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Lloyd M, Loke P, Ashley S, Lozinsky AC, Orsini F, O'Sullivan M, Gold M, Quinn P, Metcalfe J, Tang MLK. Interaction Between Baseline Participant Factors and Treatment Effects Following Peanut Oral Immunotherapy. The Journal of Allergy and Clinical Immunology: In Practice 2024; 12:1019-1028.e2. [PMID: 38154554 DOI: 10.1016/j.jaip.2023.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/22/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND The Probiotic Peanut Oral Immunotherapy-003 multicenter randomized trial found that both probiotic peanut oral immunotherapy (PPOIT) and peanut OIT alone (OIT) were effective compared with placebo in inducing clinical remission after 18 months of treatment, and improving health-related quality of life (HRQL) at 12 months after treatment. Understanding treatment effect modifiers can optimize outcomes through precision care. OBJECTIVES This post hoc study examined baseline clinical and demographic participant factors that modified treatment effects. METHODS The study sample included 201 children (aged 1-10 years) with challenge-confirmed peanut allergy. Exposure variables were baseline clinical and demographic factors. Outcomes were remission (double-blind, placebo-controlled food challenge, cumulative 4,950-mg peanut protein at 8 weeks after treatment) and HRQL (change in Food Allergy Quality of Life Questionnaire-Parent Form score). Interactions between baseline factors and treatment effects on remission and HRQL were explored with regression models. RESULTS A higher degree of peanut sensitivity (large peanut skin prick test, high peanut specific IgE, and low reaction-eliciting dose at study entry challenge) and other concurrent allergic conditions (multiple food allergies, asthma, or wheeze) were associated with the decreased likelihood of attaining remission after both PPOIT and OIT treatment. History of anaphylaxis was associated with the reduced likelihood of remission after PPOIT compared with OIT. For the HRQL outcome, there was evidence that sex, history of anaphylaxis, and age modified treatment effects. CONCLUSIONS Baseline participant factors modify PPOIT and OIT effects on remission and HRQL. Considering modifiers of treatment effect during participant selection may optimize treatment success and clinical trial design toward specific outcomes, such as the achievement of remission.
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Affiliation(s)
- Melanie Lloyd
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia
| | - Paxton Loke
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Sarah Ashley
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Adriana C Lozinsky
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Francesca Orsini
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Clinical Epidemiology and Biostatistics, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Michael O'Sullivan
- Department of Immunology, Perth Children's Hospital, Nedlands, Western Australia, Australia; Telethon Kid Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Michael Gold
- Department of Paediatrics, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Department of Allergy and Clinical Immunology, Women's and Children's Health Network, North Adelaide, South Australia, Australia
| | - Patrick Quinn
- Department of Allergy and Clinical Immunology, Women's and Children's Health Network, North Adelaide, South Australia, Australia
| | - Jessica Metcalfe
- Department of Immunology, Perth Children's Hospital, Nedlands, Western Australia, Australia; Telethon Kid Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Mimi L K Tang
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia.
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O'Konek JJ. Animal Models in the Study of Food Allergens: Long-Term Maintenance of Allergic Reactivity in Mouse Models of Food Allergy. Methods Mol Biol 2024; 2717:321-335. [PMID: 37737995 DOI: 10.1007/978-1-0716-3453-0_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Multiple mouse models have been used to characterize mechanisms of allergic sensitization and anaphylaxis and are widely used for preclinical development of novel therapeutics. However, the majority of published works with mouse models of food allergy have very short intervals between the time of sensitization and the end of the study, and the duration of maintenance of reactivity has not been widely reported. This chapter focuses on two of the most commonly used mouse models with sensitization to peanut or ovalbumin, with the focus on the long-term durability of sensitization to allow for longer therapeutic protocols and assessment of sustained unresponsiveness.
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Affiliation(s)
- Jessica J O'Konek
- Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, MI, USA.
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3
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Macdougall JD, Kim EH. A clinical focus on oral tolerance in the development, prevention, and management of food allergy. Cell Immunol 2023; 386:104693. [PMID: 36854214 DOI: 10.1016/j.cellimm.2023.104693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 02/27/2023]
Abstract
Food allergy impacts up to 10 % of the population and can result in life-threatening anaphylactic reactions. The pathogenesis of food allergy is not entirely understood but the disruption in naturally occurring oral tolerance is presumed to be involved. Research has been directed not only toward prevention of food allergy but on the restoration of oral tolerance by various means including immunotherapy (oral, sublingual, and epicutaneous), as well as adjunctive therapies including biologicals and probiotics. This review paper briefly discusses the involvement of oral tolerance in the pathogenesis of food allergy and how food allergy might be prevented; however, the main focus is on the potential for restoration of oral tolerance with various treatment modalities (oral immunotherapy with and without adjunctive therapies).
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Affiliation(s)
- Jessica D Macdougall
- Department of Pediatric Allergy and Immunology, University of North Carolina School of Medicine, 5004 Mary Ellen Jones Bldg, 116 Manning Dr. CB 8035, Chapel Hill, NC 27599-8035, United States.
| | - Edwin H Kim
- Department of Pediatric Allergy and Immunology, University of North Carolina School of Medicine, 5004 Mary Ellen Jones Bldg, 116 Manning Dr. CB 8035, Chapel Hill, NC 27599-8035, United States.
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4
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Zuberbier T, Wood RA, Bindslev-Jensen C, Fiocchi A, Chinthrajah RS, Worm M, Deschildre A, Fernandez-Rivas M, Santos AF, Jaumont X, Tassinari P. Omalizumab in IgE-Mediated Food Allergy: A Systematic Review and Meta-Analysis. J Allergy Clin Immunol Pract 2022; 11:1134-1146. [PMID: 36529441 DOI: 10.1016/j.jaip.2022.11.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/14/2022] [Accepted: 11/26/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND A growing number of studies have shown encouraging results with omalizumab (OMA) as monotherapy and as an adjunct to oral immunotherapy (OMA+OIT) in patients with single/multiple food allergies. OBJECTIVES To evaluate the efficacy and safety of OMA or OMA+OIT in patients with immunoglobulin E (IgE)-mediated food allergy. METHODS An extensive literature search (inception to December 31, 2020) was performed to identify randomized, controlled, and observational studies that assessed OMA as monotherapy or OMA+OIT in patients with IgE-mediated food allergy. The outcomes were an increase in tolerated dose of foods, successful desensitization, sustained unresponsiveness, immunological biomarkers, severity of allergic reactions to food, quality of life (QoL), and safety. A P less than .05 was considered significant. RESULTS In total, 36 studies were included. The OMA monotherapy (vs pre-OMA) significantly increased the tolerated dose of multiple foods; increased the threshold of tolerated dose for milk, egg, wheat, and baked milk; improved QoL; and reduced food-induced allergic reactions (all P < .01). The OMA+OIT significantly increased the tolerated dose of multiple foods (vs placebo and pre-OMA), desensitization (vs placebo+OIT and pre-OMA) (all P ≤ .01), and improved QoL (vs pre-OMA) and immunoglobulin G4 levels (both P < .01). No major safety concerns were identified. CONCLUSIONS In IgE-mediated food allergy, OMA can help patients consume multiple foods and allow for food dose escalation. As an adjunct to OIT, OMA can also support high-dose desensitization and higher maintenance doses. Further studies are warranted to empirically evaluate the effect of OMA and confirm these findings.
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Affiliation(s)
- Torsten Zuberbier
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany; Institute for Allergology, Charité - University Medicine Berlin, Corporate Member of Freie University of Berlin and Humboldt University of Berlin, Berlin, Germany.
| | - Robert A Wood
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Carsten Bindslev-Jensen
- Odense Research Centre for Anaphylaxis, Odense University Hospital, Odense, Denmark; Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Alessandro Fiocchi
- Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - R Sharon Chinthrajah
- Sean N. Parker Centre for Allergy and Asthma Research, Stanford University, Stanford, Calif; Division of Pulmonary and Critical Care Medicine, Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, Calif
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergy, Charité - University Medicine, Berlin, Germany
| | - Antoine Deschildre
- CHU Lille, Pediatric Pulmonology and Allergy Unit, Jeanne de Flandre Hospital, University of Nord de France, Lille, France
| | - Montserrat Fernandez-Rivas
- Allergy Department, Hospital Clinico San Carlos, Universidad Complutense de Madrid (UCM), Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK; Children's Allergy Service, Evelina London, Guy's and St Thomas' Hospital, London, UK; Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
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5
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Davis CM, Anagnostou A, Devaraj S, Vita DT, Rivera F, Pitts K, Hearrell M, Minard C, Guffey D, Gupta M, Watkin L, Orange JS, Anvari S. Maximum Dose Food Challenges Reveal Transient Sustained Unresponsiveness in Peanut Oral Immunotherapy (POIMD Study). J Allergy Clin Immunol Pract 2022; 10:566-576.e6. [PMID: 34890827 PMCID: PMC10404846 DOI: 10.1016/j.jaip.2021.10.074] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 10/03/2021] [Accepted: 10/13/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The maximum tolerated dose of peanut protein following peanut oral immunotherapy (POIT) is unknown because most research studies have not examined very high thresholds. OBJECTIVE To define the maximum dose tolerated by patients on POIT and severity of allergic reactions after a 1-month period of treatment discontinuation. METHODS In a phase 2 3-year POIT open-label study, we enrolled participants age 5 to 13 years with a 1-year build-up period followed by a 2-year daily maintenance dose of 3900 mg with assessment of the maximum tolerated dose using double-blind placebo-controlled food challenges (DBPCFCs) of 26,225 mg cumulative dose of peanut protein. The DBPCFC was performed at baseline, after 12-month build-up, at 2 year of maintenance, and after a 1-month period of treatment discontinuation. Biomarkers were assessed every 6 weeks for the first 6 months of therapy. A general linear mixed model was used for analysis. RESULTS The mean maximum cumulative tolerated dose after 12 months increased by 12,063 mg (P < .001) (n = 12), slightly decreased during maintenance (n = 11), and significantly decreased by 7593 mg after avoidance for 1 month (P = .03) (n = 6). Biomarker analysis revealed decreases in cytokine expression within the first 6 weeks of initiation of POIT and decreased peanut-IgG4 and increased cytokine expression after 1 month of discontinuation. The DBPCFC reaction severity, examined through a symptom score with 1 point for each defined symptom, decreased after 12 months, but did not significantly change after 1 month of POIT discontinuation. CONCLUSIONS The evaluation of POIT and sustained unresponsiveness by maximum tolerated dose by DBPCFCs in this small phase 2 trial showed that desensitization is diminished, with 100% loss of tolerated dose after 1 month of avoidance following 3 years of treatment.
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Affiliation(s)
- Carla M Davis
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Section of Immunology, Allergy and Retrovirology, Houston, Texas.
| | - Aikaterini Anagnostou
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Section of Immunology, Allergy and Retrovirology, Houston, Texas
| | - Sridevi Devaraj
- Baylor College of Medicine, Texas Children's Hospital, Department of Pathology and Immunology, Houston, Texas
| | - Daisy T Vita
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Section of Immunology, Allergy and Retrovirology, Houston, Texas
| | - Fabian Rivera
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Section of Immunology, Allergy and Retrovirology, Houston, Texas
| | - Kathleen Pitts
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Section of Immunology, Allergy and Retrovirology, Houston, Texas
| | - Melissa Hearrell
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Section of Immunology, Allergy and Retrovirology, Houston, Texas
| | - Charles Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Meera Gupta
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Section of Immunology, Allergy and Retrovirology, Houston, Texas
| | - Levi Watkin
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Section of Immunology, Allergy and Retrovirology, Houston, Texas
| | - Jordan S Orange
- Columbia University, Vagelos College of Physicians and Surgeons, New York-Presbyterian, Morgan Stanley Children's Hospital, New York, NY
| | - Sara Anvari
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Section of Immunology, Allergy and Retrovirology, Houston, Texas
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6
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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. J Allergy Clin Immunol Pract 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] [What about the content of this article? (0)] [Affiliation(s)] [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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7
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Bemanian MH, Alizadeh F, Nabavi M, Arshi S, Shokri S, Khoshmirsafa M, Seif F, Fallahpour M. Sustained Unresponsiveness Induced by Oral Immunotherapy Is Not a Completely Symptom-Free Condition: A Prospective Case Series. J Investig Allergol Clin Immunol 2021; 31:259-260. [PMID: 32732177 DOI: 10.18176/jiaci.0636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- M H Bemanian
- Allergy Department, Rasoul e Akram hospital, Iran University of Medical Sciences, Tehran, Iran
| | - F Alizadeh
- Pediatric Department, Rasoul e Akram hospital, Iran University of Medical Sciences, Tehran, Iran
| | - M Nabavi
- Allergy Department, Rasoul e Akram hospital, Iran University of Medical Sciences, Tehran, Iran
| | - S Arshi
- Allergy Department, Rasoul e Akram hospital, Iran University of Medical Sciences, Tehran, Iran
| | - S Shokri
- Allergy Department, Rasoul e Akram hospital, Iran University of Medical Sciences, Tehran, Iran
| | - M Khoshmirsafa
- Immunology Department, Medical School, Iran University of Medical Sciences, Tehran, Iran
| | - F Seif
- Department of Allergy and Immunology, Academic Center for Education, Culture, and Research, Tehran, Iran
| | - M Fallahpour
- Allergy Department, Rasoul e Akram hospital, Iran University of Medical Sciences, Tehran, Iran
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Abstract
Purpose of the Review Peanut oral immunotherapy (OIT) is one of the most studied experimental therapies for food allergy. With the recently FDA-approved peanut product, Palforzia, the goal of this article is to review the most recent data from clinical trials, discuss recent trends, and anticipate future developments. Recent Findings The latest research suggests that peanut OIT could be a promising option for peanut-allergic patients, with the majority of participants in research studies achieving the primary efficacy endpoint of desensitization, as well as sustained unresponsiveness in select populations. Some studies also showed improvements in food allergy-related quality of life. However, peanut OIT is not without risk or side effects, including potentially serious allergic reactions. Summary Future research will need to evaluate the short- and long-term effectiveness of the therapy in the real-world setting, predictors of important treatment outcomes, and the use of adjunctive therapies that may mitigate some of these allergic reactions.
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Affiliation(s)
- Meera Patrawala
- Emory University School of Medicine, 1400 Tullie Road NE 5th floor, Atlanta, GA 30329 USA
- Children’s Healthcare of Atlanta, 1400 Tullie Road NE 5th floor, Atlanta, GA 30329 USA
| | - Jennifer Shih
- Emory University School of Medicine, 1400 Tullie Road NE 5th floor, Atlanta, GA 30329 USA
- Children’s Healthcare of Atlanta, 1400 Tullie Road NE 5th floor, Atlanta, GA 30329 USA
| | - Gerald Lee
- Emory University School of Medicine, 1400 Tullie Road NE 5th floor, Atlanta, GA 30329 USA
- Children’s Healthcare of Atlanta, 1400 Tullie Road NE 5th floor, Atlanta, GA 30329 USA
| | - Brian Vickery
- Children’s Healthcare of Atlanta, 1400 Tullie Road NE 5th floor, Atlanta, GA 30329 USA
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9
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Andorf S, Purington N, Kumar D, Long A, O'Laughlin KL, Sicherer S, Sampson H, Cianferoni A, Whitehorn TB, Petroni D, Makhija M, Robison RG, Lierl M, Logsdon S, Desai M, Galli SJ, Rael E, Assa'ad A, Chinthrajah S, Pongracic J, Spergel JM, Tam J, Tilles S, Wang J, Nadeau K. A Phase 2 Randomized Controlled Multisite Study Using Omalizumab-facilitated Rapid Desensitization to Test Continued vs Discontinued Dosing in Multifood Allergic Individuals. EClinicalMedicine 2019; 7:27-38. [PMID: 31193674 PMCID: PMC6537534 DOI: 10.1016/j.eclinm.2018.12.006] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 12/19/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND As there is limited data on the sustainability of desensitization of multifood-oral immunotherapy (multifood-OIT), we conducted a multisite multifood-OIT study to compare the efficacy of successful desensitization with sustained dosing vs discontinued dosing after multifood-OIT. METHODS We enrolled 70 participants, aged 5-22 years with multiple food allergies confirmed by double-blind placebo-controlled food challenges (DBPCFCs). In the open-label phase of the study, all participants received omalizumab (weeks 1-16) and multi-OIT (2-5 allergens; weeks 8-30) and eligible participants (on maintenance dose of each allergen by weeks 28-29) were randomized 1:1:1 to 1 g, 300 mg, or 0 mg arms (blinded, weeks 30-36) and then tested by food challenge at week 36. Success was defined as passing 2 g food challenge to at least 2 foods in week 36. FINDINGS Most participants were able to reach a dose of 2 g or higher of each of 2, 3, 4, and 5 food allergens (as applicable to the participant's food allergens in OIT) in week 36 food challenges. Using an intent-to-treat analysis, we did not find evidence that a 300 mg dose was effectively different than a 1 g dose in maintaining desensitization, and both together were more effective than OIT discontinuation (0 mg dose) (85% vs 55%, P = 0.03). Fifty-five percent of the intent-to-treat participants and 69% of per protocol participants randomized to the 0 mg arm showed no objective reactivity after 6 weeks of discontinuation. Cross-desensitization was found between cashew/pistachio and walnut/pecan when only one of the foods was part of OIT. No statistically significant safety differences were found between the three arms. INTERPRETATION These results suggest that sustained desensitization after omalizumab-facilitated multi-OIT best occurs through continued maintenance OIT dosing of either 300 mg or 1 g of each food allergen as opposed to discontinuation of multi-OIT. FUNDING Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Jeff and MacKenzie Bezos, NIAID AADCRC U19AI104209. TRIAL REGISTRATION NUMBER ClinicalTrials.gov number, NCT02626611.
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Affiliation(s)
- Sandra Andorf
- 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
- Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, CA, USA
| | - Natasha Purington
- 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
- Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, CA, USA
| | - Divya Kumar
- 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
- Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, CA, USA
| | - Andrew Long
- 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
- Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, CA, USA
| | - Katherine L. O'Laughlin
- 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
- Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, CA, USA
| | - Scott Sicherer
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hugh Sampson
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Antonella Cianferoni
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Terri Brown Whitehorn
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Petroni
- ASTHMA Inc. Clinical Research Center, Northwest Asthma and Allergy Center, University of Washington, Seattle, WA, USA
| | - Melanie Makhija
- Division of Allergy and Immunology, the Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Rachel G. Robison
- Division of Allergy and Immunology, the Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Michelle Lierl
- Division of Allergy and Immunology, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Stephanie Logsdon
- Division of Allergy and Immunology, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Manisha Desai
- 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
- Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, CA, USA
| | - Stephen J. Galli
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA, USA
- Department of Pathology, Stanford University, Stanford, CA, USA
- Department of Microbiology and Immunology, Stanford University, Stanford, CA, USA
| | - Efren Rael
- 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
- Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, CA, USA
| | - Amal Assa'ad
- Division of Allergy and Immunology, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Sharon Chinthrajah
- 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
- Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, CA, USA
| | - Jacqueline Pongracic
- Division of Allergy and Immunology, the Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jonathan M. Spergel
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan Tam
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Stephen Tilles
- ASTHMA Inc. Clinical Research Center, Northwest Asthma and Allergy Center, University of Washington, Seattle, WA, USA
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kari 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
- Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, CA, USA
- Corresponding author at: Sean N. Parker Center for Allergy and Asthma Research at Stanford University, 269 Campus Drive, CCSR 3215, MC 5366, Stanford, CA 94305-5101, USA.
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Abstract
Development of active therapies for IgE-mediated food allergy is a critical action step toward alleviating the adverse medical, psychosocial, and economic burdens on affected patients and families. Significant progress has been observed specifically in the application of single-allergen oral and sublingual immunotherapy for treatment of IgE-mediated food allergy, with emphasis on milk, egg, and peanut as the primary allergens. Oral immunotherapy (OIT) has demonstrated efficacy in promoting immunomodulatory effects that lead to the clinical outcome of desensitization, defined as reduced reactivity while on active OIT, in the majority of treated individuals; however, achievement of sustained unresponsiveness following cessation of therapy has been observed in a smaller subset of treated subjects. The potential therapeutic benefits of OIT must be carefully considered in light of the significant potential for adverse events ranging from self-limited or easily treated oropharyngeal, respiratory or gastrointestinal symptoms, to persistent abdominal complaints that lead to cessation of therapy in an estimated 10-15% of treated individuals. To date, the majority of studies have focused on single-allergen OIT approaches; however, multi-allergen OIT has shown promise in initial trials and is the subject of ongoing investigation to address the complex needs of multi-food allergic individuals. Sublingual immunotherapy (SLIT) has been utilized for the treatment of food allergy and pollen-food allergy syndrome, demonstrating moderate efficacy, a favorable safety profile and variable tolerability, with oropharyngeal symptoms most commonly observed. Although studies directly comparing OIT and SLIT are limited, in general, the favorable safety profile associated with SLIT comes at the expense of reduced efficacy, while the more robust clinical effects observed with OIT come at the risk of potentially intolerable, treatment-limiting side effects. Future investigation to address specific knowledge gaps including optimal dose, duration, age of initiation, maintenance schedule, mechanisms, predictors of risk and therapeutic response will be important to maximize efficacy, minimize risk and develop personalized, effective approaches to targeting food allergy.
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11
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Rudman Spergel AK, Minnicozzi M, Wheatley LM, Togias A. Is Allergen Immunotherapy in Children Disease Modifying? A Review of the Evidence. Curr Allergy Asthma Rep 2018; 18:47. [PMID: 29995257 DOI: 10.1007/s11882-018-0801-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Although evidence supports a beneficial effect of allergen immunotherapy on the symptoms of allergic respiratory disease and food allergy, it is not clear whether immunotherapy modifies the natural history of these conditions. RECENT FINDINGS In aeroallergen immunotherapy, studies suggest that prevention of asthma can be attained. Less evident is the ability of immunotherapy to prevent new allergen sensitizations and more studies are needed to test whether immunotherapy can continue suppressing airway symptoms after treatment discontinuation. In food allergen immunotherapy, there is evidence that unresponsiveness to a food challenge can be sustained in some treatment recipients, but little knowledge exists as to the dose and duration of treatment that can optimize this effect. Suggestive evidence exists that allergen immunotherapy can modify allergic disease in children, but definitive studies are lacking. More research in the field is required.
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Affiliation(s)
- Amanda K Rudman Spergel
- Division of Allergy, Immunology and Transplantation, Allergy, Asthma and Airway Biology Branch, National Institute of Allergy and Infectious Diseases, NIH, 5601 Fishers Lane, Rockville, MD, 20892, USA.
| | - Michael Minnicozzi
- Division of Allergy, Immunology and Transplantation, Allergy, Asthma and Airway Biology Branch, National Institute of Allergy and Infectious Diseases, NIH, 5601 Fishers Lane, Rockville, MD, 20892, USA
| | - Lisa M Wheatley
- Division of Allergy, Immunology and Transplantation, Allergy, Asthma and Airway Biology Branch, National Institute of Allergy and Infectious Diseases, NIH, 5601 Fishers Lane, Rockville, MD, 20892, USA
| | - Alkis Togias
- Division of Allergy, Immunology and Transplantation, Allergy, Asthma and Airway Biology Branch, National Institute of Allergy and Infectious Diseases, NIH, 5601 Fishers Lane, Rockville, MD, 20892, USA
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12
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Loh W, Tang MLK. Debates in Allergy Medicine: Oral immunotherapy shortens the duration of milk and egg allergy - the con argument. World Allergy Organ J 2018; 11:12. [PMID: 29977439 PMCID: PMC6002984 DOI: 10.1186/s40413-018-0189-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 05/15/2018] [Indexed: 11/10/2022] Open
Abstract
Oral immunotherapy (OIT) has been shown to be effective for inducing desensitization in children with cow’s milk and egg allergy. In contrast, there is limited evidence that OIT can induce tolerance or sustained unresponsiveness in food allergic patients. Sustained unresponsiveness, determined by a food challenge following a period of secondary avoidance, has been suggested to reflect a more enduring state of tolerance and is pertinent when considering the ability of OIT to shorten the duration of food allergy. While it has been shown that children who tolerate baked forms of egg and milk are more likely to develop tolerance compared to those who are allergic to baked forms of these foods, there is no convincing evidence that OIT using modified allergen in baked foods can hasten resolution of cow’s milk and egg allergy. Instead, it is likely that baked milk and baked egg tolerant children represent a sub-phenotype of milk and egg allergy that is more likely to resolve spontaneously over time.
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Affiliation(s)
- Wenyin Loh
- 1Allergy and Immune Disorders, Murdoch Children's Research Institute, Melbourne, Australia.,2Allergy Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Mimi L K Tang
- 1Allergy and Immune Disorders, Murdoch Children's Research Institute, Melbourne, Australia.,3Department of Allergy and Immunology, The Royal Children's Hospital, Melbourne, Australia.,4Department of Paediatrics, University of Melbourne, Melbourne, Australia
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13
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Pecora V, Valluzzi RL, Mennini M, Fierro V, Dahdah L. Debates in Allergy Medicine: Does oral immunotherapy shorten the duration of milk and egg allergy? The pro argument. World Allergy Organ J 2018; 11:11. [PMID: 29977438 PMCID: PMC6003149 DOI: 10.1186/s40413-018-0191-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/27/2018] [Indexed: 01/08/2023] Open
Abstract
The development of oral tolerance or food allergy is an active process, related to dynamic interactions between host immune cells, microbiome, dietary factors, and food allergens. Oral tolerance is the default immune response in the gut. A food allergy occurs when this process fails and a pathologic Th2 response is activated. Oral food immunotherapy (OIT) aims to restore immune tolerance in food-allergic individuals. The stimulation of Tregs production seems to represent a crucial step in inducing long-term tolerance, but other mechanisms (e.g., the suppression of mast cell and basophil reactivity, changes in allergen-specific cells with regulatory markers) are involved. Several studies reported the efficacy of OIT in terms of "sustained unresponsiveness" (SU), an operational definition of immune tolerance. In successfully treated subjects, the ability to pass an oral food challenge 2 to 8 weeks after stopping the food allergen exposure seems to be conditioned by the treatment starting age, frequency, amount or type of food consumed, and by the duration of the maintenance phase. Based on the available data, the percentage of milk- and egg-allergic subjects achieving sustained unresponsiveness after an OIT ranges from 21% to 58,3%. A comprehensive understanding of mechanisms underlying the induction of oral tolerance with OIT, or natural tolerance to food allergens in healthy individuals, could potentially lead to advances in development of better treatment options for food allergic patients.
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Affiliation(s)
- Valentina Pecora
- Division of Allergy, IRCCS Ospedale Pediatrico Bambino Gesù, Piazza Sant'Onofrio, 4, 00165 Rome, Italy
| | - Rocco Luigi Valluzzi
- Division of Allergy, IRCCS Ospedale Pediatrico Bambino Gesù, Piazza Sant'Onofrio, 4, 00165 Rome, Italy
| | - Maurizio Mennini
- Division of Allergy, IRCCS Ospedale Pediatrico Bambino Gesù, Piazza Sant'Onofrio, 4, 00165 Rome, Italy
| | - Vincenzo Fierro
- Division of Allergy, IRCCS Ospedale Pediatrico Bambino Gesù, Piazza Sant'Onofrio, 4, 00165 Rome, Italy
| | - Lamia Dahdah
- Division of Allergy, IRCCS Ospedale Pediatrico Bambino Gesù, Piazza Sant'Onofrio, 4, 00165 Rome, Italy
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Abstract
Food allergy is a pathological, potentially deadly cascade of immune responses to molecules or molecular fragments that are normally innocuous when encountered in foods, such as milk, egg, or peanut. As the incidence and prevalence of food allergy rise, the standard of care is poised to advance beyond food allergen avoidance coupled with injectable epinephrine treatment of allergen-induced systemic reactions. Recent studies provide evidence that oral immunotherapy may effectively redirect the atopic immune responses of food allergy patients as they ingest small but gradually increasing allergen doses over many months, eliciting safer immune responses to these antigens. Research into the molecular and cellular bases of pathological and therapeutic immune responses, and into the possibilities for their safe and effective modulation, is generating tremendous interest in basic and clinical immunology. We synthesize developments, innovations, and key challenges in our understanding of the immune mechanisms associated with atopy and oral immunotherapy for food allergy.
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Affiliation(s)
- Deborah M Hussey Freeland
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA 94305, USA; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA 94305, USA
| | - Monali Manohar
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA 94305, USA; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA 94305, USA
| | - Sandra Andorf
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA 94305, USA; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA 94305, USA
| | - Benjamin D Hobson
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA 94305, USA
| | - Wenming Zhang
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA 94305, USA; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA 94305, USA
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA 94305, USA; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA 94305, USA; Division of Allergy, Immunology and Rheumatology, Department of Medicine, Stanford University, Stanford, CA 94305, USA.
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15
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Abstract
Food allergy is a potentially life-threatening condition with no approved therapies, apart from avoidance and injectable epinephrine for acute allergic reactions. Oral immunotherapy (OIT) is an experimental treatment in which food-allergic patients consume gradually increasing quantities of the food to increase their threshold for allergic reaction. This therapy carries significant risk of allergic reactions. The ability of OIT to desensitize patients to particular foods is well-documented, although the ability to induce tolerance has not been established. This review focuses on recent studies for the treatment of food allergies such as cow's milk, hen's egg, and peanut.
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16
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Abstract
Food allergies continue to increase in prevalence. Standard care is a strict elimination diet, but life-threatening reactions still occur. Allergen immunotherapy has the most potential in treating food allergy. Subcutaneous immunotherapy has not been adopted into food allergy therapy. Oral immunotherapy has a high rate of adverse reactions. Sublingual immunotherapy (SLIT) uses the tolerogenic environment of the oral mucosa and epicutaneous immunotherapy (EPIT) uses the immune cells of the epidermis to transport antigens to afferent lymph nodes to activate immune responses. SLIT and EPIT can successfully desensitize patients. More research is needed to define optimal doses and administration protocols.
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Affiliation(s)
- Sayantani Sindher
- Division of Allergy and Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399, USA
| | - David M Fleischer
- Section of Allergy, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver School of Medicine, 13123 East 16th Avenue, B518, Aurora, CO 80045, USA
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399, USA.
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Takahashi M, Taniuchi S, Soejima K, Hatano Y, Yamanouchi S, Kaneko K. Two-weeks- sustained unresponsiveness by oral immunotherapy using microwave heated cow's milk for children with cow's milk allergy. Allergy Asthma Clin Immunol 2016; 12:44. [PMID: 27570533 PMCID: PMC5002153 DOI: 10.1186/s13223-016-0150-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 08/12/2016] [Indexed: 11/10/2022] Open
Abstract
Background Several studies have reported that oral immunotherapy (OIT) is effective for children with cow’s milk (CM) allergy. These studies reported the efficacy of OIT in terms of desensitization, but did not describe sustained unresponsiveness to CM. The aim of this study was to evaluate the efficacy of the OIT protocol using microwave heated cow’s milk (MH-CM) in terms of 2-weeks-sustained unresponsiveness (2-weeks-SU) and safety. Methods Forty-eight children were enrolled in this study. Thirty-one children agreed to receive rush OIT using MH-CM (the OIT group) and another 17 children who did not want to receive rush OIT formed the untreated group. Rates of desensitization and 2-weeks-sustained unresponsiveness were compared between the two groups at 1 year after the start of OIT. We followed up these rates and safety data for another year and for longer in the OIT group. Results No children in the untreated group did not pass an open food challenge to CM. Of the 31 children in the OIT group, 14 (P = 0.002) achieved desensitization, and 8 (P = 0.036) achieved 2-weeks-SU to CM at 1 year from the start of OIT. Two years after the start of OIT, both the rate of desensitization and the rate of 2-weeks-SU in the OIT group significantly increased compared with the rates at 1 year (P = 0.025 and P = 0.008 respectively). Conclusions The rush OIT protocol using MH-CM was effective at inducing 2-weeks-SU s to CM and had a good safety profile in children with CM allergy. Trial registration Approval number: 324, Registered 3 February 2009
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Affiliation(s)
- Masaya Takahashi
- Department of Pediatrics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka Japan
| | - Shoichiro Taniuchi
- Department of Pediatrics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka Japan
| | - Kazuhiko Soejima
- Department of Pediatrics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka Japan
| | - Yasuko Hatano
- Department of Pediatrics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka Japan
| | - Sohsaku Yamanouchi
- Department of Pediatrics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka Japan
| | - Kazuanri Kaneko
- Department of Pediatrics, Kansai Medical University, 2-5-1 Shin-machi, Hirakata, Osaka Japan
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