REVUE FRANÇAISE D'ALLERGOLOGIE 2022. [DOI: 10.1016/s1877-0320(22)00488-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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15
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Masuda MY, Barshow SM, Garg S, Putikova A, LeSuer WE, Alexander JA, Katzka DA, Dellon ES, Kita H, Horsley-Silva JL, Doyle AD, Wright BL. Eosinophil Peroxidase Staining Enhances the Diagnostic Utility of the Cytosponge in Eosinophilic Esophagitis. Clin Transl Gastroenterol 2022; 13:e00534. [PMID: 36137185 PMCID: PMC10476857 DOI: 10.14309/ctg.0000000000000534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/30/2022] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION We aimed to assess the diagnostic utility of eosinophil peroxidase (EPX) staining on Cytosponge (CS) samples in eosinophilic esophagitis (EoE). METHODS Esophageal biopsy (BX) samples from adult subjects with EoE were assessed using peak eosinophils per high-power field (eos/hpf), EPX, and the EoE histologic scoring system. EPX staining and eos/hpf were compared (BX vs CS). RESULTS CS EPX positivity correlated with eos/hpf (CS [ r = 0.82, P < 0.0001]; BX [ r = 0.65, P < 0.0001]) and EoE histologic scoring system (grade [ r = 0.62, P < 0.00001]; stage [ r = 0.61, P < 0.0001]). CS EPX identified subjects with active EoE (area under the curve = 0.86, P < 0.0001). DISCUSSION The correlation of CS EPX with eosinophilic inflammation and histologic disease severity supports its diagnostic utility in EoE.
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Affiliation(s)
- Mia Y. Masuda
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
- Department of Immunology, Mayo Clinic, Rochester, Minnesota, USA and Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Suzanne M. Barshow
- Section of Allergy and Immunology, Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Shipra Garg
- Division of Laboratory Medicine and Pathology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Arina Putikova
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - William E. LeSuer
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Jeffrey A. Alexander
- Division of Gastroenterology and Hepatology, Department of Medicine, Rochester, Minnesota, USA
| | - David A. Katzka
- Division of Gastroenterology and Hepatology, Department of Medicine, Rochester, Minnesota, USA
| | - Evan S. Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Hirohito Kita
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
- Department of Immunology, Mayo Clinic, Rochester, Minnesota, USA and Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Jennifer L. Horsley-Silva
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Alfred D. Doyle
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Benjamin L. Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
- Section of Allergy and Immunology, Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Arizona, USA
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16
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Rossi CM, Lenti MV, Merli S, Licari A, Votto M, Marseglia GL, Di Sabatino A. Primary eosinophilic gastrointestinal disorders and allergy: Clinical and therapeutic implications. Clin Transl Allergy 2022; 12:e12146. [PMID: 35620572 PMCID: PMC9125508 DOI: 10.1002/clt2.12146] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 12/14/2022] Open
Abstract
Primary eosinophilic gastrointestinal disorders (EGID) are increasingly prevalent, immune‐mediated, chronic conditions which primarily affect pediatric and young adult patients, leading to substantial disease burden, and poor quality of life. EGID may either involve single portions of the gastrointestinal tract (i.e., esophagus, stomach, small bowel, and colon) or a combination. Their strong association with allergic disorders has been recently recognized, and although their shared pathophysiological basis remains partly elusive, this feature greatly impacts the diagnostic and treatment work‐up. We herein critically discuss the current knowledge on the association of EGID and allergic disorders, including atopic dermatitis, allergic rhinitis, allergic asthma, and food or drug allergy. In particular, we reviewed the literature focusing on their epidemiology, pathophysiological basis and mechanisms, and diagnostic strategies. Finally, we discuss the currently ongoing clinical trials targeting EGID and allergic diseases, including, among others the monoclonal antibodies dupilumab, mepolizumab, benralizumab, and lirentelimab.
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Affiliation(s)
- Carlo Maria Rossi
- First Department of Internal Medicine IRCCS Fondazione Policlinico San Matteo University of Pavia Pavia Italy
| | - Marco Vincenzo Lenti
- First Department of Internal Medicine IRCCS Fondazione Policlinico San Matteo University of Pavia Pavia Italy
| | - Stefania Merli
- First Department of Internal Medicine IRCCS Fondazione Policlinico San Matteo University of Pavia Pavia Italy
| | - Amelia Licari
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences University of Pavia Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Martina Votto
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences University of Pavia Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Gian Luigi Marseglia
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences University of Pavia Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Antonio Di Sabatino
- First Department of Internal Medicine IRCCS Fondazione Policlinico San Matteo University of Pavia Pavia Italy
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17
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Perrett KP, Sindher SB, Begin P, Shanks J, Elizur A. Advances, Practical Implementation, and Unmet Needs Regarding Oral Immunotherapy for Food Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:19-33. [PMID: 34785391 DOI: 10.1016/j.jaip.2021.10.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/07/2021] [Accepted: 10/25/2021] [Indexed: 06/13/2023]
Abstract
Treatment of food allergy is a rapidly changing landscape, with arguably, the most significant advancement in recent years, the transition of oral immunotherapy (OIT) to clinical practice. As an innovation, OIT is a phase of rapidly increasing demand, particularly for some allergens such as peanut, egg, and milk, which have substantial evidence of efficacy. However, significant questions remain about how to best treat multiple food allergies and less common food allergies and how to optimize long-term safety and efficacy. This review summarizes the currently available resources for integrating food allergy OIT into clinical practice and focuses on the multiple remaining unmet needs such as providing an approach for OIT to food allergens for which there is no or limited evidence; practical issues related to food allergy treatment particularly when it is not going well; long-term outcomes and follow-up after OIT; and strategies to help meet the impending increase in demand.
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Affiliation(s)
- Kirsten P Perrett
- Population Allergy, Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia.
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford, California; Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford, California
| | - Philippe Begin
- Division of Allergy, Immunology and Rheumatology, CHU Sainte-Justine, Montréal, Canada
| | - Josiah Shanks
- Population Allergy, Murdoch Children's Research Institute, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Arnon Elizur
- Institute of Allergy, Immunology and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Be'er Ya'akov, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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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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19
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Anderson B, Wong L, Adlou B, Long A, Chinthrajah RS. Oral Immunotherapy in Children: Clinical Considerations and Practical Management. J Asthma Allergy 2021; 14:1497-1510. [PMID: 34934327 PMCID: PMC8684389 DOI: 10.2147/jaa.s282696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/09/2021] [Indexed: 01/21/2023] Open
Abstract
Oral immunotherapy (OIT) in pediatric patients provides an alternative option to the current standard of care in food allergy, which is allergen avoidance and reactive treatment. Because patients are exposed to one or more food allergens during treatment, OIT is associated with adverse events and can be a cumbersome process for children, their caregivers, and clinicians. However, there have been an overwhelming number of studies that show high efficacy in both single- and multi-allergen OIT, and that quality of life is greatly improved for both patients and their families after undergoing immunotherapy. This review discusses clinical considerations for OIT in pediatrics, including efficacy and safety, practical management, and future directions of treatment.
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Affiliation(s)
- Brent Anderson
- Sean N Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA, USA
| | - Lauren Wong
- Sean N Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA, USA
| | - Bahman Adlou
- Sean N Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA, USA
| | - Andrew Long
- Sean N Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA, USA
| | - R Sharon Chinthrajah
- Sean N Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA, USA
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20
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Yamamoto K, Okamoto T, Fukuda K. Asymptomatic Eosinophilic Infiltration with Endoscopic and Histological Findings Consistent with Eosinophilic Gastritis. Case Rep Gastroenterol 2021; 15:652-656. [PMID: 34720822 PMCID: PMC8458926 DOI: 10.1159/000516688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/16/2021] [Indexed: 11/19/2022] Open
Abstract
Eosinophilic gastritis often presents with gastrointestinal symptoms in the absence of abnormal endoscopic findings. On the other hand, endoscopic changes due to eosinophilic infiltration in an asymptomatic patient are rare. A 29-year-old woman with a history of asthma on steroid inhalers presented for an annual medical checkup. Esophagogastroduodenoscopy revealed diffuse white granular patches in the body of the stomach, suggestive of eosinophilic gastritis. Histology showed over 100 eosinophils per high-power field, also consistent with eosinophilic gastritis. As the absence of symptoms precluded the diagnosis of eosinophilic gastritis, the patient was diagnosed with asymptomatic eosinophilic infiltration of the stomach.
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Affiliation(s)
- Kazuki Yamamoto
- Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan
| | - Takeshi Okamoto
- Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan
| | - Katsuyuki Fukuda
- Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan
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21
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Chen PH, Anderson L, Zhang K, Weiss GA. Eosinophilic Gastritis/Gastroenteritis. Curr Gastroenterol Rep 2021; 23:13. [PMID: 34331146 DOI: 10.1007/s11894-021-00809-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Eosinophilic gastritis/gastroenteritis (EG/EGE) are rare eosinophilic infiltrative disorders in children and adults that fall under the umbrella term eosinophilic gastrointestinal disorders (EGIDs). EGIDs also include eosinophilic esophagitis (EoE) and eosinophilic colitis. In this article, we present the current literature regarding the clinical presentation, diagnostic criteria, and management of EG/EGE. RECENT FINDINGS The underlying complex pathophysiology remains unknown, yet hypersensitivity response is a central component. Unlike EoE, standardized diagnostic criteria are lacking but, promising research employing tissue-based and blood-based methods of diagnosis have been reported. Non-EoE EGIDs are more challenging to treat than EoE. More than a third of patients may achieve spontaneous remission. Still, most will require dietary elimination and/or pharmaceutical interventions, mainly corticosteroids, but also biologics (monoclonal antibodies against IL-4, IL-5, TNFα, integrin α4β7, and IgE), mast-cell stabilizers, leukotriene (LT)-receptor antagonists, and antihistamines. Promising research suggests the role of AK002, an anti-siglec antibody, in clinical and histological improvement. Given the rarity and underdiagnosis of EG/EGE, different natural progression compared to EoE, heterogeneous clinical manifestations, and probable normal endoscopic appearance, it is vital to maintain a high suspicion index in atopic patients, obtain at least 5-6 random biopsies from each site for gastro/duodenal eosinophilic infiltrate with the subsequent exclusion of inflammatory, allergic and infectious differential diagnoses to increase the yield of an accurate diagnosis. Corticosteroids remain the mainstay of treatment, often requiring long-term use. Steroid-sparing agents remain experimental. Goals of therapy move beyond clinical remission but lack evidence to support histological remission.
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Affiliation(s)
- Phillip H Chen
- David Geffen School of Medicine at UCLA, 100 UCLA Medical Plaza, suite 345, Los Angeles, CA, 90095, USA.,Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Lorraine Anderson
- Department of Allergy-Immunology, University of California Los Angeles, Los Angeles, CA, USA
| | - Kuixing Zhang
- Department of Pathology, University of California Los Angeles, Los Angeles, CA, USA
| | - Guy A Weiss
- David Geffen School of Medicine at UCLA, 100 UCLA Medical Plaza, suite 345, Los Angeles, CA, 90095, USA. .,Celiac Disease Program, Vatche and Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, CA, USA.
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22
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Management of Eosinophilic Esophagitis During Oral Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3282-3287. [PMID: 34325036 DOI: 10.1016/j.jaip.2021.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 01/25/2023]
Abstract
Food allergies are antigen-driven diseases that can lead to IgE-mediated reactions of immediate hypersensitivity (eg, anaphylaxis triggered by a single food) or non-IgE reactions of delayed hypersensitivity such as eosinophilic esophagitis (eg, inability to eat multiple foods manifesting as abdominal pain, choking, dysphagia, vomiting, reflux, food impaction). Although both types of disease have their own unique set of challenges in diagnosis and management, it is a particularly vexing problem when a patient is afflicted by both conditions. This situation can happen when individuals with IgE-mediated food allergy undergo desensitization using currently available forms of oral immunotherapy. In this Grand Rounds Review, we review diagnostic approaches to oral immunotherapy-associated eosinophilic esophagitis, potential relationships between primary and secondary eosinophilic esophagitis, potential management approaches, areas of uncertainty, and upcoming research. Optimally supporting patients in their journey with food allergy requires shared decision making regarding alternative management strategies and the stimulation of robust research.
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23
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Votto M, De Filippo M, Caminiti L, Carella F, de Castro G, Landi M, Olcese R, Vernich M, Marseglia GL, Ciprandi G, Barberi S. Eosinophilic gastrointestinal disorders and allergen immunotherapy: Lights and shadows. Pediatr Allergy Immunol 2021; 32:814-823. [PMID: 33503273 DOI: 10.1111/pai.13458] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 01/07/2023]
Abstract
Allergic diseases, such as IgE-mediated food allergy, asthma, and allergic rhinitis, are relevant health problems worldwide and show an increasing prevalence. Therapies for food allergies are food avoidance and the prompt administration of intramuscular epinephrine in anaphylaxis occurring after accidental exposure. However, allergen immunotherapy (AIT) is being investigated as a new potential tool for treating severe food allergies. Effective oral immunotherapy (OIT) and epicutaneous immunotherapy (EPIT) induce desensitization and restore immune tolerance to the causal allergen. While immediate side effects are well known, the long-term effects of food AIT are still underestimated. In this regard, eosinophilic gastrointestinal disorders (EGIDs), mainly eosinophilic esophagitis, have been reported as putative complications of OIT for food allergy and sublingual immunotherapy (SLIT) for allergic asthma and rhinitis. Fortunately, these complications are usually reversible and the patient recovers after AIT discontinuation. This review summarizes current knowledge on the possible causative link between eosinophilic gastrointestinal disorders and AIT, highlighting recent evidence and controversies.
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Affiliation(s)
- Martina Votto
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Maria De Filippo
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Lucia Caminiti
- Department of Pediatrics, Allergy Unit, University of Messina, Messina, Italy
| | - Francesco Carella
- Pediatric Unit, Azienza Ospedaliera Universitaria Policlinico Giovanni XXIII, Bari, Italy
| | | | - Massimo Landi
- Pediatric National Healthcare System, Turin - Istituto di Biomedicina e Immunologia molecolare, Italian National Research Council, Palermo, Italy
| | - Roberta Olcese
- Allergy Center, Department of Pediatrics, Istituto Giannina Gaslini, Genoa, Italy
| | | | - Gian Luigi Marseglia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
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24
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The role of the allergist in the management of eosinophilic esophagitis. Curr Opin Gastroenterol 2021; 37:390-396. [PMID: 34059605 PMCID: PMC8527848 DOI: 10.1097/mog.0000000000000746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide the current understanding of the role of allergens/antigens, the use of allergy testing, and to elucidate the role of the allergist in the management of eosinophilic esophagitis (EoE). RECENT FINDINGS EoE is a T2 immune disorder that is part of the atopic march. EoE patients commonly have multiple concurrent allergic disorders. Recent studies demonstrate that, like other allergic diseases, epithelial barrier dysfunction plays a key role in EoE pathogenesis. Aero- and food allergens have been identified as EoE triggers. EoE management includes the assessment and avoidance of its instigating antigens. Due to the integrated T2 immune response in an allergic individual, proper EoE care should include the control of underlying atopic disorders. EoE is a complex disease that is optimally managed by a multidisciplinary approach. SUMMARY This review provides an update on the role of the allergist in the clinical management of EoE.
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25
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Wright BL, Fernandez-Becker NQ, Kambham N, Purington N, Cao S, Tupa D, Zhang W, Sindher SB, Rank MA, Kita H, Katzka DA, Shim KP, Bunning BJ, Doyle AD, Jacobsen EA, Tsai M, Boyd SD, Manohar M, Chinthrajah RS. Gastrointestinal Eosinophil Responses in a Longitudinal, Randomized Trial of Peanut Oral Immunotherapy. Clin Gastroenterol Hepatol 2021; 19:1151-1159.e14. [PMID: 32434067 PMCID: PMC8445108 DOI: 10.1016/j.cgh.2020.05.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Gastrointestinal side effects are common during oral immunotherapy (OIT) and eosinophilic esophagitis (EoE) is a potential complication. We aimed to characterize eosinophilic gastrointestinal responses to peanut OIT, in which peanut protein is given orally, with incremental increases in dose over time. METHODS Twenty adults with IgE-mediated peanut allergy were randomly assigned to groups given peanut OIT (n = 15) or placebo (n = 5); 1 additional subject withdrew before randomization. Serial gastrointestinal biopsies were collected at baseline (n = 21, 0 weeks), following dose escalation (n = 10, 52 weeks), and during the maintenance phase (n = 11, 104 weeks). Endoscopic findings were characterized using the EoE endoscopic reference score. Biopsies were assessed for eosinophils per high-power field (eos/hpf) and other pathology features using EoE histologic scoring system scores. We performed immunohistochemical analyses of eosinophil peroxidase deposition, quantified using automated image analysis. RESULTS At baseline, no subjects reported current gastrointestinal symptoms. However, 3 of the 21 subjects (14%) had esophageal peak eosinophil counts ≥15 eos/hpf and all subjects had dilated intercellular spaces (DIS). OIT induced or exacerbated esophageal eosinophilia (EE) at 52 weeks in most subjects (peak eosinophil counts >5 eos/hpf in 6 of 7 patients [86%]; peak eosinophil counts ≥15 eos/hpf in 4 of 7 patients [57%]). One subject met clinicopathologic criteria for EoE and withdrew; no significant changes in esophageal peak eosinophil counts were observed in the placebo group. EE in the OIT group corresponded with significant increases in EoE histologic scoring system scores and deposition of eosinophil peroxidase. In 4 of 6 participants (67%), OIT-induced EE and gastrointestinal eosinophilia resolved by the end of the maintenance phase. Gastrointestinal symptoms were not clearly associated with EE or gastrointestinal eosinophilia. CONCLUSIONS In this pilot study, we found that peanut OIT-induced EE and gastrointestinal eosinophilia are usually transient and are not always associated with gastrointestinal symptoms. Clinicaltrials.gov no: NCT02103270.
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Affiliation(s)
- Benjamin L. Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States,Division of Pulmonology, Phoenix Children’s Hospital, Phoenix, AZ, United States
| | - Nielsen Q. Fernandez-Becker
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Neeraja Kambham
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Natasha Purington
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Shu Cao
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Dana Tupa
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Wenming Zhang
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Sayantani B. Sindher
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Matthew A. Rank
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States,Division of Pulmonology, Phoenix Children’s Hospital, Phoenix, AZ, United States
| | - Hirohito Kita
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States,Department of Immunology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - David A. Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN. United States
| | - Kelly P. Shim
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States,Division of Pulmonology, Phoenix Children’s Hospital, Phoenix, AZ, United States
| | - Bryan J. Bunning
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - Alfred D. Doyle
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Elizabeth A. Jacobsen
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States,Department of Immunology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Mindy Tsai
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Scott D. Boyd
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States,Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Monali Manohar
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
| | - R. Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA, United States
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Image Analysis of Eosinophil Peroxidase Immunohistochemistry for Diagnosis of Eosinophilic Esophagitis. Dig Dis Sci 2021; 66:775-783. [PMID: 32248390 PMCID: PMC7541435 DOI: 10.1007/s10620-020-06230-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diagnosis of eosinophilic esophagitis (EoE) requires manual quantification of tissue eosinophils. Eosinophil peroxidase (EPX) is an eosinophil-specific, cytoplasmic granule protein released during degranulation. AIMS The objective of this study was to evaluate image analysis of EPX immunohistochemistry as an automated method for histologic diagnosis of EoE. METHODS We performed a secondary analysis of prospectively collected esophageal biopsies obtained from adult subjects with EoE and controls. Tissue sections were stained with hematoxylin and eosin (H&E) and evaluated for peak eosinophils per high power field (eos/hpf). The same slides were de-stained and re-stained to detect EPX for direct comparison. Slides were digitized, and EPX staining area/mm2 was quantified using image analysis. Paired samples were compared for changes in EPX staining in treatment responders and non-responders. RESULTS Thirty-eight EoE cases and 49 controls were analyzed. Among EoE subjects, matched post-treatment biopsies were available for 21 responders and 10 non-responders. Baseline EPX/mm2 was significantly increased in EoE subjects and decreased in treatment responders. EPX quantification correlated strongly with eos/hpf (r = 0.84, p < 0.0001) and identified EoE subjects with high diagnostic accuracy (AUC 0.95, p < 0.0001). The optimal diagnostic EPX-positive pixel/area threshold was 17,379 EPX/mm2. Several controls (5/49) with < 15 eos/hpf on H&E staining exceeded this cutoff. CONCLUSIONS EPX/mm2 correlates strongly with eos/hpf, accurately identifies subjects with EoE, and decreases in treatment responders. Automated quantification of intact eosinophils and their degranulation products may enhance pathologic assessment. Future studies are needed to correlate EPX/mm2 with symptoms, endoscopic findings, and esophageal distensibility.
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27
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Leonard SA, Laubach S, Wang J. Integrating oral immunotherapy into clinical practice. J Allergy Clin Immunol 2021; 147:1-13. [PMID: 33436161 DOI: 10.1016/j.jaci.2020.11.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/04/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
In 2020, the first food allergy treatment, an oral immunotherapy (OIT) product for peanut allergy, was approved by the Food and Drug Administration, and a peanut epicutaneous immunotherapy patch was under review. As food allergy therapies become available and widespread, allergy offices will need to adjust practices to be able to offer their patients these new treatments. OIT is an intensive therapy that requires commitment from patients and their families, and open communication with the practice is paramount. OIT may not be the right therapy for every patient, and although identifying good candidates is still an area rich for research opportunity, experience from cohorts and clinical trials provides some insight. It is important to understand the scope of practice for each member of the OIT team based on state regulations for a particular location. Staffing and space will likely dictate how many patients at an individual office could be on active OIT at one time. Emergency medications, supplies, and protocols must be in place. Screening, scheduling, visit procedures, monitoring, home dosing, dose modifications, safety precautions, adverse reactions, and maintenance will be addressed in this article. Finally, adjunct therapies under investigation will be reviewed.
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Affiliation(s)
- Stephanie A Leonard
- Division of Pediatric Allergy & Immunology, University of California San Diego, Rady Children's Hospital San Diego, San Diego, Calif.
| | - Susan Laubach
- Division of Pediatric Allergy & Immunology, University of California San Diego, Rady Children's Hospital San Diego, San Diego, Calif
| | - Julie Wang
- Jaffe Food Allergy Institute, Division of Pediatric Allergy, Mount Sinai School of Medicine, New York, NY
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28
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Hamant L, Freeman C, Garg S, Wright BL, Schroeder S. Eosinophilic esophagitis may persist after discontinuation of oral immunotherapy. Ann Allergy Asthma Immunol 2020; 126:299-302. [PMID: 33340664 DOI: 10.1016/j.anai.2020.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 11/28/2020] [Accepted: 12/07/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Laura Hamant
- Division of Gastroenterology, Phoenix Children's Hospital, Phoenix, AZ
| | - Catherine Freeman
- Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ; Division of Pathology and Laboratory Medicine, Phoenix Children's Hospital, Phoenix, AZ
| | - Shipra Garg
- Division of Pathology and Laboratory Medicine, Phoenix Children's Hospital, Phoenix, AZ; Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ
| | - Benjamin L Wright
- Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ; Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ; Division of Allergy, Asthma and Clinical Immunology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Shauna Schroeder
- Division of Gastroenterology, Phoenix Children's Hospital, Phoenix, AZ; Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ.
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29
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Wilson JM, Li RC, McGowan EC. The Role of Food Allergy in Eosinophilic Esophagitis. J Asthma Allergy 2020; 13:679-688. [PMID: 33364787 PMCID: PMC7751314 DOI: 10.2147/jaa.s238565] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/26/2020] [Indexed: 12/30/2022] Open
Abstract
Food allergy is often understood as an IgE-mediated hypersensitivity, characterized by allergic symptoms which occur “immediately” after the ingestion of a relevant food allergen. Increasingly, however, other food-related immune-mediated disorders are recognized in which symptoms can have a delayed onset and IgE does not play a central role. One of the described examples of the latter is eosinophilic esophagitis (EoE) – a disease defined pathologically by local eosinophilic inflammation in the esophagus in the setting of symptoms of esophageal dysfunction. The evidence that EoE is a food-mediated allergic disease includes i) almost all patients respond to an elemental diet and many respond to a diet in which dairy, wheat, eggs and/or soy are eliminated, ii) the presence of food-specific IgE and Th2 cells are consistent with a loss of tolerance to trigger foods and iii) many EoE patients have concomitant IgE-mediated food allergy and other allergic co-morbidities. This narrative review focuses on the hypothesis that EoE is a form of chronic food allergy. The goal is to describe similarities and differences in EoE and IgE-mediated food allergy, and to consider ways that these two increasingly common forms of food allergy are related to each other.
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Affiliation(s)
- Jeffrey M Wilson
- Division of Allergy and Immunology, University of Virginia, Charlottesville, VA, USA
| | - Rung-Chi Li
- Division of Allergy and Immunology, University of Virginia, Charlottesville, VA, USA
| | - Emily C McGowan
- Division of Allergy and Immunology, University of Virginia, Charlottesville, VA, USA
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30
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Doyle AD, Masuda MY, Kita H, Wright BL. Eosinophils in Eosinophilic Esophagitis: The Road to Fibrostenosis is Paved With Good Intentions. Front Immunol 2020; 11:603295. [PMID: 33335531 PMCID: PMC7736408 DOI: 10.3389/fimmu.2020.603295] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 11/03/2020] [Indexed: 12/15/2022] Open
Abstract
Eosinophilic esophagitis (EoE) is an antigen-driven disease associated with epithelial barrier dysfunction and chronic type 2 inflammation. Eosinophils are the defining feature of EoE histopathology but relatively little is known about their role in disease onset and progression. Classically defined as destructive, end-stage effector cells, eosinophils (a resident leukocyte in most of the GI tract) are increasingly understood to play roles in local immunity, tissue homeostasis, remodeling, and repair. Indeed, asymptomatic esophageal eosinophilia is observed in IgE-mediated food allergy. Interestingly, EoE is a potential complication of oral immunotherapy (OIT) for food allergy. However, we recently found that patients with peanut allergy may have asymptomatic esophageal eosinophilia at baseline and that peanut OIT induces transient esophageal eosinophilia in most subjects. This is seemingly at odds with multiple studies which have shown that EoE disease severity correlates with tissue eosinophilia. Herein, we review the potential role of eosinophils in EoE at different stages of disease pathogenesis. Based on current literature we suggest the following: (1) eosinophils are recruited to the esophagus as a homeostatic response to epithelial barrier disruption; (2) eosinophils mediate barrier-protective activities including local antibody production, mucus production and epithelial turnover; and (3) when type 2 inflammation persists, eosinophils promote fibrosis.
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Affiliation(s)
- Alfred D Doyle
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Mia Y Masuda
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Hirohito Kita
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Department of Immunology, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | - Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, United States.,Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, United States
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31
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Eosinophilic Esophagitis as a Side Effect of Food Oral Immunotherapy. ACTA ACUST UNITED AC 2020; 56:medicina56110618. [PMID: 33207848 PMCID: PMC7697667 DOI: 10.3390/medicina56110618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 02/06/2023]
Abstract
Food allergies (FAs) include a spectrum of immune-mediated serious and potentially life-threatening medical conditions with an overall estimated prevalence ranging from 4% to 8% in the U.S. and Europe. Significant progress in food allergen-specific immunotherapy has been accomplished over the past 10 years. The most studied strategy has been oral immunotherapy (OIT), also known as food desensitization, a treatment in which a child is slowly and deliberately given a small amount of the food to ingest (that previously was a food allergy trigger) with the ultimate goal of the child eating that food without a reaction. OIT is now recommended in the European guidelines for the treatment of milk, egg, and peanut allergies and was the first American Food Drug Administration (FDA) approved product for the prevention of severe reaction to peanuts in 4–17 year olds to be released on the market. The side effects associated with OIT treatment trials are mild to moderate, predominantly oropharyngeal, and easily treated. More severe reactions, such as generalized urticaria/angioedema, wheezing/respiratory distress, laryngeal edema, and repetitive emesis, have been reported. However systemic reactions are very rare. Low-dose immunotherapy is associated with significantly fewer side effects. Currently, its most limiting allergic side effect is that approximately 10–15% of subjects treated with OIT experience gastrointestinal symptoms, preventing the continuation of therapy. Eosinophilic esophagitis (EoE) has also been reported as a cause of persistent abdominal symptoms in OIT.
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32
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Manresa MC, Chiang AWT, Kurten RC, Dohil R, Brickner H, Dohil L, Herro R, Akuthota P, Lewis NE, Croft M, Aceves SS. Increased Production of LIGHT by T Cells in Eosinophilic Esophagitis Promotes Differentiation of Esophageal Fibroblasts Toward an Inflammatory Phenotype. Gastroenterology 2020; 159:1778-1792.e13. [PMID: 32712105 PMCID: PMC7726704 DOI: 10.1053/j.gastro.2020.07.035] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/07/2020] [Accepted: 07/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis (EoE) is an antigen-mediated eosinophilic disease of the esophagus that involves fibroblast activation and progression to fibrostenosis. Cytokines produced by T-helper type 2 cells and transforming growth factor beta 1 (TGFβ1) contribute to the development of EoE, but other cytokines involved in pathogenesis are unknown. We investigate the effects of tumor necrosis factor superfamily member 14 (TNFSF14, also called LIGHT) on fibroblasts in EoE. METHODS We analyzed publicly available esophageal CD3+ T-cell single-cell sequencing data for expression of LIGHT. Esophageal tissues were obtained from pediatric patients with EoE or control individuals and analyzed by immunostaining. Human primary esophageal fibroblasts were isolated from esophageal biopsy samples of healthy donors or patients with active EoE. Fibroblasts were cultured; incubated with TGFβ1 and/or LIGHT; and analyzed by RNA sequencing, flow cytometry, immunoblots, immunofluorescence, or reverse transcription polymerase chain reaction. Eosinophils were purified from peripheral blood of healthy donors, incubated with interleukin 5, cocultured with fibroblasts, and analyzed by immunohistochemistry. RESULTS LIGHT was up-regulated in the esophageal tissues from patients with EoE, compared with control individuals, and expressed by several T-cell populations, including T-helper type 2 cells. TNF receptor superfamily member 14 (TNFRSF14, also called HVEM) and lymphotoxin beta receptor are receptors for LIGHT that were expressed by fibroblasts from healthy donors or patients with active EoE. Stimulation of esophageal fibroblasts with LIGHT induced inflammatory gene transcription, whereas stimulation with TGFβ1 induced transcription of genes associated with a myofibroblast phenotype. Stimulation of fibroblasts with TGFβ1 increased expression of HVEM; subsequent stimulation with LIGHT resulted in their differentiation into cells that express markers of myofibroblasts and inflammatory chemokines and cytokines. Eosinophils tethered to esophageal fibroblasts after LIGHT stimulation via intercellular adhesion molecule-1. CONCLUSIONS T cells in esophageal tissues from patients with EoE express increased levels of LIGHT compared with control individuals, which induces differentiation of fibroblasts into cells with inflammatory characteristics. TGFβ1 increases fibroblast expression of HVEM, a receptor for LIGHT. LIGHT mediates interactions between esophageal fibroblasts and eosinophils via ICAM1. This pathway might be targeted for the treatment of EoE.
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Affiliation(s)
- Mario C Manresa
- Department of Pediatrics, University of California, San Diego, San Diego; Division of Allergy Immunology; La Jolla Institute for Immunology, La Jolla, California
| | - Austin W T Chiang
- Department of Pediatrics, University of California, San Diego, San Diego; Novo Nordisk Foundation Center for Biosustainability at the University of California, San Diego, San Diego, California
| | - Richard C Kurten
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital Research Institute, Little Rock, Arkansas
| | | | - Howard Brickner
- Department of Medicine, University of California, San Diego, San Diego, California
| | - Lucas Dohil
- Department of Pediatrics, University of California, San Diego, San Diego
| | - Rana Herro
- Cincinnati Children's Hospital Medical Center, Immunobiology Division, Cincinnati, Ohio
| | - Praveen Akuthota
- Division of Gastroenterology, Department of Pediatrics, University of California, San Diego; Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California
| | - Nathan E Lewis
- Department of Pediatrics, University of California, San Diego, San Diego; Novo Nordisk Foundation Center for Biosustainability at the University of California, San Diego, San Diego, California; Department of Bioengineering, University of California, San Diego, San Diego, California
| | - Michael Croft
- La Jolla Institute for Immunology, La Jolla, California; Division of Gastroenterology, Department of Pediatrics, University of California, San Diego
| | - Seema S Aceves
- Department of Pediatrics, University of California, San Diego, San Diego; Division of Allergy Immunology; Rady Children's Hospital, San Diego; Division of Gastroenterology, Department of Pediatrics, University of California, San Diego.
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33
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Schreiner P, Biedermann L, Greuter T, Wright BL, Straumann A. How to approach adult patients with asymptomatic esophageal eosinophilia. Dis Esophagus 2020; 34:5917397. [PMID: 33016307 PMCID: PMC7947174 DOI: 10.1093/dote/doaa105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/25/2020] [Accepted: 09/06/2020] [Indexed: 12/11/2022]
Abstract
As the awareness among gastroenterologists regarding endoscopic features suggesting eosinophilic esophagitis is increasing, individuals without symptoms of esophageal dysfunction are increasingly being found to have esophageal eosinophilia on biopsies performed during upper gastrointestinal endoscopies. However, the course of disease and the management of these asymptomatic individuals with esophageal eosinophilia remain elusive. In this review, we propose a definition of asymptomatic individuals with esophageal eosinophilia and discuss the prevalence, risk factors, and course of disease of this specific patient group. Furthermore, we have established a diagnostic and therapeutic pathway based on the most recent available data.
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Affiliation(s)
- Philipp Schreiner
- Address correspondence to: Dr. Philipp Schreiner, Department of Gastroenterology and Hepatology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - Luc Biedermann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Thomas Greuter
- Department of Gastroenterology & Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA,Division of Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Alex Straumann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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34
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Eosinophilic esophagitis as a complication of food oral immunotherapy. Curr Opin Allergy Clin Immunol 2020; 20:616-623. [DOI: 10.1097/aci.0000000000000688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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35
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Abstract
PURPOSE OF REVIEW To critically appraise the recent most relevant studies in the rapidly advancing field of food oral and sublingual immunotherapy. RECENT FINDINGS Food allergen-specific immunotherapy via oral (OIT) and sublingual route (SLIT) increases the threshold of reactivity to peanut, cow's milk, egg, wheat, and many other foods in the majority of the treated individuals. This desensitized state is contingent upon the continued ingestion of the maintenance doses of the food. Permanent oral tolerance is achievable in a smaller subset of the treated individuals. The optimal duration of therapy has not been firmly established but is likely dependent on the phenotype (severity and persistence). Efficacy of food-OIT is superior compared with SLIT, whereas the safety of OIT is less favorable. Standardization of treatment protocols, maintenance dosing, duration of therapy, target populations and harmonization of the outcomes are top priorities at this stage. SUMMARY OIT and SLIT represent two different routes of food allergen-specific immunotherapy. Although significant progress has been made in the last decade, both treatment modalities are still in the very early stages of development and further investigations are necessary to optimize the protocols and improve safety while maximizing efficacy.
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36
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Abstract
The US Food and Drug Administration's approval of a peanut oral immunotherapy product in January 2020 is a landmark development in the field of food allergy therapy. While food allergy prevalence has been increasing, this product is the first approved therapy for food allergy. Oral immunotherapy has many similarities to subcutaneous immunotherapy and drug desensitization protocols, but does not lead to sustained unresponsiveness. The studies leading to approval of the Palforzia product demonstrated increase in the amount of peanut protein able to be consumed, with 67% of subjects randomized to the treatment arm able to consume 600 mg of peanut protein in double-blind placebo-controlled food challenge at study exit. However, side effects are an important consideration, and dropout rates in studies of Palforzia ranged from 11% to 21%. Postmarketing surveillance of this product will be critical in assessing its long-term risks and benefits.
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Affiliation(s)
- Joan H Dunlop
- Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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37
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Sampath V, Sindher SB, Alvarez Pinzon AM, Nadeau KC. Can food allergy be cured? What are the future prospects? Allergy 2020; 75:1316-1326. [PMID: 31733120 DOI: 10.1111/all.14116] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 10/15/2019] [Accepted: 10/17/2019] [Indexed: 12/31/2022]
Abstract
Food allergies have become a significant heath burden as prevalence continues to rise, affecting 6%-13% of the global population. In the absence of drugs approved by regulatory agencies, the current standard of care remains avoidance of allergenic foods and management of acute allergic reactions with antihistamines and epinephrine autoinjectors. Allergen immunotherapy has been shown to increase the threshold of reactivity in the majority of food-allergic individuals. However, challenges include long treatment periods, high rates of adverse reactions, and lack of permanence of desensitization and established protocols. To address these limitations, adjunctive allergen-specific immunotherapy, vaccines, and non-allergen-specific therapies (eg, monoclonal antibodies) are being explored. The future of food allergy treatment is promising with a number of clinical trials in progress. Currently, although desensitization can be achieved for the majority of individuals with food allergy through immunotherapy, continued ingestion of allergen is needed for most individuals to maintain desensitization. Further understanding of the mechanisms of food allergy and identification of biomarkers to distinguish between temporary and permanent resolution of allergies is needed before a cure, where reactivity to the allergen is permanently lost enabling the individual to consume the allergen in any amount at any time, can be envisioned.
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Affiliation(s)
- Vanitha Sampath
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
- Division of Pulmonary and Critical Care Medicine Stanford University Stanford CA USA
| | - Sayantani B. Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
- Division of Pulmonary and Critical Care Medicine Stanford University Stanford CA USA
| | - Andres M. Alvarez Pinzon
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
- Division of Pulmonary and Critical Care Medicine Stanford University Stanford CA USA
| | - Kari C. Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
- Division of Pulmonary and Critical Care Medicine Stanford University Stanford CA USA
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38
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Eosinophilic Esophagitis Histology Remission Score: Significant Relations to Measures of Disease Activity and Symptoms. J Pediatr Gastroenterol Nutr 2020; 70:598-603. [PMID: 31977951 PMCID: PMC7183895 DOI: 10.1097/mpg.0000000000002637] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Eosinophilic esophagitis (EoE) is characterized by remissions and relapses. Guidelines defining remission do not exist and therefore remission is inconsistently identified. We sought to define histology remission in EoE. METHODS Esophageal biopsies, obtained at the time the validated pediatric EoE symptoms scores v2.0 (PEESS v2.0) questionnaire was completed (N = 42), were scored using the validated EoE Histology Scoring System. An EoE Histology Remission Score (EoEHRS) was constructed and specified that in all esophageal sites sampled the peak eosinophil count was <15 per high power field (HPF); in addition, neither the total grade (severity of pathology) nor stage (extent of pathology) scores could exceed 3 (possible total maximum score for each was 24). Spearman correlation coefficients were generated for histology/symptom correlations; coefficient range 0.31 to 0.50 was considered moderate. RESULTS EoE Histology Scoring System composite and individual feature scores from proximal and distal esophageal biopsies correlated moderately with PEESS v2.0 mean scores (0.48-0.36, P < 0.01), and with scores in the dysphagia (0.39-0.30, P ≤ 0.01), pain (0.48-0.34, P ≤ 0.01), and gastroesophageal reflux disease (0.51-0.32, P ≤ 0.01) domains. Biopsies that met full EoEHRS criteria had reduced biomarkers, specifically expression of the mast cell markers CPA3 and tryptase mRNA, and reduced eosinophil peroxidase deposition (P < 0.03), compared to those with nonremission scores. Subjects whose biopsies met EoEHRS remission criteria reported reduced symptoms for all domains except nausea and vomiting (P ≤ 0.01). CONCLUSIONS The EoEHRS correlated with reduced biomarkers of disease activity and reduced symptoms, and therefore may be useful to inform clinical care and interstudy comparisons.
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Nicolaides RE, Parrish CP, Bird JA. Food Allergy Immunotherapy with Adjuvants. Immunol Allergy Clin North Am 2020; 40:149-173. [DOI: 10.1016/j.iac.2019.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Long A, Borro M, Sampath V, Chinthrajah RS. New Developments in Non-allergen-specific Therapy for the Treatment of Food Allergy. Curr Allergy Asthma Rep 2020; 20:3. [PMID: 31950290 DOI: 10.1007/s11882-020-0897-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW The prevalence of food allergy is increasing. At the current time, there are no approved treatments for food allergy. Major limitations of immunotherapy are long treatment periods (months or years), frequent clinic visits, high costs, increased risk of adverse events during treatment, and lack of durability of desensitization. Additionally, it is allergen-specific, and in those allergic to multiple allergens, the length and cost of treatment are further increased. In this review, we summarize recent developments in novel non-allergen-specific treatments for food allergy. RECENT FINDINGS A number of monoclonal antibodies that block IgE or specific pro-allergenic cytokines or their receptors have shown promise in clinical trials for food allergy. The insight we have gained through the use of one drug for the treatment of an atopic disease is quickly being translated to other atopic diseases, including food allergy. The future for food allergy treatment with biologics looks bright.
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Affiliation(s)
- Andrew Long
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Grant Building, S093, 300 Pasteur Dr., Stanford, CA, 94305-5101, USA.,Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Matteo Borro
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Grant Building, S093, 300 Pasteur Dr., Stanford, CA, 94305-5101, USA.,Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.,Department of Internal Medicine, Clinical Immunology Unit, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Vanitha Sampath
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Grant Building, S093, 300 Pasteur Dr., Stanford, CA, 94305-5101, USA.,Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Grant Building, S093, 300 Pasteur Dr., Stanford, CA, 94305-5101, USA. .,Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA.
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Chinthrajah RS, Purington N, Andorf S, Long A, O'Laughlin KL, Lyu SC, Manohar M, Boyd SD, Tibshirani R, Maecker H, Plaut M, Mukai K, Tsai M, Desai M, Galli SJ, Nadeau KC. Sustained outcomes in oral immunotherapy for peanut allergy (POISED study): a large, randomised, double-blind, placebo-controlled, phase 2 study. Lancet 2019; 394:1437-1449. [PMID: 31522849 PMCID: PMC6903389 DOI: 10.1016/s0140-6736(19)31793-3] [Citation(s) in RCA: 187] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/08/2019] [Accepted: 06/14/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Dietary avoidance is recommended for peanut allergies. We evaluated the sustained effects of peanut allergy oral immunotherapy (OIT) in a randomised long-term study in adults and children. METHODS In this randomised, double-blind, placebo-controlled, phase 2 study, we enrolled participants at the Sean N Parker Center for Allergy and Asthma Research at Stanford University (Stanford, CA, USA) with peanut allergy aged 7-55 years with a positive result from a double-blind, placebo-controlled, food challenge (DBPCFC; ≤500 mg of peanut protein), a positive skin-prick test (SPT) result (≥5 mm wheal diameter above the negative control), and peanut-specific immunoglobulin (Ig)E concentration of more than 4 kU/L. Participants were randomly assigned (2·4:1·4:1) in a two-by-two block design via a computerised system to be built up and maintained on 4000 mg peanut protein through to week 104 then discontinued on peanut (peanut-0 group), to be built up and maintained on 4000 mg peanut protein through to week 104 then to ingest 300 mg peanut protein daily (peanut-300 group) for 52 weeks, or to receive oat flour (placebo group). DBPCFCs to 4000 mg peanut protein were done at baseline and weeks 104, 117, 130, 143, and 156. The pharmacist assigned treatment on the basis of a randomised computer list. Peanut or placebo (oat) flour was administered orally and participants and the study team were masked throughout by use of oat flour that was similar in look and feel to the peanut flour and nose clips, as tolerated, to mask taste. The statistician was also masked. The primary endpoint was the proportion of participants who passed DBPCFCs to a cumulative dose of 4000 mg at both 104 and 117 weeks. The primary efficacy analysis was done in the intention-to-treat population. Safety was assessed in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT02103270. FINDINGS Between April 15, 2014, and March 2, 2016, of 152 individuals assessed, we enrolled 120 participants, who were randomly assigned to the peanut-0 (n=60), peanut-300 (n=35), and placebo groups (n=25). 21 (35%) of peanut-0 group participants and one (4%) placebo group participant passed the 4000 mg challenge at both 104 and 117 weeks (odds ratio [OR] 12·7, 95% CI 1·8-554·8; p=0·0024). Over the entire study, the most common adverse events were mild gastrointestinal symptoms, which were seen in 90 of 120 patients (50/60 in the peanut-0 group, 29/35 in the peanut-300 group, and 11/25 in the placebo group) and skin disorders, which were seen in 50/120 patients (26/60 in the peanut-0 group, 15/35 in the peanut-300 group, and 9/25 in the placebo group). Adverse events decreased over time in all groups. Two participants in the peanut groups had serious adverse events during the 3-year study. In the peanut-0 group, in which eight (13%) of 60 participants passed DBPCFCs at week 156, higher baseline peanut-specific IgG4 to IgE ratio and lower Ara h 2 IgE and basophil activation responses were associated with sustained unresponsiveness. No treatment-related deaths occurred. INTERPRETATION Our study suggests that peanut OIT could desensitise individuals with peanut allergy to 4000 mg peanut protein but discontinuation, or even reduction to 300 mg daily, could increase the likelihood of regaining clinical reactivity to peanut. Since baseline blood tests correlated with week 117 treatment outcomes, this study might aid in optimal patient selection for this therapy. FUNDING National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- R Sharon Chinthrajah
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Natasha Purington
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA; Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - Sandra Andorf
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Andrew Long
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Katherine L O'Laughlin
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Shu Chen Lyu
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Monali Manohar
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Scott D Boyd
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Pathology, Stanford University, Stanford, CA, USA
| | - Robert Tibshirani
- Department of Biomedical Data Sciences, Stanford University, Stanford, CA, USA; Department of Statistics, Stanford University, Stanford, CA, USA
| | - Holden Maecker
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Microbiology and Immunology, Stanford University, Stanford, CA, USA
| | - Marshall Plaut
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Kaori Mukai
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Pathology, Stanford University, Stanford, CA, USA
| | - Mindy Tsai
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Pathology, Stanford University, Stanford, CA, USA
| | - Manisha Desai
- Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - Stephen J Galli
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Pathology, Stanford University, Stanford, CA, USA; Department of Microbiology and Immunology, Stanford University, Stanford, CA, USA
| | - Kari C Nadeau
- Sean N Parker Center for Allergy and Asthma Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA.
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Risk Factors and Treatment Outcomes for Oral Immunotherapy-Induced Gastrointestinal Symptoms and Eosinophilic Responses (OITIGER). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:125-131. [PMID: 31382040 DOI: 10.1016/j.jaip.2019.07.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 07/24/2019] [Accepted: 07/24/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND We recently described that oral immunotherapy (OIT)-induced gastrointestinal symptoms were associated with peripheral eosinophilic responses (termed OITIGER). OBJECTIVE To identify treatment outcomes after dose modification and risk factors for developing OITIGER. METHODS Treatment modifications in patients with OITIGER (n = 65) including cumulative dose reductions or treatment suspension were individualized and based on the severity of symptoms and an associated absolute eosinophil count (AEC, eosinophils/μL) of more than 900. Multivariate analysis for risk factors associated with OITIGER was performed in milk-OIT subjects. RESULTS Treatment modifications reduced the cumulative daily dosage load by a median of 50% (interquartile range, 50%-67%) in 43 of 65 (66.1%) patients, deferred dose increases in 2 of 65 (3.1%) patients, or temporarily suspended treatment in 18 of 65 (27.7%) patients. Two patients (3.1%) had no treatment intervention. Symptoms and eosinophilia abated on dosage modification, allowing for resumption of dose increases (n = 34) or reinitiation of treatment (n = 9) after a median of 29 (interquartile range, 20-56) and 19 (interquartile range, 17-44) days, respectively. OITIGER reoccurred during treatment in 10 of 54 (18.5%) patients, which resolved after further dose modification. In long-term follow-up (>3-26 months), 31 of 32 patients were asymptomatic with stable AECs. Patients with OITIGER had a higher OIT failure rate (P = .004) and were less likely to reach full desensitization (P < .001), as compared with asymptomatic patients (n = 684). Multivariate analysis identified several risk factors for OITIGER: starting dose more than 120 mg (P < .001; odds ratio, 7.14), second-month dose more than 4-fold over the starting dose (P = .037; odds ratio, 2.18), and baseline AEC more than 600/μL (P = .002; odds ratio, 3.2). CONCLUSIONS OITIGER is transient or reversible in most subjects, and its occurrence is related to OIT starting dose, its rate of increase, and baseline AECs.
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Ruffner MA, Capucilli P, Hill DA, Spergel JM. Screening children for eosinophilic esophagitis: allergic and other risk factors. Expert Rev Clin Immunol 2019; 15:315-318. [PMID: 30722709 DOI: 10.1080/1744666x.2019.1579643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Melanie A Ruffner
- a Division of Allergy & Immunology , Children's Hospital of Philadelphia , Philadelphia , PA , USA.,b Department of Pediatrics , University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
| | - Peter Capucilli
- a Division of Allergy & Immunology , Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - David A Hill
- a Division of Allergy & Immunology , Children's Hospital of Philadelphia , Philadelphia , PA , USA.,b Department of Pediatrics , University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
| | - Jonathan M Spergel
- a Division of Allergy & Immunology , Children's Hospital of Philadelphia , Philadelphia , PA , USA.,b Department of Pediatrics , University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
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