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Yamashita K, Nakamura T, Imai T, Honda A, Okada Y, Maeda M, Kamiya T. Optimal period for achieving sustained unresponsiveness in peanut oral immunotherapy. Asia Pac Allergy 2023; 13:97-104. [PMID: 37744963 PMCID: PMC10516315 DOI: 10.5415/apallergy.0000000000000110] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/30/2023] [Indexed: 09/26/2023] Open
Abstract
Background Oral immunotherapy (OIT) can help children with persistent food allergies achieve sustained unresponsiveness (SU). However, the optimal therapeutic period for obtaining SU remains unclear. Objective We aimed to retrospectively investigate the association between the OIT treatment period and achievement of SU. Methods We enrolled patients who received OIT for peanut allergy between January 1, 2018 and December 31, 2022. OIT comprised the build-up phase, maintenance phase, complete avoidance, and an oral food challenge (OFC) for confirming SU. The peanut dose in the OFC was gradually increased to 3,000 mg (peanut protein: 795 mg), which was subsequently maintained for ≥5 months. SU was defined as a negative response to 795 mg of peanut protein after ≥2 weeks of complete avoidance. We evaluated the therapeutic OIT period for achieving SU using Kaplan-Meier analysis. Results Forty-eight patients underwent peanut OIT. The starting age at OIT initiation was 8 (interquartile range [IQR], 7-10) years. Forty-one (85%) patients had a history of anaphylaxis. The median specific immunoglobulin E concentration to peanut and Ara h 2 at OIT initiation was 85.3 (IQR, 33.7-100) and 57.6 (IQR, 21.9-100) UA/mL, respectively. The median observational period was 2.1 (IQR, 1.6-3.0) person-years (PY). Thirty-four (71%) patients achieved SU, with the rate of SU achievement gradually increasing with the therapeutic period. The median period until SU achievement was 2.1 (95% confidence interval, 1.6-2.5) PY. The rate of SU achievement slowed down after 2.7 PY. Conclusion OIT for at least 2.7 PY can increase the rate of SU achievement. The protocol No. 3107.
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Affiliation(s)
- Kosei Yamashita
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Toshinori Nakamura
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Takanori Imai
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Aiko Honda
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Yuki Okada
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Mayu Maeda
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Taro Kamiya
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
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Lodge CJ, Waidyatillake N, Peters RL, Netting M, Dai X, Burgess J, Hornung CJ, Perrett KP, Tang MLK, Koplin JJ, Dharmage SC. Efficacy and safety of oral immunotherapy for peanut, cow's milk, and hen's egg allergy: A systematic review of randomized controlled trials. Clin Transl Allergy 2023; 13:e12268. [PMID: 37488726 PMCID: PMC10314278 DOI: 10.1002/clt2.12268] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 04/18/2023] [Accepted: 05/17/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Oral immunotherapy (OIT) is a promising treatment for food allergies; however, safety is a concern. We synthesized evidence from the best randomized controlled trials (RCTs) on efficacy/safety of OIT for desensitization (DS) and remission (sustained unresponsiveness (SU)) in IgE mediated allergy to peanut, hen's eggs, and cow's milk. BODY: We searched Pubmed, EMBASE, and Cochrane databases (Until Oct 22) identifying 16 eligible RCTs published in English measuring food allergy by food challenge at the beginning and at the end of the study. The Cochrane Risk of Bias tool was used to assess study quality. We found 18 eligible studies. There was evidence of efficacy for DS for all allergens: peanut (RR 11.32; 95% CI 5.93, 21.60, I2 49%, 8 studies); hen's egg (RR 4.67; 2.66, 8.21, I2 0%, 5 studies); cow's milk (RR 13.98; 3.51, 55.65, I2 0%, 4 studies) and evidence for SU for peanut (RR 7.74; 2.90, 20.69, I2 0%, 3 studies) and hen's egg (RR 6.91; 1.67, 28.57, I2 0%, 2 studies). Allergic events were increased with intervention, and risk of adrenaline use increased for peanut RR 2.96; 1.63, 5.35, I2 0%, 8 studies; egg RR 1.71; 0.42, 6.92, I2 0%, 6 studies; and milk RR 8.45; 2.02, 35.27, I2 0%, 4 studies. CONCLUSION We found strong evidence that peanut, hen's egg, and cow's milk OIT can induce DS and some evidence for remission. There was a high risk of allergic reactions. Generalizability to the entire food allergic population is not known.
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Affiliation(s)
- Caroline J Lodge
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Nilakshi Waidyatillake
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
| | - Rachel L Peters
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Merryn Netting
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Women and Kids Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
- Discipline of Paediatrics, University of Adelaide, Adelaide, South Australia, Australia
| | - Xin Dai
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
| | - John Burgess
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Catherine J Hornung
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Kirsten P Perrett
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Mimi L K Tang
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
- Allergy Immunology, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Jennifer J Koplin
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Child Research Centre, University of Queensland, South Brisbane, Queensland, Australia
| | - Shyamali C Dharmage
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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Braun C, Azzano P, Gingras-Lessard F, Roy É, Samaan K, Graham F, Paradis L, Des Roches A, Bégin P. Abatacept to induce remission of peanut allergy during oral immunotherapy (ATARI): protocol for a phase 2a randomized controlled trial. Front Med (Lausanne) 2023; 10:1198173. [PMID: 37448803 PMCID: PMC10336224 DOI: 10.3389/fmed.2023.1198173] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/06/2023] [Indexed: 07/15/2023] Open
Abstract
Context While oral immunotherapy (OIT) has been shown to promote the remission of mild peanut allergy in young children, there is still an unmet need for a disease-modifying intervention for older patients and those with severe diseases. In mice models, abatacept, a cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) immunoglobulin fusion protein, has been shown to promote immune tolerance to food when used as an adjuvant to allergen immunotherapy. The goal of this study is to explore the potential efficacy of abatacept in promoting immune tolerance to food allergens during OIT in humans. Methods In this phase 2a proof-of-concept study (NCT04872218), 14 peanut-allergic participants aged from 14 to 55 years will be randomized at a 1:1 ratio to abatacept vs. placebo for the first 24 weeks of a peanut OIT treatment (target maintenance dose of 300 mg peanut protein). The primary outcome will be the suppression of the OIT-induced surge in peanut-specific IgE/total IgE at 24 weeks, relative to the baseline. Sustained unresponsiveness will be assessed as a secondary outcome starting at 36 weeks by observing incremental periods of peanut avoidance followed by oral food challenges. Discussion This is the first study assessing the use of abatacept as an adjuvant to allergen immunotherapy in humans. As observed in preclinical studies, the ability of abatacept to modulate the peanut-specific immune response during OIT will serve as a proxy outcome for the development of clinical tolerance, given the small sample size. The study will also test a new patient-oriented approach to sustained tolerance testing in randomized controlled trials.
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Affiliation(s)
- Camille Braun
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
- Department of Pediatrics, Pneumology, Allergy, Cystic Fibrosis, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- Centre International de Recherche en Infectiologie, INSERM U1111, CNRS UMR 5308, Université Lyon 1, ENS de Lyon, Lyon, France
| | - Pauline Azzano
- Department of Pediatric Hepatogastroenterology and Nutrition, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Florence Gingras-Lessard
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Émilie Roy
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Kathryn Samaan
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - François Graham
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
- Department of Medicine, Section of Allergy and Clinical Immunology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Louis Paradis
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
- Department of Medicine, Section of Allergy and Clinical Immunology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Anne Des Roches
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Philippe Bégin
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
- Department of Medicine, Section of Allergy and Clinical Immunology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
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Bohle B. Evidence for sustained desensitization after sublingual peanut immunotherapy. J Allergy Clin Immunol 2023:S0091-6749(23)00509-2. [PMID: 37086923 DOI: 10.1016/j.jaci.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 04/24/2023]
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Kim EH, Keet CA, Virkud YV, Chin S, Ye P, Penumarti A, Smeekens J, Guo R, Yue X, Li Q, Kosorok MR, Kulis MD, Burks AW. Open-label study of the efficacy, safety, and durability of peanut sublingual immunotherapy in peanut-allergic children. J Allergy Clin Immunol 2023:S0091-6749(23)00218-X. [PMID: 36828080 DOI: 10.1016/j.jaci.2023.01.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 12/15/2022] [Accepted: 01/25/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Studies on the efficacy of peanut sublingual immunotherapy (SLIT) are limited. The durability of desensitization after SLIT has not been well described. OBJECTIVE We sought to evaluate the efficacy and safety of 4-mg peanut SLIT and persistence of desensitization after SLIT discontinuation. METHODS Challenge-proven peanut-allergic 1- to 11-year-old children were treated with open-label 4-mg peanut SLIT for 48 months. Desensitization after peanut SLIT was assessed by a 5000-mg double-blind, placebo-controlled food challenge (DBPCFC). A novel randomly assigned avoidance period of 1 to 17 weeks was followed by the DBPCFC. Skin prick test results immunoglobulin levels, basophil activation test results, TH1, TH2, and IL-10 cytokines were measured longitudinally. Safety was assessed through patient-reported home diaries. RESULTS Fifty-four participants were enrolled and 47 (87%) completed peanut SLIT and the 48-month DBPCFC per protocol. The mean successfully consumed dose (SCD) during the DBPCFC increased from 48 to 2723 mg of peanut protein after SLIT (P < .0001), with 70% achieving clinically significant desensitization (SCD > 800 mg) and 36% achieving full desensitization (SCD = 5000 mg). Modeled median time to loss of clinically significant desensitization was 22 weeks. Peanut skin prick test; peanut-specific IgE, IgG4, and IgG4/IgE ratio; and peanut-stimulated basophil activation test, IL-4, IL-5, IL-13, IFN-γ, and IL-10 changed significantly compared with baseline, with changes seen as early as 6 months. Median rate of reaction per dose was 0.5%, with transient oropharyngeal itching being the most common, and there were no dosing symptoms requiring epinephrine. CONCLUSIONS In this open-label, prospective study, peanut SLIT was safe and induced clinically significant desensitization in most of the children, lasting more than 17 weeks after discontinuation of therapy.
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Ashley SE, Jones AC, Anderson D, Holt PG, Bosco A, Tang MLK. Remission of peanut allergy is associated with rewiring of allergen-driven T helper 2-related gene networks. Allergy 2022; 77:3015-3027. [PMID: 35615783 PMCID: PMC9790273 DOI: 10.1111/all.15324] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 02/27/2022] [Accepted: 03/15/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND The immunological changes underpinning acquisition of remission (also called sustained unresponsiveness) following food immunotherapy remain poorly defined. Limited access to effective therapies and biosamples from treatment responders has prevented progress. Probiotic peanut oral immunotherapy is highly effective at inducing remission, providing an opportunity to investigate immune changes. METHODS Using a systems biology approach, we examined gene co-expression network patterns in peanut-specific CD4+ T cell responses before and after probiotic and peanut oral immunotherapy in subjects enrolled in the PPOIT-001 randomized trial: Responders who attained remission (n = 16), placebo-treated who remained allergic (n = 16). RESULTS Acquisition of remission was associated with rewiring of gene network patterns, which was characterized by integration of T helper 2 and interferon signalling modules, markedly reduced T helper 2 gene connectivity, and shutdown in co-expression activity between T helper 2 effectors and cell cycle regulators. CONCLUSION The immunological changes underlying remission following peanut oral immunotherapy are mediated by reprogramming of T helper 2-associated gene networks in the CD4+ T cell compartment. Findings provide insight into immune mechanisms driving the acquisition of remission following oral immunotherapy, paving the way for the development of improved approaches to induce remission/sustained unresponsiveness in patients with food allergy.
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Affiliation(s)
- Sarah E. Ashley
- Allergy ImmunologyMurdoch Children’s Research InstituteMelbourneVictoriaAustralia,Department of PaediatricsThe University of MelbourneMelbourneVictoriaAustralia,The Royal Children’s HospitalMelbourneVictoriaAustralia
| | - Anya C. Jones
- Telethon Kids InstitutePerthWestern AustraliaAustralia,The University of Western AustraliaPerthWestern AustraliaAustralia
| | - Denise Anderson
- Telethon Kids InstitutePerthWestern AustraliaAustralia,The University of Western AustraliaPerthWestern AustraliaAustralia
| | - Patrick G. Holt
- Telethon Kids InstitutePerthWestern AustraliaAustralia,The University of Western AustraliaPerthWestern AustraliaAustralia
| | - Anthony Bosco
- Telethon Kids InstitutePerthWestern AustraliaAustralia,The University of Western AustraliaPerthWestern AustraliaAustralia
| | - Mimi L. K. Tang
- Allergy ImmunologyMurdoch Children’s Research InstituteMelbourneVictoriaAustralia,Department of PaediatricsThe University of MelbourneMelbourneVictoriaAustralia,The Royal Children’s HospitalMelbourneVictoriaAustralia
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Loke P, Hsiao KC, Lozinsky AC, Ashley SE, Lloyd M, Pitkin S, Axelrad CJ, Jayawardana KS, Tey D, Su EL, Robinson M, Leung ASY, Dunn Galvin A, Tang MLK. Probiotic peanut oral immunotherapy is associated with long-term persistence of 8-week sustained unresponsiveness and long-lasting quality-of-life improvement. Clin Exp Allergy 2022; 52:806-811. [PMID: 35485166 DOI: 10.1111/cea.14137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 12/18/2022]
Affiliation(s)
- 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.,Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Kuang-Chih Hsiao
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Immunology, Starship Children's Hospital, Auckland, New Zealand.,Department of Paediatrics, University of Auckland, Auckland, New Zealand
| | | | - Sarah E 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
| | - Melanie Lloyd
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Sigrid Pitkin
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Christine Jean Axelrad
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Kaushala S Jayawardana
- Centre for Biostatistics and Epidemiology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Dean Tey
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Ee Lyn Su
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Marnie Robinson
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Agnes S Y Leung
- Allergy Immunology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Audrey Dunn Galvin
- School of Applied Psychology, University College Cork, Cork City, Ireland
| | - 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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8
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Pourvali A, Arshi S, Nabavi M, Bemanian MH, Shokri S, Khajoei S, Seif F, Fallahpour M. Sustained unresponsiveness development in wheat oral immunotherapy: predictive factors and flexible regimen in the maintenance phase. Eur Ann Allergy Clin Immunol 2022. [PMID: 35620981 DOI: 10.23822/eurannaci.1764-1489.254] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Summary Background and aim. Immunotherapy may induce sustained unresponsiveness (SU) in which the patient can tolerate the allergen without any severe symptoms after discontinuing immunotherapy. The present study evaluated serum and cutaneous markers for predicting SU in patients with wheat anaphylaxis who underwent oral immunotherapy. Moreover, we investigated the effectiveness of a flexible regimen of 5 to 10 g wheat protein (WP) in the maintenance phase of oral immunotherapy (OIT). Methods. This study was conducted on 19 patients with wheat anaphylaxis who underwent OIT. The result of the skin prick test (SPT), besides specific serum IgE (sIgE) and IgG4 (sIgG4) to WP, were evaluated before the desensitization. The maintenance dose started from the preferred dose of 5 to 10 g WP after the build-up phase, if the patient could tolerate it. All patients were recruited 7 to 9 months after undergoing this flexible regimen, and the results of SPT and sIgE, and sIgG4 levels were obtained once more. The patients underwent oral food challenge (OFC) after a 3-4-week avoidance to evaluate SU. Results. There was an association between mean IgE reduction and SU (p less than 0.0006), while no association was observed between the mean increase in specific IgG4 (p = 0.1) and the mean wheal diameter decrease (p = 0.29). In the present study, a 50% reduction in sIgE was associated with SU. Thirteen patients were considered to have a SU. Moreover, there was no association between the flexible regimen and the desensitization rate. Conclusions. The results revealed that the reduction of 50% sIgE is a predictive factor for SU in patients with IgE-mediated wheat allergy.
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Affiliation(s)
- A Pourvali
- Department of Pediatrics, Amir Kabir Hospital, Arak University of Medical Sciences, Arak, Iran
| | - S Arshi
- Department of Allergy, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - M Nabavi
- Department of Allergy, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - M H Bemanian
- Department of Allergy, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - S Shokri
- Department of Allergy, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - S Khajoei
- Clinical Research Development Center, Imam Khomeini Hospital, Jiroft University of Medical Sciences, Jiroft, Iran
| | - F Seif
- Department of Immunology and Allergy, Academic Center for Education, Culture, and Research (ACECR), Tehran, Iran.,Neuroscience Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - M Fallahpour
- Department of Allergy, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Ayats-Vidal R, Riera-Rubió S, Valdesoiro-Navarrete L, García-González M, Larramona-Carrera H, Cruz OA, Bosque-García M. Long-term outcome of omalizumab-assisted desensitisation to cow's milk and eggs in patients refractory to conventional oral immunotherapy: real-life study. Allergol Immunopathol (Madr) 2022; 50:1-7. [PMID: 35527650 DOI: 10.15586/aei.v50i3.537] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/17/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Oral immunotherapy (OIT) is a promising approach to cow's milk and egg allergies, but reactions are frequent and some patients cannot be desensitized. OBJECTIVE To evaluate long-term OIT outcomes with omalizumab (OMZ) in paediatric patients with severe egg and/or milk allergies. METHODS This retrospective real-life study analysed findings in children with Immunoglobulin E-mediated allergy to cow's milk and/or hen eggs refractory to conventional OIT, who underwent OIT with OMZ in our department between 1 January 2010 and 31 December 2015. RESULTS In all, 41 patients were included (median age: 7 years; interquartile range [IQR]: 5.5-9.5); 26/41 (63.4%) underwent OIT for milk, 8/41 (19.5%) for egg and 7/41 (17.1%) for both. The median time between initiation of OMZ and OIT was 27 weeks (IQR: 22-33). Forty (97.56%) patients reached the maintenance phase (200 mL of cow's milk and 30 mL of raw egg or 1 cooked egg) in a median time of 27 weeks (IQR: 18-37). The median total time with OMZ was 117 weeks (IQR: 88-144). During the OMZ period, 2.44% (1/41) of patients presented anaphylaxis. After discontinuation of OMZ, 29.3% (12/41) presented anaphylaxis, 50% of them had a poor adherence to daily ingestion. One patient (2.44%) was diagnosed with eosinophilic esophagitis after 2 years of discontinuation of OMZ. Currently, after a median time of 9 years (IQR: 7-10) since the initiation of OMZ, 75.6% (31/41) are desensitized (27/31 without OMZ). CONCLUSIONS Omalizumab allows desensitisation of children with severe allergies to cow's milk and/or egg without developing severe reactions while receiving this treatment. However, discontinuation of OMZ leads to severe allergic reactions, and hence must be monitored carefully.
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10
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Hsiao KC, Ponsonby AL, Ashley S, Lee CYY, Jindal L, Tang MLK. Longitudinal antibody responses to peanut following probiotic and peanut oral immunotherapy (PPOIT) in children with peanut allergy. Clin Exp Allergy 2022; 52:735-746. [PMID: 35403286 DOI: 10.1111/cea.14146] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 04/02/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Probiotic and Peanut Oral Immunotherapy (PPOIT) is effective at inducing sustained unresponsiveness (SU) at end-of-treatment and this effect persists up to four years post-treatment, referred to as persistent SU. We sought to evaluate (i) how PPOIT altered peanut-specific humoral immune indices, and (ii) how such longitudinal indices relate to persistent SU. METHODS Longitudinal serum/plasma levels of whole peanut- and peanut component- (Ara-h1, -h2, -h3, -h8, -h9) specific-IgE (sIgE) and specific-IgG4 (sIgG4) antibodies were measured by ImmunoCAP and salivary peanut-specific-IgA (sIgA) by ELISA in children (n=62) enrolled in the PPOIT-001 randomised trial from baseline (T0) to 4-years post-treatment (T5). Multivariate regression analyses of log-transformed values were used for point-in-time between group comparisons. Generalised estimating equations (GEE) were used for longitudinal comparisons between groups. RESULTS PPOIT was associated with changes in sIgE and sIgG4 over time. sIgE levels were significantly reduced post-treatment [T5, PPOIT v.s. Placebo ratio of geometric mean (GM): Ara-h1 0.07, p=0.008; Ara-h2 0.08, p=0.007; Ara-h3 0.15, p=0.021]. sIgG4 levels were significantly increased by end-of-treatment (T1, PPOIT v.s. Placebo ratio of GM: Ara-h1 3.77, p=0.011; Ara-h2 17.97, p<0.001; Ara-h3 10.42, p<0.001) but levels in PPOIT group decreased once treatment was stopped and returned to levels comparable with Placebo group by T5. Similarly, salivary peanut sIgA increased during treatment, as early as 4 months of treatment (PPOIT v.s. Placebo, ratio of GM: 2.04, p=0.014), then reduced post-treatment. CONCLUSION PPOIT was associated with broad reduction in peanut specific humoral responses which may mediate the clinical effects of SU that persists to 4-years post-treatment.
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Affiliation(s)
- Kuang-Chih Hsiao
- Department of Immunology, Starship Children's Hospital, Auckland, New Zealand
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
- Allergy Immunology Research, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Anne-Louise Ponsonby
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Sarah Ashley
- Allergy Immunology Research, Murdoch Childrens Research Institute, Melbourne, Australia
| | | | | | - Mimi L K Tang
- Allergy Immunology Research, Murdoch Childrens Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
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11
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Nguyen DTI, Sindher SB, Chinthrajah RS, Nadeau K, Davis CM. Shrimp-allergic patients in a multi-food oral immunotherapy trial. Pediatr Allergy Immunol 2022; 33:e13679. [PMID: 34655480 PMCID: PMC9297938 DOI: 10.1111/pai.13679] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Diem-Tran I Nguyen
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University, Palo Alto, California, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford, California, USA
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University, Palo Alto, California, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford, California, USA
| | - Kari Nadeau
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University, Palo Alto, California, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford, California, USA
| | - Carla M Davis
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Section of Immunology, Allergy and Retrovirology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
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12
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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13
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Anagnostou A. A Practical, Stepwise Approach to Peanut Oral Immunotherapy in Clinical Practice: Benefits and Risks. J Asthma Allergy 2021; 14:277-285. [PMID: 33790583 PMCID: PMC8006756 DOI: 10.2147/jaa.s290915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/01/2021] [Indexed: 11/23/2022] Open
Abstract
Food allergies are common, affecting 6–8% of the children in the United States. There is a significant burden on the quality of life of allergic children and their caregivers, due to multiple dietary, social and psychological restrictions. Peanut allergy affects approximately 2–5% of the school-age children. Despite the recommended dietary avoidance, reactions tend to occur due to unintentional exposures and the fear of accidental ingestions potentially resulting in anaphylaxis and death, which creates a lot of anxiety in peanut-allergic individuals. Peanut oral immunotherapy (POIT) has emerged as a form of active treatment and has shown high efficacy in research trials with the majority of participants achieving desensitization and protection from trace exposures. An improved quality of life has also been noted following successful POIT. The risks of POIT should be balanced against the benefits resulting from successful treatment for each individual. Rates of allergic reactions and anaphylaxis are reported to be higher in individuals pursuing therapy, but most subjects will experience mild or moderate reactions during treatment. The landscape of peanut allergy management is changing and the future offers more options for patients than were previously available. Shared decision-making, which is the process of how to choose between different available options, becomes an ongoing discussion between the clinician and the patient, which will ensure achievement of the best possible outcome for the peanut-allergic child. This is a multistep process that evaluates the benefits and risks of therapy or no therapy, as well as patient and family preferences and we review it in detail in this manuscript with the aim to provide clinicians with a practical approach.
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Affiliation(s)
- Aikaterini Anagnostou
- Baylor College of Medicine, Section of Pediatric Immunology, Allergy and Rheumatology, Houston, TX, USA.,Texas Children's Hospital, Department of Pediatrics, Section of Immunology, Allergy and Rheumatology, Houston, TX, USA
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14
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Fleischer DM, Shreffler WG, Campbell DE, Green TD, Anvari S, Assa'ad A, Bégin P, Beyer K, Bird JA, Brown-Whitehorn T, Byrne A, Chan ES, Cheema A, Chinthrajah S, Chong HJ, Davis CM, Ford LS, Gagnon R, Greenhawt M, Hourihane JO, Jones SM, Kim EH, Lange L, Lanser BJ, Leonard S, Mahler V, Maronna A, Nowak-Wegrzyn A, Oriel RC, O'Sullivan M, Petroni D, Pongracic JA, Prescott SL, Schneider LC, Smith P, Staab D, Sussman G, Wood R, Yang WH, Lambert R, Peillon A, Bois T, Sampson HA. Long-term, open-label extension study of the efficacy and safety of epicutaneous immunotherapy for peanut allergy in children: PEOPLE 3-year results. J Allergy Clin Immunol 2020; 146:863-874. [PMID: 32659313 DOI: 10.1016/j.jaci.2020.06.028] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND The PEPITES (Peanut EPIT Efficacy and Safety) trial, a 12-month randomized controlled study of children with peanut allergy and 4 to 11 years old, previously reported the safety and efficacy of epicutaneous immunotherapy (EPIT) for peanut allergy (250 μg, daily epicutaneous peanut protein; DBV712 250 μg). OBJECTIVE We sought to assess interim safety and efficacy of an additional 2 years of EPIT from the ongoing (5-year treatment) PEOPLE (PEPITES Open-Label Extension) study. METHODS Subjects who completed PEPITES were offered enrollment in PEOPLE. Following an additional 2 years of daily DBV712 250 μg, subjects who had received DBV712 250 μg in PEPITES underwent month-36 double-blind, placebo-controlled food challenge with an optional month-38 sustained unresponsiveness assessment. RESULTS Of 213 eligible subjects who had received DBV712 250 μg in PEPITES, 198 (93%) entered PEOPLE, of whom 141 (71%) had assessable double-blind, placebo-controlled food challenge at month 36. At month 36, 51.8% of subjects (73 of 141) reached an eliciting dose of ≥1000 mg, compared with 40.4% (57 of 141) at month 12; 75.9% (107 of 141) demonstrated increased eliciting dose compared with baseline; and 13.5% (19 of 141) tolerated the full double-blind, placebo-controlled food challenge of 5444 mg. Median cumulative reactive dose increased from 144 to 944 mg. Eighteen subjects underwent an optional sustained unresponsiveness assessment; 14 of those (77.8%) maintained an eliciting dose of ≥1000 mg at month 38. Local patch-site skin reactions were common but decreased over time. There was no treatment-related epinephrine use in years 2 or 3. Compliance was high (96.9%), and withdrawals due to treatment-related adverse events were low (1%). CONCLUSIONS These results demonstrate that daily EPIT treatment for peanut allergy beyond 1 year leads to continued response from a well-tolerated, simple-to-use regimen.
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Affiliation(s)
- David M Fleischer
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, Colo.
| | - Wayne G Shreffler
- Food Allergy Center, Departments of Pediatrics and Medicine, Massachusetts General Hospital, Boston, Mass
| | - Dianne E Campbell
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Sydney, Australia; DBV Technologies, Montrouge, France
| | - Todd D Green
- DBV Technologies, Montrouge, France; Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Sara Anvari
- Section of Immunology, Allergy and Rheumatology, Texas Children's Hospital, Houston, Tex; Department of Pediatrics, Allergy and Immunology Section, Baylor College of Medicine, Houston, Tex
| | - Amal Assa'ad
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, The University of Cincinnati, Cincinnati, Ohio
| | - Philippe Bégin
- Division of Clinical Immunology and Allergy, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Kirsten Beyer
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Universitatsmedizin Berlin, Berlin, Germany
| | - J Andrew Bird
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Terri Brown-Whitehorn
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Aideen Byrne
- Paediatric Allergy Department, Our Lady's Children's Hospital, Dublin, Ireland
| | - Edmond S Chan
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research, Stanford University, Palo Alto, Calif
| | - Hey Jin Chong
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Carla M Davis
- Department of Pediatrics, Allergy and Immunology Section, Baylor College of Medicine, Houston, Tex
| | - Lara S Ford
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Sydney, Australia; Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
| | - Rémi Gagnon
- Service d'Allergie et Immunologie, Département de Médecine, Centre Hospitalier Universitaire de Québec, Quebec, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, Colo
| | - Jonathan O'B Hourihane
- Paediatrics and Child Health, INFANT Centre and Health Research Board-Clinical Research Facility, University College Cork, Cork, Ireland; Department of Paediatrics, Royal College of Surgeons, Dublin, Ireland
| | - Stacie M Jones
- Pediatrics - Allergy and Immunology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Ark
| | - Edwin H Kim
- Division of Rheumatology, Allergy and Immunology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Lars Lange
- Department of Pediatrics, St. Marien Hospital Bonn, Bonn, Germany
| | - Bruce J Lanser
- Division of Pediatric Allergy and Clinical Immunology, National Jewish Health, Denver, Colo
| | - Stephanie Leonard
- Department of Pediatrics, University of California San Diego, San Diego, Calif; Rady Children's Hospital, San Diego, Calif
| | - Vera Mahler
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University, Erlangen, Germany
| | - Andreas Maronna
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University, Erlangen, Germany
| | - Anna Nowak-Wegrzyn
- Hassenfeld Children's Hospital at New York University Langone Health, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Roxanne C Oriel
- Division of Pediatric Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Daniel Petroni
- Seattle Allergy and Asthma Research Institute, Seattle, Wash
| | - Jacqueline A Pongracic
- Allergy and Immunology Division, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Susan L Prescott
- Perth Children's Hospital, Nedlands, Australia; Department of Paediatrics, The University of Western Australia School of Medicine, Perth, Australia
| | | | - Peter Smith
- School of Medical Science, Griffith University, Southport, Australia
| | - Doris Staab
- Department of Pediatrics, Division of Pulmonology, Immunology and Critical Care Medicine, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Gordon Sussman
- Gordon Sussman Clinical Research, Toronto, Ontario, Canada
| | - Robert Wood
- Division of Allergy and Clinical Immunology, Johns Hopkins Hospital, Baltimore, Md
| | - William H Yang
- Department of Medicine, University of Ottawa Medical School, Ottawa, Ontario, Canada
| | | | | | | | - Hugh A Sampson
- DBV Technologies, Montrouge, France; Division of Pediatric Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
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15
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Kim EH, Perry TT, Wood RA, Leung DYM, Berin MC, Burks AW, Cho CB, Jones SM, Scurlock A, Sicherer SH, Henning AK, Dawson P, Lindblad RW, Plaut M, Sampson HA; Consortium for Food Allergy Research (CoFAR). Induction of sustained unresponsiveness after egg oral immunotherapy compared to baked egg therapy in children with egg allergy. J Allergy Clin Immunol 2020; 146:851-862.e10. [PMID: 32535135 DOI: 10.1016/j.jaci.2020.05.040] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 05/17/2020] [Accepted: 05/19/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND While desensitization and sustained unresponsiveness (SU) have been shown with egg oral immunotherapy (OIT), the benefits of baked egg (BE) therapy for egg allergy have not been well studied. OBJECTIVES This study sought to evaluate the safety and efficacy of BE ingestion compared with egg OIT in participants allergic to unbaked egg but tolerant to BE. METHODS Children who are BE-tolerant but unbaked egg reactive ages 3 to 16 years were randomized to 2 years of treatment with either BE or egg OIT. Double-blind, placebo-controlled food challenges were conducted after 1 and 2 years of treatment to assess for desensitization, and after 2 years of treatment followed by 8 to 10 weeks off of treatment to assess for SU. Mechanistic studies were conducted to assess for immune modulation. A cohort of participants who are BE-reactive underwent egg OIT and identical double-blind, placebo-controlled food challenges as a comparator group. RESULTS Fifty participants (median age 7.3 years) were randomized and initiated treatment. SU was achieved in 3 of 27 participants assigned to BE (11.1%) versus 10 of 23 participants assigned to egg OIT (43.5%) (P = .009). In the BE-reactive comparator group, 7 of 39 participants (17.9%) achieved SU. More participants who are BE-tolerant withdrew from BE versus from egg OIT (29.6% vs 13%). Dosing symptom frequency in participants who are BE-tolerant was similar with BE and egg OIT, but more frequent in participants who are BE-reactive. Egg white-specific IgE, skin testing, and basophil activation decreased similarly after BE and egg OIT. CONCLUSIONS Among children allergic to unbaked egg but tolerant to BE, those treated with egg OIT were significantly more likely to achieve SU than were children ingesting BE.
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16
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Kim EH, Burks AW. Food allergy immunotherapy: Oral immunotherapy and epicutaneous immunotherapy. Allergy 2020; 75:1337-1346. [PMID: 32034781 DOI: 10.1111/all.14220] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [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: 07/31/2019] [Revised: 01/07/2020] [Accepted: 01/23/2020] [Indexed: 01/14/2023]
Abstract
IgE-mediated food allergy remains a significant and growing problem across the globe. Of the various treatment modalities, oral immunotherapy (OIT) and epicutaneous immunotherapy (EPIT) have been the best studied. Across various studies of OIT for egg, milk, and peanut allergy, strong levels of desensitization have been shown. With egg and peanut OIT, a limited remission, or sustained unresponsiveness (SU), has further been demonstrated. These advances have been further validated by successful phase 2 and phase 3 studies of peanut OIT. EPIT, using daily administrations of a proprietary patch, demonstrated efficacy as well as safety and tolerability in parallel phase 2 studies; however, its phase 3 study did not meet its primary efficacy outcome. Despite its good track record of desensitization, the safety and tolerability of OIT has remained a question. EPIT, on the other hand, has proven safe and tolerable; however, the adequacy of its desensitization has remained to be determined. As OIT and EPIT continue their march toward regulatory review, optimizations for immunotherapy and novel therapies continue to be developed providing hope for food allergy patients everywhere.
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Affiliation(s)
- Edwin H. Kim
- University of North Carolina School of Medicine Chapel Hill North Carolina
| | - Arvil Wesley Burks
- University of North Carolina School of Medicine Chapel Hill North Carolina
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17
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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Kim EH, Yang L, Ye P, Guo R, Li Q, Kulis MD, Burks AW. Long-term sublingual immunotherapy for peanut allergy in children: Clinical and immunologic evidence of desensitization. J Allergy Clin Immunol 2019; 144:1320-1326.e1. [PMID: 31493887 DOI: 10.1016/j.jaci.2019.07.030] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/12/2019] [Accepted: 07/18/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Peanut sublingual immunotherapy (SLIT) for 1 year has been shown to induce modest clinical desensitization in allergic children. Studies of oral immunotherapy, epicutaneous immunotherapy, and SLIT have suggested additional benefit with extended treatment. OBJECTIVE We sought to investigate the safety, clinical effectiveness, and immunologic changes with long-term SLIT in children with peanut allergy. METHODS Children with peanut allergy aged 1 to 11 years underwent extended maintenance SLIT with 2 mg/d peanut protein for up to 5 years. Subjects with peanut skin test wheals of less than 5 mm and peanut-specific IgE levels of less than 15 kU/L were allowed to discontinue therapy early. Desensitization was assessed through a double-blind, placebo-controlled food challenge (DBPCFC) with up to 5000 mg of peanut protein after completion of SLIT dosing. Sustained unresponsiveness was further assessed by using identical DBPCFCs after 2 to 4 weeks without peanut exposure. RESULTS Thirty-seven of 48 subjects completed 3 to 5 years of peanut SLIT, with 67% (32/48) successfully consuming 750 mg or more during DBPCFCs. Furthermore, 25% (12/48) passed the 5000-mg DBPCFC without clinical symptoms, with 10 of these 12 demonstrating sustained unresponsiveness after 2 to 4 weeks. Side effects were reported with 4.8% of doses, with transient oropharyngeal itching reported most commonly. Side effects requiring antihistamine treatment were uncommon (0.21%), and no epinephrine was administered. Peanut skin test wheals, peanut-specific IgE levels, and basophil activation decreased significantly, and peanut-specific IgG4 levels increased significantly after peanut SLIT. CONCLUSION Extended-therapy peanut SLIT provided clinically meaningful desensitization in the majority of children with peanut allergy that was balanced with ease of administration and a favorable safety profile.
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Affiliation(s)
- Edwin H Kim
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Luanna Yang
- Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Ping Ye
- Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Rishu Guo
- Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Quefeng Li
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
| | - Michael D Kulis
- Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - A Wesley Burks
- Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, University of North Carolina School of Medicine, Chapel Hill, NC
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Sampson HA, O'Mahony L, Burks AW, Plaut M, Lack G, Akdis CA. Mechanisms of food allergy. J Allergy Clin Immunol 2018; 141:11-9. [PMID: 29307410 DOI: 10.1016/j.jaci.2017.11.005] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/10/2017] [Accepted: 11/14/2017] [Indexed: 01/08/2023]
Abstract
Although oral tolerance is the normal physiologic response to ingested antigens, a breakdown in this process appears to have occurred in the past 2 decades, leading to an increasing prevalence of sensitization to food allergens. Over the past decade, basic research has intensified in an attempt to better understand the mechanisms leading to sensitization and disease versus desensitization and short- and long-term tolerance. In this review we assess various factors that can influence tissue and immune responses to food antigens, the current understanding of immune tolerance development, the role of the gastrointestinal microbiota, and current knowledge regarding immunologic mechanisms involved in desensitization and sustained unresponsiveness, although perhaps the latter is more appropriately termed remission.
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20
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Suárez-Fariñas M, Suprun M, Chang HL, Gimenez G, Grishina G, Getts R, Nadeau K, Wood RA, Sampson HA. Predicting development of sustained unresponsiveness to milk oral immunotherapy using epitope-specific antibody binding profiles. J Allergy Clin Immunol 2018; 143:1038-1046. [PMID: 30528770 DOI: 10.1016/j.jaci.2018.10.028] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 08/30/2018] [Accepted: 10/05/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND In a recent trial of milk oral immunotherapy (MOIT) with or without omalizumab in 55 patients with milk allergy treated for 28 months, 44 of 55 subjects passed a 10-g desensitization milk protein challenge; 23 of 55 subjects passed the 10-g sustained unresponsiveness (SU) challenge 8 weeks after discontinuing MOIT. OBJECTIVE We sought to determine whether IgE and IgG4 antibody binding to allergenic milk protein epitopes changes with MOIT and whether this could predict the development of SU. METHODS By using a novel high-throughput Luminex-based assay to quantitate IgE and IgG4 antibody binding to 66 sequential epitopes on 5 milk proteins, serum samples from 47 subjects were evaluated before and after MOIT. Machine learning strategies were used to predict whether a subject would have SU after 8 weeks of MOIT discontinuation. RESULTS MOIT profoundly altered IgE and IgG4 binding to epitopes, regardless of treatment outcome. At the initiation of MOIT, subjects achieving SU exhibited significantly less antibody binding to 40 allergenic epitopes than subjects who were desensitized only (false discovery rate ≤ 0.05 and fold change > 1.5). Based on baseline epitope-specific antibody binding, we developed predictive models of SU. Using simulations, we show that, on average, IgE-binding epitopes alone perform significantly better than models using standard serum component proteins (average area under the curve, >97% vs 80%). The optimum model using 6 IgE-binding epitopes achieved a 95% area under the curve and 87% accuracy. CONCLUSION Despite the relatively small sample size, we have shown that by measuring the epitope repertoire, we can build reliable models to predict the probability of SU after MOIT. Baseline epitope profiles appear more predictive of MOIT response than those based on serum component proteins.
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Affiliation(s)
- Mayte Suárez-Fariñas
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY; Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Maria Suprun
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY; Pediatrics, Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Helena L Chang
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gustavo Gimenez
- Pediatrics, Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Galina Grishina
- Pediatrics, Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Kari Nadeau
- Department of Pediatrics, Stanford University School of Medicine, Stanford, Calif
| | - Robert A Wood
- Department of Pediatrics, Division of Allergy/Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Hugh A Sampson
- Pediatrics, Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY.
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Nowak-Węgrzyn A, Wood RA, Nadeau KC, Pongracic JA, Henning AK, Lindblad RW, Beyer K, Sampson HA. Multicenter, randomized, double-blind, placebo-controlled clinical trial of vital wheat gluten oral immunotherapy. J Allergy Clin Immunol 2018; 143:651-661.e9. [PMID: 30389226 DOI: 10.1016/j.jaci.2018.08.041] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 07/11/2018] [Accepted: 08/06/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Wheat is a common food allergen that can cause anaphylaxis. OBJECTIVE We sought to determine the efficacy and safety of vital wheat gluten (VWG) oral immunotherapy (OIT). METHODS After baseline double-blind, placebo-controlled food challenge (DBPCFC), 46 patients with wheat allergy (median age, 8.7 years; range, 4.2-22.3 years) were randomized 1:1 to low-dose VWG OIT or placebo, with biweekly escalation to 1445 mg of wheat protein (WP). After a year 1 DBPCFC, active subjects continued low-dose VWG OIT for another year and underwent a year 2 DBPCFC and, if passed, a subsequent off-therapy DBPCFC. Placebo-treated subjects crossed over to high-dose VWG OIT (maximum, 2748 mg of WP). RESULTS The median baseline successfully consumed dose (SCD) was 43 mg of WP in both groups. At year 1, 12 (52.2%) of 23 low-dose VWG OIT-treated and 0 (0%) of 23 placebo-treated subjects achieved the primary end point of an SCD of 4443 mg of WP or greater (P < .0001); median SCDs were 4443 and 143 mg, respectively. At year 2, 7 (30.4%) of 23 low-dose VWG OIT-treated subjects were desensitized to an SCD of 7443 mg of WP; 3 (13%) achieved sustained unresponsiveness 8 to 10 weeks off therapy. Among placebo-treated subjects who crossed over to high-dose VWG OIT, 12 (57.1%) of 21 were desensitized after 1 year (median SCD, 7443 mg of WP; nonsignificant vs low-dose VWG OIT). At year 1, skin prick test responses and wheat- and omega-5 gliadin-specific IgE levels did not differ between groups; the low-dose VWG OIT median specific IgG4 level was greater than placebo (wheat, P = .0005; omega-5 gliadin, P = .0001). Year 1 SCDs correlated with wheat-specific (rho = 0.55, P = .0003) and omega-5 gliadin-specific (rho = 0.51, P = .001) IgG4 levels in all subjects. Among 7822 low-dose VWG OIT doses in year 1, 15.4% were associated with adverse reactions: 0.04% were severe, and 0.08% subjects received epinephrine. Among 7921 placebo doses, 5.8% were associated with adverse reactions; none were severe. CONCLUSIONS Low- and high-dose VWG OIT induced desensitization in about one half of the subjects after 1 year of treatment. Two years of low-dose VWG OIT resulted in 30% desensitization, and 13% had sustained unresponsiveness.
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Affiliation(s)
- Anna Nowak-Węgrzyn
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, NY
| | - Robert A Wood
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Kari C Nadeau
- Division of Allergy and Immunology, Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Palo Alto, Calif
| | - Jacqueline A Pongracic
- Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | | | | | - Kirsten Beyer
- Charité Universitätsmedizin Berlin, Department of Pediatric Pneumology and Immunology, Berlin, Germany
| | - Hugh A Sampson
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, NY.
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Nagakura KI, Yanagida N, Sato S, Nishino M, Asaumi T, Ogura K, Ebisawa M. Low-dose oral immunotherapy for children with anaphylactic peanut allergy in Japan. Pediatr Allergy Immunol 2018; 29:512-518. [PMID: 29603410 DOI: 10.1111/pai.12898] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Oral immunotherapy (OIT) is a promising treatment for persons with allergy; however, it can also cause adverse allergic reactions. In this study, we investigated the efficacy of low-dose OIT for anaphylactic peanut allergy. METHODS Twenty-four children (median age, 9.6 years) with anaphylaxis to peanuts were hospitalized for 5 days and then gradually fed increasing amounts of peanut powder up to 133 mg/day. One year later, they underwent an oral food challenge after 2 weeks of peanut avoidance. Those who were asymptomatic after ingesting 795 mg of peanut protein were defined as having achieved sustained unresponsiveness. We measured peanut- and Ara h2-specific immunoglobulin (Ig) E, IgG, and IgG4 levels at 0, 1, 3, 6, and 12 months in the OIT group and at 0 and 12 months in the control group. RESULTS At baseline, all children in the OIT group and 8 in the control group had a history of anaphylaxis. The median peanut-/Ara h2-specific IgE levels in the OIT and control groups were 55.4/48.6 and 58.2/38.1 kUa/L, respectively. One year later, 8 (33.3%) children in the OIT group exhibited sustained unresponsiveness, while none in the control group did. In the OIT group, the median peanut-specific IgE levels significantly increased to 194.0 kUa/L, after 1 month and then significantly decreased to 57.5 kUa/L at 12 months. Meanwhile, the median peanut- and Ara h2-specific IgG and IgG4 levels increased significantly after 1 month. CONCLUSION Low-dose OIT induces immunological changes and has the capability of achieving sustained unresponsiveness in children with peanut anaphylaxis.
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Affiliation(s)
- Ken-Ichi Nagakura
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan.,Department of Pediatrics, Jikei University School of Medicine, Tokyo, Japan
| | - Noriyuki Yanagida
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Sakura Sato
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan
| | - Makoto Nishino
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Tomoyuki Asaumi
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Kiyotake Ogura
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan
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Sampath V, Sindher SB, Zhang W, Nadeau KC. New treatment directions in food allergy. Ann Allergy Asthma Immunol 2018; 120:254-262. [PMID: 29508712 PMCID: PMC5978756 DOI: 10.1016/j.anai.2018.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/03/2018] [Accepted: 01/04/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Vanitha Sampath
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, California; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, California; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California
| | - Wenming Zhang
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, California; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, California; Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California; Division of Allergy, Immunology and Rheumatology, Department of Medicine, Stanford University, Stanford, California.
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24
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Kulis MD, Patil SU, Wambre E, Vickery BP. Immune mechanisms of oral immunotherapy. J Allergy Clin Immunol 2017; 141:491-498. [PMID: 29288078 DOI: 10.1016/j.jaci.2017.12.979] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/30/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
Oral immunotherapy (OIT) has demonstrated reproducibly successful desensitization in patients with food allergy completing clinical trials and, in some studies, sustained unresponsiveness. These clinical outcomes have been associated with characteristic modifications in the allergen-specific immune response, but a detailed synthesis of OIT's mechanisms of action is lacking. In this rostrum we review the current evidence regarding the human immune response to OIT, explore possible mechanisms, and identify knowledge gaps for future research.
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Affiliation(s)
- Michael D Kulis
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Sarita U Patil
- Department of Pediatrics, Massachusetts General Hospital, Boston, Mass
| | - Erik Wambre
- Department of Immunology, Benaroya Research Institute, Seattle, Wash
| | - Brian P Vickery
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC.
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25
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Nurmatov U, Dhami S, Arasi S, Pajno GB, Fernandez-Rivas M, Muraro A, Roberts G, Akdis C, Alvaro-Lozano M, Beyer K, Bindslev-Jensen C, Burks W, du Toit G, Ebisawa M, Eigenmann P, Knol E, Makela M, Nadeau KC, O'Mahony L, Papadopoulos N, Poulsen LK, Sackesen C, Sampson H, Santos AF, van Ree R, Timmermans F, Sheikh A. Allergen immunotherapy for IgE-mediated food allergy: a systematic review and meta-analysis. Allergy 2017; 72:1133-1147. [PMID: 28058751 DOI: 10.1111/all.13124] [Citation(s) in RCA: 276] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The European Academy of Allergy and Clinical Immunology (EAACI) is developing Guidelines for Allergen Immunotherapy (AIT) for IgE-mediated Food Allergy. To inform the development of clinical recommendations, we sought to critically assess evidence on the effectiveness, safety and cost-effectiveness of AIT in the management of food allergy. METHODS We undertook a systematic review and meta-analysis that involved searching nine international electronic databases for randomized controlled trials (RCTs) and nonrandomized studies (NRS). Eligible studies were independently assessed by two reviewers against predefined eligibility criteria. The quality of studies was assessed using the Cochrane Risk of Bias tool for RCTs and the Cochrane ACROBAT-NRS tool for quasi-RCTs. Random-effects meta-analyses were undertaken, with planned subgroup and sensitivity analyses. RESULTS We identified 1814 potentially relevant papers from which we selected 31 eligible studies, comprising of 25 RCTs and six NRS, studying a total of 1259 patients. Twenty-five trials evaluated oral immunotherapy (OIT), five studies investigated sublingual immunotherapy, and one study evaluated epicutaneous immunotherapy. The majority of these studies were in children. Twenty-seven studies assessed desensitization, and eight studies investigated sustained unresponsiveness postdiscontinuation of AIT. Meta-analyses demonstrated a substantial benefit in terms of desensitization (risk ratio (RR) = 0.16, 95% CI 0.10, 0.26) and suggested, but did not confirm sustained unresponsiveness (RR = 0.29, 95% CI 0.08, 1.13). Only one study reported on disease-specific quality of life (QoL), which reported no comparative results between OIT and control group. Meta-analyses revealed that the risk of experiencing a systemic adverse reaction was higher in those receiving AIT, with a more marked increase in the risk of local adverse reactions. Sensitivity analysis excluding those studies judged to be at high risk of bias demonstrated the robustness of summary estimates of effectiveness and safety of AIT for food allergy. None of the studies reported data on health economic analyses. CONCLUSIONS AIT may be effective in raising the threshold of reactivity to a range of foods in children with IgE-mediated food allergy whilst receiving (i.e. desensitization) and post-discontinuation of AIT. It is, however, associated with a modest increased risk in serious systemic adverse reactions and a substantial increase in minor local adverse reactions. More data are needed in relation to adults, long term effects, the impact on QoL and the cost-effectiveness of AIT.
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Affiliation(s)
- U. Nurmatov
- Division of Population Medicine Neuadd Meirionnydd; School of Medicine; Cardiff University; Cardiff UK
| | - S. Dhami
- Evidence-Based Health Care Ltd; Edinburgh UK
| | - S. Arasi
- Department of Pediatrics; Allergy Unit; University of Messina; Messina Italy
- Molecular Allergology and Immunomodulation-Department of Pediatric Pneumology and Immunology; Charité Medical University; Berlin Germany
| | - G. B. Pajno
- Department of Pediatrics; Allergy Unit; University of Messina; Messina Italy
| | | | - A. Muraro
- Department of Women and Child Health; Food Allergy Referral Centre Veneto Region; Padua General University Hospital; Padua Italy
| | - G. Roberts
- The David Hide Asthma and Allergy Research Centre; St Mary's Hospital, Newport; Isle of WIght UK
- NIHR Respiratory Biomedial Research Unit and Faculty of Medicine; University of Southampton; Southampton UK
| | - C. Akdis
- Swiss Institute for Allergy and Asthma Research; Davos Platz Switzerland
| | - M. Alvaro-Lozano
- Paediatric Allergy and Clinical Immunology Section; Hospital Sant Joan de Déu; Universitat de Barcelona; Barcelona Spain
| | - K. Beyer
- Pediatric Pneumology and Immunology; Charité Universitätsmedizin; Berlin Germany
- Icahn School of Medicine at Mount Sinai; New York NY USA
| | - C. Bindslev-Jensen
- Department of Dermatology and Allergy Centre; Odense University Hospital; Odense Denmark
| | - W. Burks
- Department of Pediatrics; School of Medicine; University of North Carolina at Chapel Hill; Chapel Hill NC USA
| | - G. du Toit
- Department of Paediatric Allergy; Division of Asthma, Allergy and Lung Biology; MRC & Asthma Centre in Allergic Mechanisms of Asthma; King's College London; St Thomas NHS Foundation Trust; London UK
| | - M. Ebisawa
- Department of Allergy; Clinical Research Center for Allergy & Rheumatology; Sagamihara National Hospital; Sagamihara Kanagawa Japan
| | - P. Eigenmann
- University Hospitals of Geneva and Medical School of the University of Geneva; Geneva Switzerland
| | - E. Knol
- Department of Immunology and Department of Dermatology & Allergology; University Medical Center; Utrecht The Netherlands
| | - M. Makela
- Skin and Allergy Hospital; Helsinki University Hospital; Helsinki Finland
| | - K. C. Nadeau
- Department of Pediatrics; Division of Immunology, Allergy and Rheumatology; Stanford University; Stanford CA USA
| | - L. O'Mahony
- Swiss Institute of Allergy and Asthma Research (SIAF); University of Zurich; Davos Switzerland
| | - N. Papadopoulos
- Department of Allergy; 2nd Pediatric Clinic; University of Athens; Athens Greece
| | - L. K. Poulsen
- Department of Allergy Clinic; Copenhagen University Hospital; Gentofte Denmark
| | - C. Sackesen
- Department of Pediatric Allergist; Koç University Hospital; İstanbul Turkey
| | - H. Sampson
- World Allergy Organization (WAO); Mount Sinai Hospital NY, USA
| | - A. F. Santos
- Department of Paediatric Allergy; Division of Asthma, Allergy and Lung Biology; King's College London; Guy's and St Thomas’ Hospital NHS Foundation Trust; London UK
| | - R. van Ree
- Department of Otorhinolaryngology; Academic Medical Center; Amsterdam The Netherlands
| | - F. Timmermans
- Nederlands Anafylaxis Netwerk - European Anaphylaxis Taskforce; Dordrecht The Netherlands
| | - A. Sheikh
- Allergy and Respiratory Research Group; Centre of Medical Informatics; Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; Edinburgh UK
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Frischmeyer-Guerrerio PA, Masilamani M, Gu W, Brittain E, Wood R, Kim J, Nadeau K, Jarvinen KM, Grishin A, Lindblad R, Sampson HA. Mechanistic correlates of clinical responses to omalizumab in the setting of oral immunotherapy for milk allergy. J Allergy Clin Immunol 2017; 140:1043-1053.e8. [PMID: 28414061 DOI: 10.1016/j.jaci.2017.03.028] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/10/2017] [Accepted: 03/15/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND In our recent clinical trial, the addition of omalizumab to oral immunotherapy (OIT) for milk allergy improved safety, but no significant clinical benefit was detected. OBJECTIVE We sought to investigate mechanisms by which omalizumab modulates immunity in the context of OIT and to identify baseline biomarkers that predict subgroups of patients most likely to benefit from omalizumab. METHODS Blood was obtained at baseline and multiple time points during a placebo-controlled trial of OIT for milk allergy in which subjects were randomized to receive omalizumab or placebo. Immunologic outcomes included measurement of basophil CD63 expression and histamine release and casein-specific CD4+ regulatory T-cell proliferation. Biomarkers were analyzed in relationship to measurements of safety and efficacy. RESULTS Milk-induced basophil CD63 expression was transiently reduced in whole blood samples from both omalizumab- and placebo-treated subjects. However, IgE-dependent histamine release increased in washed cell preparations from omalizumab- but not placebo-treated subjects. No increase in regulatory T-cell frequency was evident in either group. Subjects with lower rates of adverse reactions, regardless of arm, experienced better clinical outcomes. Pre-OIT basophil reactivity positively associated with occurrence of symptoms during OIT, whereas the baseline milk IgE/total IgE ratio correlated with the likelihood of achieving sustained unresponsiveness. A combination of baseline basophil and serologic biomarkers defined a subset of patients in which adjunctive therapy with omalizumab was associated with attainment of sustained unresponsiveness and a reduction in adverse reactions. CONCLUSIONS Combining omalizumab therapy with milk OIT led to distinct alterations in basophil reactivity but not T-cell responses. Baseline biomarkers can identify subjects most likely to benefit from adjunctive therapy with omalizumab.
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Affiliation(s)
- Pamela A Frischmeyer-Guerrerio
- Laboratory of Allergic Diseases, Food Allergy Research Unit, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Madhan Masilamani
- Department of Pediatrics, Division of Allergy & Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Wenjuan Gu
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, NCI Campus, Frederick, Md
| | - Erica Brittain
- Biostatistics Research Branch, Division of Clinical Research, National Institutes of Health, Bethesda, Md
| | - Robert Wood
- Department of Pediatrics, Division of Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jennifer Kim
- Department of Pediatrics, Division of Allergy & Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kari Nadeau
- Departments of Medicine and Pediatrics, Sean N. Parker Center for Allergy and Asthma Research, Stanford School of Medicine, Stanford, Calif
| | - Kirsi M Jarvinen
- Department of Pediatrics, Division of Allergy and Immunology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY
| | - Alexander Grishin
- Department of Pediatrics, Division of Allergy & Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Hugh A Sampson
- Department of Pediatrics, Division of Allergy & Immunology, Icahn School of Medicine at Mount Sinai, New York, NY.
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27
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Affiliation(s)
- Brian P Vickery
- a Department of Pediatrics , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
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28
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Escudero C, Rodríguez Del Río P, Sánchez-García S, Pérez-Rangel I, Pérez-Farinós N, García-Fernández C, Ibáñez MD. Early sustained unresponsiveness after short-course egg oral immunotherapy: a randomized controlled study in egg-allergic children. Clin Exp Allergy 2016; 45:1833-43. [PMID: 26236997 DOI: 10.1111/cea.12604] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [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: 03/08/2015] [Revised: 07/20/2015] [Accepted: 07/27/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND No studies have evaluated the potential of egg oral immunotherapy (egg-OIT) to induce sustained unresponsiveness after discontinuing therapy following short-term treatments. OBJECTIVE We assessed the efficacy of short-course egg-OIT to induce sustained unresponsiveness. METHODS Sixty-one egg-allergic children, 5 to 17 years old, with positive double-blind placebo-controlled food challenge (DBPCFC) to dehydrated egg white (EW) were randomized to receive egg-OIT (OITG) for 3 months (maintenance dose one undercooked egg every 48 hours) or to continue egg avoidance diet (control group, CG) for 4 months. Children who completed egg-OIT avoided egg for 1 month. At 4 months, both groups underwent a DBPCFC. OITG participants who passed this challenge were instructed to add egg to their diet ad libitum. Immune markers were studied at different time points. RESULTS Ninety-three percent (28/30) of OITG children were desensitized in a median of 32.5 days (IQR, 14 days). At 4 months, 1/31 (3%) in CG passed DBPCFC and 11/30 (37%) of OITG (95% CI, 14 to 51%; P = 0.003), all of them were consuming egg at 36 months. A decrease in EW, OVA and OVM skin test results and OVA-specific IgE (sIgE) levels was observed on OITG at 4 months (P = 0.001). EW-, OVA- and OVM-sIgE levels prior to the start of egg avoidance diet were lower in OITG children who passed DBPCFC at 4 months than in those who did not pass it. EW- and OVM-sIgE showed the best diagnostic performance in predicting DBPCFC result at 4 months. Levels above optimal EW-sIgE cut-off of 7.1 kU/L indicated 90% probability of failing DBPCFC. CONCLUSION This is the first demonstration of sustained unresponsiveness with a three-month egg-OIT protocol. Almost all treated subjects were desensitized and 37% achieved sustained unresponsiveness. EW-sIgE levels at the end of treatment predicted sustained unresponsiveness. This protocol shows a new approach to OIT for egg-allergic children.
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Affiliation(s)
- C Escudero
- Allergy Department, Hospital InfantilUniversitario Niño Jesús, IIS-Princesa, Madrid, Spain
| | - P Rodríguez Del Río
- Allergy Department, Hospital InfantilUniversitario Niño Jesús, IIS-Princesa, Madrid, Spain
| | - S Sánchez-García
- Allergy Department, Hospital InfantilUniversitario Niño Jesús, IIS-Princesa, Madrid, Spain
| | - I Pérez-Rangel
- Allergy Department, Hospital InfantilUniversitario Niño Jesús, IIS-Princesa, Madrid, Spain
| | - N Pérez-Farinós
- Preventive Medicine Department, School of Medicine, Universidad Complutense, Madrid, Spain
| | - C García-Fernández
- Preventive Medicine Department, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - M D Ibáñez
- Allergy Department, Hospital InfantilUniversitario Niño Jesús, IIS-Princesa, Madrid, Spain
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Vickery BP, Berglund JP, Burk CM, Fine JP, Kim EH, Kim JI, Keet CA, Kulis M, Orgel KG, Guo R, Steele PH, Virkud YV, Ye P, Wright BL, Wood RA, Burks AW. Early oral immunotherapy in peanut-allergic preschool children is safe and highly effective. J Allergy Clin Immunol 2017; 139:173-181.e8. [PMID: 27522159 DOI: 10.1016/j.jaci.2016.05.027] [Citation(s) in RCA: 262] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 04/26/2016] [Accepted: 05/25/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Oral immunotherapy (OIT) is an effective experimental food allergy treatment that is limited by treatment withdrawal and the frequent reversibility of desensitization if interrupted. Newly diagnosed preschool children may have clinical and immunological characteristics more amenable to treatment. OBJECTIVE We sought to test the safety, effectiveness, and feasibility of early OIT (E-OIT) in the treatment of peanut allergy. METHODS We enrolled 40 children aged 9 to 36 months with suspected or known peanut allergy. Qualifying subjects reacted to peanut during an entry food challenge and were block-randomized 1:1 to receive E-OIT at goal maintenance doses of 300 or 3000 mg/d in a double-blinded fashion. The primary end point, sustained unresponsiveness at 4 weeks after stopping early intervention oral immunotherapy (4-SU), was assessed by double-blinded, placebo-controlled food challenge either upon achieving 4 prespecified criteria, or after 3 maintenance years. Peanut-specific immune responses were serially analyzed. Outcomes were compared with 154 matched standard-care controls. RESULTS Of 40 consented subjects, 3 (7.5%) did not qualify. Overall, 29 of 37 (78%) in the intent-to-treat analysis achieved 4-SU (300-mg arm, 17 of 20 [85%]; 3000 mg, 12 of 17 [71%], P = .43) over a median of 29 months. Per-protocol, the overall proportion achieving 4-SU was 29 of 32 (91%). Peanut-specific IgE levels significantly declined in E-OIT-treated children, who were 19 times more likely to successfully consume dietary peanut than matched standard-care controls, in whom peanut-specific IgE levels significantly increased (relative risk, 19.42; 95% CI, 8.7-43.7; P < .001). Allergic side effects during E-OIT were common but all were mild to moderate. CONCLUSIONS At both doses tested, E-OIT had an acceptable safety profile and was highly successful in rapidly suppressing allergic immune responses and achieving safe dietary reintroduction.
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Abstract
Food allergy is a potentially life-threatening condition affecting up to 8% of children and up to 2% of adults in westernized countries. There are currently no approved treatments for food allergy apart from avoidance. The apparent increase in incidence of food allergies over the past few decades calls attention to the need for effective, disease-modifying therapies for food allergies. Oral immunotherapy (OIT) is a promising experimental treatment in which food allergic patients consume increasing quantities of food in attempt to increase their threshold for allergic reaction. Studies are ongoing to determine whether OIT is capable of safely inducing not only desensitization but also tolerance to the allergenic foods. This article focuses on recent relevant studies of OIT for the treatment of common food allergies.
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Affiliation(s)
- Allison J Burbank
- a University of North Carolina, Department of Allergy, Immunology, and Rheumatology, Chapel Hill, NC, USA
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31
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Jones SM, Burks AW, Keet C, Vickery BP, Scurlock AM, Wood RA, Liu AH, Sicherer SH, Henning AK, Lindblad RW, Dawson P, Berin C, Fleischer DM, Leung DYM, Plaut M, Sampson HA. Long-term treatment with egg oral immunotherapy enhances sustained unresponsiveness that persists after cessation of therapy. J Allergy Clin Immunol 2016; 137:1117-1127.e10. [PMID: 26924470 DOI: 10.1016/j.jaci.2015.12.1316] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 11/09/2015] [Accepted: 12/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND We previously reported the results of a randomized placebo-controlled study of egg oral immunotherapy (eOIT) in which 27.5% of subjects achieved sustained unresponsiveness (SU) after 2 years. Here we report the results of treatment through 4 years and long-term follow-up. OBJECTIVE We sought to evaluate the efficacy and safety of eOIT in participants treated up to 4 years. METHODS Children with egg allergy (5-18 years old) received eOIT (n = 40) for up to 4 years or placebo (n = 15) for 1 year or less. The key outcome was the percentage of subjects achieving SU by year 4. Safety and immunologic assessments were performed, and long-term follow-up questionnaires (LFQs) were administered after study conclusion (LFQ-1) and 1 year later (LFQ-2). RESULTS Of 40 eOIT-treated subjects, 20 (50.0%) of 40 demonstrated SU by year 4. For those subjects still dosing during years 3 and 4, mild symptoms were present in 12 (54.5%) of 22 subjects. At the time of the LFQ, more subjects receiving eOIT (LFQ-1, 23/34 [68%]; LFQ-2, 21/33 [64%]) were consuming unbaked and baked egg versus placebo (LFQ-1, 2/11 [18%], P = .006; LFQ-2, 3/12 [25%], P = .04). Of subjects achieving SU, 18 (90%) of 20 completed the LFQ, with 18 (100%) of 18 reporting consumption of all forms of egg. When compared with subjects not achieving SU, subjects achieving SU had higher IgG4 values (P = .001) and lower egg skin prick test scores (P = .0002) over time and a lower median baseline ratio of egg-specific IgE to total IgE (1.1% vs 2.7%, P = .04). CONCLUSIONS SU after eOIT is enhanced with longer duration of therapy and increases the likelihood of tolerating unbaked egg in the diet.
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Affiliation(s)
- Stacie M Jones
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark.
| | - A Wesley Burks
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Corinne Keet
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Brian P Vickery
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Amy M Scurlock
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Robert A Wood
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Andrew H Liu
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Scott H Sicherer
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | - Cecilia Berin
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Marshall Plaut
- National Institutes of Health (National Institute of Allergy and Infectious Diseases), Bethesda, Md
| | - Hugh A Sampson
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
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Wood RA, Kim JS, Lindblad R, Nadeau K, Henning AK, Dawson P, Plaut M, Sampson HA. A randomized, double-blind, placebo-controlled study of omalizumab combined with oral immunotherapy for the treatment of cow's milk allergy. J Allergy Clin Immunol 2015; 137:1103-1110.e11. [PMID: 26581915 DOI: 10.1016/j.jaci.2015.10.005] [Citation(s) in RCA: 227] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/07/2015] [Accepted: 10/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although studies of oral immunotherapy (OIT) for food allergy have shown promise, treatment is frequently complicated by adverse reactions and, even when successful, has limited long-term efficacy because benefits usually diminish when treatment is discontinued. OBJECTIVE We sought to examine whether the addition of omalizumab to milk OIT reduces treatment-related reactions, improves outcomes, or both. METHODS This was a double-blind, placebo-controlled trial with subjects randomized to omalizumab or placebo. Open-label milk OIT was initiated after 4 months of omalizumab/placebo with escalation to maintenance over 22 to 40 weeks, followed by daily maintenance dosing through month 28. At month 28, omalizumab was discontinued, and subjects passing an oral food challenge (OFC) continued OIT for 8 weeks, after which OIT was discontinued with rechallenge at month 32 to assess sustained unresponsiveness (SU). RESULTS Fifty-seven subjects (7-32 years) were randomized, with no significant baseline differences in age, milk-specific IgE levels, skin test results, or OFC results. At month 28, 24 (88.9%) omalizumab-treated subjects and 20 (71.4%) placebo-treated subjects passed the 10-g "desensitization" OFC (P = .18). At month 32, SU was demonstrated in 48.1% in the omalizumab group and 35.7% in the placebo group (P = .42). Adverse reactions were markedly reduced during OIT escalation in omalizumab-treated subjects for percentages of doses per subject provoking symptoms (2.1% vs 16.1%, P = .0005), dose-related reactions requiring treatment (0.0% vs 3.8%, P = .0008), and doses required to achieve maintenance (198 vs 225, P = .008). CONCLUSIONS In this first randomized, double-blind, placebo-controlled trial of omalizumab in combination with food OIT, we found significant improvements in measurements of safety but not in outcomes of efficacy (desensitization and SU).
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Affiliation(s)
- Robert A Wood
- Johns Hopkins University School of Medicine, Baltimore, Md
| | | | | | - Kari Nadeau
- Stanford University School of Medicine, Stanford, Calif
| | | | | | - Marshall Plaut
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
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Affiliation(s)
- Brian P Vickery
- Division of Pediatric Allergy, Immunology & Rheumatology, University of North Carolina, Chapel Hill, NC, USA
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Tang MLK, Ponsonby AL, Orsini F, Tey D, Robinson M, Su EL, Licciardi P, Burks W, Donath S. Administration of a probiotic with peanut oral immunotherapy: A randomized trial. J Allergy Clin Immunol 2015; 135:737-44.e8. [PMID: 25592987 DOI: 10.1016/j.jaci.2014.11.034] [Citation(s) in RCA: 298] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 11/22/2014] [Accepted: 11/26/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Coadministration of a bacterial adjuvant with oral immunotherapy (OIT) has been suggested as a potential treatment for food allergy. OBJECTIVE To evaluate a combined therapy comprising a probiotic together with peanut OIT. METHODS We performed a double-blind, placebo-controlled randomized trial of the probiotic Lactobacillus rhamnosus CGMCC 1.3724 and peanut OIT (probiotic and peanut oral immunotherapy [PPOIT]) in children (1-10 years) with peanut allergy. The primary outcome was induction of sustained unresponsiveness 2 to 5 weeks after discontinuation of treatment (referred to as possible sustained unresponsiveness). Secondary outcomes were desensitization, peanut skin prick test, and specific IgE and specific IgG4 measurements. RESULTS Sixty-two children were randomized and stratified by age (≤5 and >5 years) and peanut skin test wheal size (≤10 and >10 mm); 56 reached the trial's end. Baseline demographics were similar across groups. Possible sustained unresponsiveness was achieved in 82.1% receiving PPOIT and 3.6% receiving placebo (P < .001). Nine children need to be treated for 7 to achieve sustained unresponsiveness (number needed to treat, 1.27; 95% CI, 1.06-1.59). Of the subjects, 89.7% receiving PPOIT and 7.1% receiving placebo were desensitized (P < .001). PPOIT was associated with reduced peanut skin prick test responses and peanut-specific IgE levels and increased peanut-specific IgG4 levels (all P < .001). PPOIT-treated participants reported a greater number of adverse events, mostly with maintenance home dosing. CONCLUSION This is the first randomized placebo-controlled trial evaluating the novel coadministration of a probiotic and peanut OIT and assessing sustained unresponsiveness in children with peanut allergy. PPOIT was effective in inducing possible sustained unresponsiveness and immune changes that suggest modulation of the peanut-specific immune response. Further work is required to confirm sustained unresponsiveness after a longer period of secondary peanut elimination and to clarify the relative contributions of probiotics versus OIT.
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Affiliation(s)
- Mimi L K Tang
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Allergy and Immune Disorders, Murdoch Childrens Research Institute, Melbourne, Australia.
| | - Anne-Louise Ponsonby
- Environmental and Genetic Epidemiology, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Dean Tey
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Australia; Allergy and Immune Disorders, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Marnie Robinson
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Australia; Allergy and Immune Disorders, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Ee Lyn Su
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Australia; Allergy and Immune Disorders, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Paul Licciardi
- Allergy and Immune Disorders, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Wesley Burks
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Susan Donath
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, Australia
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Gorelik M, Narisety SD, Guerrerio AL, Chichester KL, Keet CA, Bieneman AP, Hamilton RG, Wood RA, Schroeder JT, Frischmeyer-Guerrerio PA. Suppression of the immunologic response to peanut during immunotherapy is often transient. J Allergy Clin Immunol 2014; 135:1283-92. [PMID: 25542883 DOI: 10.1016/j.jaci.2014.11.010] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [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: 08/08/2014] [Revised: 10/31/2014] [Accepted: 11/05/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Studies suggest that oral immunotherapy (OIT) and sublingual immunotherapy (SLIT) for food allergy hold promise; however, the immunologic mechanisms underlying these therapies are not well understood. OBJECTIVE We sought to generate insights into the mechanisms and duration of suppression of immune responses to peanut during immunotherapy. METHODS Blood was obtained from subjects at baseline and at multiple time points during a placebo-controlled trial of peanut OIT and SLIT. Immunologic outcomes included measurement of spontaneous and stimulated basophil activity by using automated fluorometry (histamine) and flow cytometry (activation markers and IL-4), measurement of allergen-induced cytokine expression in dendritic cell (DC)-T-cell cocultures by using multiplexing technology, and measurement of MHC II and costimulatory molecule expression on DCs by using flow cytometry. RESULTS Spontaneous and allergen-induced basophil reactivity (histamine release, CD63 expression, and IL-4 production) were suppressed during dose escalation and after 6 months of maintenance dosing. Peanut- and dust mite-induced expression of TH2 cytokines was reduced in DC-T-cell cocultures during immunotherapy. This was associated with decreased levels of CD40, HLA-DR, and CD86 expression on DCs and increased expression of CD80. These effects were most striking in myeloid DC-T-cell cocultures from subjects receiving OIT. Many markers of immunologic suppression reversed after withdrawal from immunotherapy and in some cases during ongoing maintenance therapy. CONCLUSION OIT and SLIT for peanut allergy induce rapid suppression of basophil effector functions, DC activation, and TH2 cytokine responses during the initial phases of immunotherapy in an antigen-nonspecific manner. Although there was some interindividual variation, in many patients suppression appeared to be temporary.
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Affiliation(s)
- Mark Gorelik
- Department of Pediatrics, Division of Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Satya D Narisety
- Department of Pediatrics, Division of Allergy, Immunology and Infectious Diseases, University of Medicine and Dentistry of New Jersey, Newark, NJ
| | - Anthony L Guerrerio
- Department of Pediatrics, Division of Gastroenterology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Kristin L Chichester
- Department of Pediatrics, Division of Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Corinne A Keet
- Department of Pediatrics, Division of Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Anja P Bieneman
- Department of Medicine, Division of Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Robert G Hamilton
- Department of Medicine, Division of Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Robert A Wood
- Department of Pediatrics, Division of Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - John T Schroeder
- Department of Medicine, Division of Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Pamela A Frischmeyer-Guerrerio
- Department of Pediatrics, Division of Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, Md.
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Vickery BP, Scurlock AM, Kulis M, Steele PH, Kamilaris J, Berglund JP, Burk C, Hiegel A, Carlisle S, Christie L, Perry TT, Pesek RD, Sheikh S, Virkud Y, Smith PB, Shamji MH, Durham SR, Jones SM, Burks AW. Sustained unresponsiveness to peanut in subjects who have completed peanut oral immunotherapy. J Allergy Clin Immunol 2013; 133:468-75. [PMID: 24361082 DOI: 10.1016/j.jaci.2013.11.007] [Citation(s) in RCA: 315] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 11/05/2013] [Accepted: 11/07/2013] [Indexed: 01/17/2023]
Abstract
BACKGROUND Although peanut oral immunotherapy (OIT) has been conclusively shown to cause desensitization, it is currently unknown whether clinical protection persists after stopping therapy. OBJECTIVE Our primary objective was to determine whether peanut OIT can induce sustained unresponsiveness after withdrawal of OIT. METHODS We conducted a pilot clinical trial of peanut OIT at 2 US centers. Subjects age 1 to 16 years were recruited and treated for up to 5 years with peanut OIT. The protocol was modified over time to permit dose increases to a maximum of 4000 mg/d peanut protein. Blood was collected at multiple time points. Clinical end points were measured with 5000-mg double-blinded, placebo-controlled food challenges once specific criteria were met. RESULTS Of the 39 subjects originally enrolled, 24 completed the protocol and had evaluable outcomes. Twelve (50%) of 24 successfully passed a challenge 1 month after stopping OIT and achieved sustained unresponsiveness. Peanut was added to the diet. At baseline and the time of challenge, such subjects had smaller skin test results, as well as lower IgE levels specific for peanut, Ara h 1, and Ara h 2 and lower ratios of peanut-specific IgE/total IgE compared with subjects not passing. There were no differences in peanut IgG₄ levels or functional activity at the end of the study. CONCLUSIONS This is the first demonstration of sustained unresponsiveness after peanut OIT, occurring in half of subjects treated for up to 5 years. OIT favorably modified the peanut-specific immune response in all subjects completing the protocol. Smaller skin test results and lower allergen-specific IgE levels were predictive of successful outcome.
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Affiliation(s)
- Brian P Vickery
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Amy M Scurlock
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Michael Kulis
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Pamela H Steele
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Janet Kamilaris
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Caitlin Burk
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Anne Hiegel
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Suzanna Carlisle
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Lynn Christie
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Tamara T Perry
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Robbie D Pesek
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Saira Sheikh
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Yamini Virkud
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Mohamed H Shamji
- Section of Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Stephen R Durham
- Section of Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Stacie M Jones
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - A Wesley Burks
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
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